Review for 10.1186/s12876-025-04061-0 (2025)

Title: Unveiling the diagnostic and pro-inflammatory role of Crohn’s disease: insights from
16S-guided discovery and species-specific validation
Version: 5 Date: 01 May 2025
Reviewer's report:
I have carefully reviewed the manuscript titled "Effect of ERAS pathway nursing on
postoperative rehabilitation of patients undergoing gastrointestinal surgery: a meta-analysis."
This study addresses a highly relevant and clinically impactful topic, namely, the
implementation of Enhanced Recovery After Surgery (ERAS) protocols in the context of
gastrointestinal surgical care. The intention to synthesize evidence across studies via meta-
analysis is commendable. However, several scientific and methodological concerns require
substantial clarification and revision before this manuscript is suitable for publication.
1. Title and Abstract
The title is generally adequate but could be more specific by indicating “systematic review and
meta-analysis of ERAS protocols in GI surgery.”
The abstract lacks clarity in its objectives and results. The number of included studies, total
sample size, effect measures, and statistical results should be explicitly presented. Additionally,
conclusions should be more cautious and aligned with the evidence strength.
2. Keywords
Please revise the keywords to include standardized PubMed MeSH terms such as: Enhanced
Recovery After Surgery, Gastrointestinal Surgical Procedures, Postoperative Care, Systematic
Review, Meta-Analysis.
3. Introduction
The introduction does not adequately establish the knowledge gap. Prior systematic reviews on
ERAS protocols are not referenced.
There is no discussion of heterogeneity in existing ERAS protocols or their variable impact
across GI surgical subtypes.
I recommend including a formal PICO (Population, Intervention, Comparator, Outcome)
framework to define the review question explicitly.
4. Methods
While it is commendable that the study is registered in PROSPERO (ID: CRD42024608876),
the search strategy lacks transparency. Full Boolean logic, filters used, and search date ranges
should be reported or made available in supplementary material.
Inclusion/exclusion criteria are described vaguely. Definitions for “ERAS pathway” should be
standardized.
Risk of bias assessments using the Cochrane RoB2 tool (for RCTs) and Newcastle-Ottawa Scale
(for observational studies) are stated but not shown. Results of these assessments (e.g., scores
or graphical summaries) are essential and should be provided.
It is not clear how heterogeneity was interpreted (e.g., based on I² thresholds), nor whether
random-effects models were selected a priori.
There is no description of subgroup or sensitivity analyses, nor is there any funnel plot or Egger’s
test to evaluate publication bias.
5. Results
The PRISMA flow diagram is absent, which is critical to understanding how studies were
identified and selected.
Basic study characteristics are not summarized in a table—key information (study design,
country, sample size, type of surgery, specific ERAS elements) must be tabulated.
Forest plots are presented without corresponding data tables for mean differences, relative risks,
confidence intervals, and weights.
Substantial heterogeneity is noted but not addressed. Subgroup analysis (e.g., colorectal vs.
gastric surgery) is necessary to clarify sources of inconsistency.
6. Discussion
The discussion offers limited interpretation. Comparative analysis with previous reviews is
missing.
The authors should discuss how their findings align or contrast with established evidence on
ERAS outcomes in GI surgery.
Major limitations—such as protocol heterogeneity, variable study quality, and lack of blinding
—are not adequately acknowledged.
The conclusion that ERAS reduces complication and mortality rates must be tempered, as the
evidence base is too heterogeneous for such a definitive claim.
7. Figures, Tables, and Supplementary Files
All figures (forest plots and supplementary figures) need higher resolution and clear legends.
Table S1–S5 should be expanded to include characteristics of all included studies.
No graphical representation of bias (e.g., RoB2 or NOS summaries) or publication bias
diagnostics is provided.
8. Ethical and Bioethical Compliance
The manuscript includes ethics certificates; however, as a secondary analysis, a formal statement
that "no new human or animal subjects were involved" should be added.
Funding sources and potential conflicts of interest must be explicitly declared.
9. Summary of Required Revisions
To move forward toward acceptance, I recommend the following essential improvements:
Inclusion of PRISMA 2020 checklist and flow diagram.
Full presentation of risk-of-bias assessments and tabulation of study characteristics.
Detailed statistical analysis section, including justification of model choices and treatment of
heterogeneity.
Careful revision of abstract and conclusion to match the strength of the available evidence.
Integration of subgroup analysis and potential sources of bias in interpretation.
Recommendation
Major Revision Required
This study addresses a pertinent clinical question, but to ensure its scientific validity and
methodological transparency, substantial revisions are necessary. I strongly encourage the
authors to address the outlined issues to meet the standards of evidence synthesis in surgical
and clinical research.