Review for 10.1186/s12876-025-03842-x (2025)

Title: Global Burden of Gallbladder and Biliary Diseases (1990-2021) with Healthcare
Workforce Analysis and Projections to 2035
Version: 3 Date: 13 Mar 2025
Reviewer:  Kaibo Guo
Reviewer's report:
1. Disease Classification and Surgical Relevance
Concerns:
#Lack of surgical context: While cholecystitis and cholangitis are mentioned, the study does not
stratify data by disease severity (e.g., acute vs. chronic cholecystitis) or surgical urgency (e.g.,
elective vs. emergency cholecystectomy).
#Missing surgical outcome metrics: Postoperative mortality/complication rates, minimally
invasive vs. open surgery trends, and regional disparities in surgical access are not addressed,
limiting relevance to surgical practice.
Recommendations:
#Add a subsection analyzing surgical incidence rates (e.g., cholecystectomy rates) using GBD
data or regional registries.
#Discuss how variations in surgical infrastructure (e.g., laparoscopic availability in low-SDI
regions) might influence disease burden projections.
2. Methodology and Data Interpretation
Concerns:
#Underrepresentation of surgical complications: GBD data may not fully capture complications
(e.g., bile duct injuries, retained stones) that contribute to DALYs and reoperation rates.
#Ambiguity in “prevalence” definition: For conditions like asymptomatic gallstones, prevalence
rates do not distinguish between cases requiring surveillance vs. intervention, muddying clinical
relevance.
Recommendations:
#Incorporate surgical complication data from existing studies (e.g., WHO Global Health
Estimates) to enrich DALY calculations.
#Clarify how asymptomatic vs. symptomatic cases are classified in GBD and discuss
implications for surgical workload.
3. Regional Disparities and Access to Care
Concerns:
#Lack of surgical resource analysis: The study does not correlate disease burden with surgical
workforce density (e.g., surgeons per 100,000 population) or infrastructure (e.g., laparoscopic
equipment availability).
#Overlooked cultural factors: Dietary habits (e.g., high-fat diets) and patient preferences (e.g.,
reluctance toward elective surgery) are not discussed as contributors to regional variations.
Recommendations:
#Map disease burden against surgical resource indicators (e.g., WHO surgical workforce data)
to identify underserved regions.
#Discuss cultural/behavioral factors (e.g., delayed presentation due to traditional medicine use)
in high-burden areas like Asia.
4. Clinical and Policy Implications
Concerns:
#Vague surgical recommendations: The conclusion calls for “targeted interventions” but lacks
specific strategies (e.g., promoting day-case cholecystectomy, training non-specialist surgeons
in rural areas).
#Ignored cost-effectiveness: The economic impact of rising surgical demand (e.g., laparoscopy
vs. open surgery costs) is not addressed, limiting utility for policymakers.
Recommendations:
#Propose region-specific surgical protocols, such as telehealth-guided preoperative assessment
in remote areas or task-shifting to mid-level providers.
#Include a cost-effectiveness analysis comparing early surgery vs. conservative management
for asymptomatic gallstones.
5. Technical and Ethical Rigor
Concerns:
#Ethical gaps: While no primary data were collected, the manuscript does not acknowledge
ethical approval for GBD data usage or compliance with institutional review protocols.
#Formatting errors: Examples include inconsistent spacing (e.g., “g astrointestinal”), missing
units (e.g., “865.4/100,000”), and citation errors (e.g., “2 .”), which detract from professionalism.
Recommendations:
#Add an ethics statement confirming adherence to GBD data use agreements and institutional
guidelines.
#Revise formatting to meet journal standards (e.g., uniform units, corrected spacing).
Overall Assessment:
This study offers valuable insights into the global burden of gallbladder and biliary
diseases, with robust epidemiological methods and actionable projections. However, integrating
surgical-specific metrics (e.g., complication rates, resource disparities) and refining policy
recommendations would significantly enhance its relevance to clinical practice and healthcare
planning. With revisions, this work could serve as a cornerstone for surgical burden research.
Decision: Major Revision (Address gaps in surgical context, regional resource analysis, and
policy recommendations to strengthen clinical applicability).