Review for 10.1186/s12876-025-04216-z (2025)

Title: The Short-term Effect of Laparoscopic Sleeve Gastrectomy with His Angle
Reconstruction (LSG-His) on Gastroesophageal Reflux Disease
Version: 5 Date: 13 Jul 2025
Reviewer's report:
This manuscript presents a retrospective observational cohort study evaluating the impact of
a novel surgical modification—laparoscopic sleeve gastrectomy with His angle reconstruction
(LSG-His)—on gastroesophageal reflux disease (GERD) symptoms and weight loss outcomes
in patients undergoing bariatric surgery. The authors compare LSG-His to standard LSG over
24 months, utilizing GERD-Q and RD-Q symptom scores, %EWL, and %TWL as primary
outcomes. The findings suggest that LSG-His is associated with significantly lower GERD
symptom burden and improved %EWL. The study addresses an important clinical question with
innovative methodology, though several issues need to be resolved before publication.
Major Concerns
1. Study Design and Selection Bias
As acknowledged by the authors, the retrospective and non-randomized design inherently limits
causal inference. Patient selection and preference for LSG-His may reflect underlying clinical
characteristics not fully captured in the analysis. Despite comparable baseline characteristics,
unmeasured confounding likely remains. A propensity score matching or adjusted sensitivity
analysis would enhance the credibility of the findings.
2. Lack of Objective GERD Assessment
The study entirely relies on patient-reported GERD-Q and RD-Q scores, without routine
objective validation (e.g., endoscopy, pH-metry, manometry). Given the high subjectivity of
reflux symptoms and the risk of placebo or expectation bias, this limitation severely weakens
the reliability of GERD outcome assessment. Although a subgroup underwent endoscopy, the
sample size was small (n=24), and findings did not reach statistical significance.
3. Surgical Technique Description and Standardization
The LSG-His procedure is described adequately, but the reproducibility of the technique requires
further clarification. For broader adoption, standardized intraoperative steps, anatomical
landmarks, and operative illustrations (preferably as supplemental videos) are recommended.
The term “His angle reconstruction” may need clarification for surgeons unfamiliar with this
approach.
4. Weight Loss Interpretation
While %EWL differences favor LSG-His, %TWL was not significantly different, and the
observed difference in %EWL may reflect the influence of BMI distribution rather than true
superiority. Moreover, %EWL values at 24 months appear unusually high (mean >84%), raising
concerns about possible measurement, selection, or reporting bias.
5. Statistical Power and Overfitting
The use of multivariate regression with a relatively small sample (n=83) and few outcome events
raises the risk of model overfitting. The number of variables included is not specified, and no
assessment of model calibration is presented.
6. Short Follow-up Duration
Given that weight regain and GERD recurrence often manifest after 3–5 years, a 24-month
follow-up is insufficient to conclude long-term efficacy. The manuscript would benefit from
emphasizing the preliminary nature of these findings.
Minor Concerns
1. Terminology and Definitions
Use of “His angle reconstruction” should be clarified, and adherence to IFSO 2025 bariatric
terminology should be confirmed—especially regarding definitions of %EWL, %TWL, GERD,
and complications.
2. Reporting of PPI Use
Postoperative PPI use is analyzed, but adherence, dosage variations, and confounding by
indication are not thoroughly discussed. A clearer stratification by medication exposure and
GERD scores could be informative.
3. Pain Score and Opioid Use Interpretation
The higher postoperative pain scores and opioid use in the LSG-His group warrant more detailed
analysis. Could this affect patient satisfaction, early recovery, or discharge timing?
4. Ethical and Registration Transparency
Although ethics approval is stated, the lack of prospective registration (despite the interventional
nature of a novel surgical procedure) may raise concerns. This point should be addressed in the
limitations.
Language and Style
The manuscript is generally well written but would benefit from focused language editing for
grammar and flow. Some specific issues include:
• Repetition of phrases (e.g., “postoperative GERD symptoms”) should be minimized.
• Sentence structure in the Discussion is occasionally convoluted.
• Terms like “significant,” “favorable,” and “improved” should be used cautiously and in the
context of statistical evidence.
Reference and Citation Issues
• Most references are up-to-date and relevant. However, a few citations (e.g., references 5, 6,
24) should be scrutinized for data source robustness.
• Adherence to the journal’s reference formatting guidelines (Vancouver style) should be
checked throughout.
• The citation of STROBE guidelines (reference 16) is appropriate and commendable.