Review for 10.1186/s12876-025-04036-1 (2025)

Title: Comparative Outcomes of ERAS and Conventional Methods in Laparoscopic Sleeve
Gastrectomy: A 5-Year Prospective Cohort Study in Saudi Arabia
Version: 2 Date: 13 Feb 2025
Reviewer:  Antonio Morandeira-Rivas
Reviewer's report:
An interesting study on the benefits of enhanced recovery after bariatric surgery. It compares
two groups of sleeve gastrectomy patients: one group that received standard care (non-
ERAS) and another group that received care after the enhanced recovery program (ERAS)
was introduced. The study examines various outcomes, including length of hospital stay,
complications, readmission rates, and healthcare costs.
Below are some questions and commentaries:
- Abstract:
o “Saudi Arabia's obesity problem is addressed with Laparoscopic Sleeve Gastrectomies (LSG),
…” I understand Laparoscopic Sleeve Gastrectomy is a piece of the armamentarium, not the
only way obesity is addressed.
o “At 5-year follow-up, the ERAS group had a better prognosis with fewer complications. At
5-year follow-up, a higher percentage of ERAS group had no complications compared to non-
ERAS group (615 vs %51%) in terms of recurrent weight gain and GERD.”,
The differences in the study were not significant.
o “… non-ERAS group (615 vs %51%) …” revise numbers and %.
- Introduction:
o “… and has an estimated prevalence [2].” This sentence seems to be incomplete.
o “It integrates evidence-based methods in order minimise postoperative complications …”
Maybe a “to” is missing after “in order”
- Methods:
o It seems that most of the measures in the ERAS program could benefit the patients. Why did
you choose to use a prospective cohort and not a retrospective one, so you could have started
implementing those measures earlier?
- Results:
o “In the entire study, a total of 94 patients were enrolled in the LSG.” Revise
o “The ERAS group has a median cost of SAR 43337” Please define the acronym SAR in its
first use.
o Same commentary for PACU or POD
o “In both groups no mortality and reoperation (Table 9).” A verb is needed in this sentence.
- Table 3.
o Consider placing the * after Age (years) instead of in the non-ERAS age results.
o p values would be helpful. It looks like the patients in the non-ERAS group had a higher BMI.
Was the median BMI different between the groups?
o Preoperative comorbidities would help assess the comparability of the two cohorts.
- Table 6.
o Please provide the units of measurement for “total surgical procedure time”
- Table 9:
o 20 % of atelectasias/pneumonia is a high incidence for this complication. p-value is almost
significant; maybe those differences would have arisen with a bigger sample size.
o Which is the author's hypothesis to explain the differences between groups regarding
postoperative reflux. This could be related to the patient's preoperative characteristics or
technical details during the sleeve gastrectomy. However, I do not understand its relation to
implementing an ERAS program.
o Revise p values. I am not sure if 1 or 1.00 are admissible p values, but >1 is not.
- Table 11
o How do the authors explain the effect of the ERAS program on postoperative exercise
compliance five years after the operation? Was exercise compliance analysed before the surgical
procedure?
- Figure 2
o Some patients have a hospital stay under 24 hours. Was a day-case bariatric surgery program
initiated during the study?
- Figure 3
o Congratulations, this figure clearly shows median differences and an important reduction in
dispersion of the cost results.
- Discussion
o “Between the non-ERAS and the ERAS groups, there was a non-significant increase in
Clavien-Dindo IIIa or higher complications [13].” Does it refer to  this study or to reference 13?
o "Moreover, our instituted smoking cessation counselling has been attributed to a lower
incidence of postoperative complications." Was the percentage of smokers before the operation
analysed in both groups? How many patients smoked before and after counselling?
o “ERAS patients with evidence of prediabetes were referred to the endocrinology clinic for
proper screening, …” Weren´t all the patients in the bariatric surgery program evaluated by an
endocrinologist?
o “STAT”, please define
o “The reported resultant effect is reduced ileus postoperatively [11].” Please revise.
o “Five years after follow-up, the ERAS group reported fewer cases of Clavien-Dindo graded
postoperative complications than the non-ERAS groups.” This does not match with the results
in table 10.