Review for 10.1186/s12876-025-04176-4 (2025)

Title: CT assessment of total abdominal muscle area index (TAMAI) as a predictive tool for
early post operative complications in laparoscopic sleeve gastrectomy: A prospective case-
control study
Version: 5 Date: 31 May 2025
Reviewer:  Dimitrios Kehagias
Reviewer's report:
Thank you for the opportunity to review this manuscript. The authors have conducted
a prospective single-center study, investigating the role of TAMA index for predicting
postoperative complications for patients undergoing laparoscopic sleeve gastrectomy. Below
are my comments to the authors:
MAJOR LIMITATIONS
1. The manuscript needs to be refined significantly in terms of language, structure and scientific
rigor.
- Abstract
Background: Reduce in length the background. Just provide “In metabolic bariatric surgery
(MBS) a lot of focus is made on preoperative risk assessment to enhance patient’s baseline
performance and improve postoperative clinical outcomes. The aim of this study is to assess
pre-operative sarcopenia by computed tomography (CT) scan, as a predictive tool for early post-
operative complications in candidates for MBS.”
Methods: In methods of the abstract, mention the study design, how many centers? Retrospective
or prospective? Then add the text you have included and then one concise sentence mentioning
the statistical method used for evaluating TAMAI as a predictive tool.
Results: In results, you have to mention how many patients were included and some basic
characteristics, probably the BMI or what you think is important to be shown in the abstract.
Conclusions: “… who are likely to get ...” These phrases are not scientifically valid.
Change keywords: “sarcopenia; obesity; metabolic bariatric surgery; postoperative
complications
Also, TAMAI is not explained as abbreviation.
All over the text instead of bariatric surgery, refer as “metabolic bariatric surgery” and use the
abbreviation MBS. This is the IFSO endorsed term. Also, check that all abbreviations in abstract
and text are mentioned in first place and then used. For instance, CT should be mentioned in
the abstract.
- The introduction cannot be published like that. There is no structure or scientific rigor, while
the background provided is not related with the aim of this study.
Introduction should be a text and must not include subsections. Provide information regarding
the current status of metabolic bariatric surgery, the complications and the need for providing
preoperative predictive tools for complications. Are there any similar studies? At the end clearly
provide the aim of the study.
- Results need to be improved in the way the authors present.
- Discussion
In the discussion, in the first paragraph mention your findings and then through the text, compare
your findings with the literature.
2. In the results, you need to provide a table presenting the patient characteristics of the two
groups (complicated vs non-complicated)”
These two groups should be comparable in terms of confounding factors. BMI, smoking, type 2
diabetes, corticosteroids, duration of surgery, left liver lobe size, age, vascular disease, metabolic
syndrome. All these are factors that can increase the chances of postoperative complications. So,
before showing that TAMA or TAMAI are associated with postoperative complications, these
parameters should be adjusted between the two groups.
This is very important because you already have a severely small sample size, with only
14 patients with complications. Therefore, you should make adjustments for these factors,
otherwise there is no value of the study.
3. Another problem is that you include all complications (anastomotic leak, ssi, effusion,
thrombosis) that have different approach for management. Therefore, this limits further the value
of your predictive tool, as it does not specify the type of complication.
4. Mitigate your conclusions, since the sample size is extremely small and there is increased
bias. “… is significantly associated with early post-operative complications in bariatric surgery
patients.” This cannot be reliable when you present only 14 cases.
5. Since, this is a prospective study, were all of these continuous cases? Meaning in the first 30
cases you had 14 patients with complications? Or you have not presented all the cohort and the
patients without complications that were removed? Ideally if it is a prospective study, you should
provide a flowchart of the patients. If it is a retrospective, then you should make amendments
through the text.
MINOR LIMITATIONS – SUGGESTIONS
1. Based on the methods, only patients with SG were included. Then you should change your
title, mentioning “in laparoscopic sleeve gastrectomy” and not “bariatric surgery”. Also, use the
abbreviation LSG for laparoscopic sleeve gastrectomy.
2. In the methods, “Cases included patient who developed early postoperative complications
that occurred within 30 days of surgical intervention.” This is also a inclusion criterion.
3. “Fourteen cases (complicated) where matched against 16 controls with no complications,
making a total of 30 cases.”
This should be at the results
4. Regarding the CT scans, why level lumbar 3 was selected? Is it explained?
Were the radiologists trained and with experience to assess this index?
5. How were postoperative complications defined for the statistical analysis? Were they
dichotomous variables?
6. In the discussion, regarding the complications, mention that anastomotic leakage after SG is
the most feared complication increasing length of stay and morbidity. Add this recent literature
“Verras, Georgios-Ioannis et al. “Risk Factors and Management Approaches for Staple Line
Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients.”
Journal of personalized medicine vol. 13,9 1422. 21 Sep. 2023, doi:10.3390/jpm13091422”
7. Mention also that malnutrition risk assessment tools should be used, to assess sarcopenia
and potentially predict further complications. This combined use of risk tools with the TAMA
index, could further optimize the preoperative status of the patient. Add this recent multicentric
study assessing these tools in surgery “Petra, Georgia et al. “Multicentre prospective study on
the diagnostic and prognostic validity of malnutrition assessment tools in surgery.” The British
journal of surgery vol. 112,2 (2025): znaf013. doi:10.1093/bjs/znaf013”
I am looking forward to receiving the revised and refined version of this manuscript. Address
carefully these comments and acknowledge rigorously all the limitations of the study.