Review for 10.1186/s12876-025-04176-4 (2025)

Title: CT assessment of total abdominal muscle area index (TAMAI) as a predictive tool for
early post operative complications in laparoscopic sleeve gastrectomy: A prospective case-
control study
Version: 5 Date: 08 Jun 2025
Reviewer:  Rodrigo Muñoz
Reviewer's report:
Dear authors,
Thank you for submitting this interesting manuscript on the predictive value of CT-derived
muscle area for postoperative complications in bariatric patients. The study touches on an
important and underexplored topic. However, several revisions are necessary to strengthen its
scientific merit and ensure appropriate interpretation of the findings.
Please address the statistical and methodological concerns, especially regarding the small
sample size, the need for sex-specific analysis, and the omission of functional assessment of
sarcopenia. Additionally, we encourage more cautious language when interpreting the findings
and improved clarity in the discussion and presentation of figures.
Major revisions
-Sample size and statistical power: the study only includes 30 patients (14 cases, 16 controls),
which is significantly underpowered for establishing reliable cut-offs or for building predictive
models. This limitation must be clearly emphasized in the Discussion and Conclusion.
- Consider discussing confidence intervals more thoroughly in tables and results.
- Sex-specific analysis: TAMAI cut-offs and muscle mass are known to differ significantly
between sexes. A pooled analysis limits interpretability and may introduce bias. Authors must
either perform sex-stratified analyses or clearly justify the rationale for combining both sexes.
- Functional assessment of sarcopenia: current definitions of sarcopenia (EWGSOP2, IWGS)
emphasize both muscle quantity and function. The study completely omits functional parameters
such as grip strength or gait speed. This should be acknowledged as a major limitation and
discussed.
- Overstatement of predictive ability: despite good AUC values, the small sample and
exploratory nature of the study preclude strong conclusions about predictive capacity. Revise
all claims about the use of TAMAI as a “predictive tool” or “independent prognostic factor” to
reflect its exploratory value and hypothesis-generating nature.
- CT methodology: the manuscript mentions the inclusion of all visible muscle in the ROI, but
no density thresholds (e.g., Hounsfield Units) were applied, potentially including intramuscular
fat. Please clarify and justify this methodological decision and its implications on the validity
of the measurements.
- Discussion section: needs better structure:  separate clearly the background on sarcopenia,
discussion of your own results, and comparison to prior studies.
Minor revisions
Language and grammar: several grammatical issues throughout the text (e.g., awkward phrasing,
run-on sentences). I recommend professional English editing for clarity and flow.
Figures and tables: improve figure quality and labeling, especially Figures 1, 2, 6, 7, and 8.
Ensure legends are descriptive and independent from main text.
Figure 9 (external) should be properly cited and permission obtained or replaced.
Consistency in terminology: use a consistent term for TAMAI throughout (e.g., avoid alternating
with “TAMA index” or “SMI”).
Ethical approval and data availability: provide the reference number of the ethics approval
explicitly as claimed in the declaration.