Review for 10.1186/s12876-025-04173-7 (2025)

Title: Preoperative Albumin-Bilirubin Grade Combined with Sarcopenia Predicts Long-term
Outcomes after Laparoscopic Gastrectomy for Advanced Gastric Cancer
Version: 1 Date: 19 Jun 2025
Reviewer's report:
1. Summary
This retrospective, multicenter study examines the combined prognostic value of preoperative
albumin–bilirubin (ALBI) grade and sarcopenia in patients with advanced gastric cancer (AGC)
undergoing laparoscopic radical gastrectomy. The authors construct a novel composite index (s-
ALBI) and demonstrate its predictive value for 5-year overall and recurrence-free survival. The
study includes 731 patients and employs robust statistical methods, with an external validation
cohort and comprehensive survival analyses. The s-ALBI index appears superior to ALBI or
sarcopenia alone in risk stratification.
2. Major Concerns
• Novelty and Clinical Impact: Although combining ALBI with sarcopenia is novel in AGC, the
incremental clinical value beyond existing staging systems (e.g., TNM) remains modest (AUCs
around 0.67). Authors should elaborate on how s-ALBI might change clinical decision-making
in real-world practice.
• Confounding Adjustment: The multivariate models adjust for several factors, but the potential
confounding effects of systemic inflammation (e.g., CRP), nutritional indices (e.g., PNI), or
performance status are not included. These may influence both ALBI and sarcopenia and thus
bias the results.
• Cutoff Selection and Reproducibility: The use of X-tile software to determine ALBI and
SMI cutoffs is appropriate, but reproducibility in other cohorts may be limited. Authors should
discuss external validity and provide justification for their chosen thresholds.
• Definition of Sarcopenia: Sarcopenia is defined using only SMI without including muscle
strength or performance, which may not fully align with EWGSOP or AWGS criteria. This
limitation should be clearly acknowledged and its implications discussed.
• Ethnicity and Generalizability: The entire cohort comprises East Asian patients from two
Chinese institutions. As such, the findings may not generalize to Western populations or diverse
ethnic groups, especially given body composition variability.
3. Minor Concerns
• Figures: Figures are generally informative, but color legends are sometimes unclear (e.g., s-
ALBI subgroups in Kaplan–Meier curves). Please ensure all figures are accessible in both color
and grayscale.
• Chemotherapy Regimens: The manuscript briefly mentions adjuvant chemotherapy but
does not stratify survival analyses by chemotherapy exposure, which may confound survival
outcomes.
• CT Imaging Standardization: The methodology would benefit from a brief note on CT scan
slice thickness or protocols, which can influence SMI measurements.
4. Unacknowledged Limitations
• The study does not control for systemic inflammatory markers (e.g., CRP, neutrophil–
lymphocyte ratio), which may be mediators or confounders in the ALBI-sarcopenia-prognosis
pathway.
• The retrospective design and exclusion of patients with missing data or incomplete follow-up
may introduce selection bias.
• Muscle function (e.g., handgrip strength or gait speed), an important component of sarcopenia,
is not assessed, potentially limiting clinical translation.
• No calibration curves or decision curve analysis (DCA) were presented to assess clinical utility
or net benefit of the s-ALBI model.
5. Language and Reference Revision
• The language is generally clear, but several sentences are long and complex, which may impair
clarity. The manuscript would benefit from minor English editing for flow and grammar (e.g.,
“This indicator demonstrated stable predictive performance for 5-year postoperative OS while
also allowing for risk stratification…” could be simplified).
• Avoid redundancy in the conclusion (e.g., repeated reference to “comparable to TNM” and
“comprehensive and early”).
• Reference [36] cites a promising mechanistic explanation regarding oxidative stress and
sarcopenia but would benefit from brief elaboration or clarification to link better with clinical
findings.