Review for 10.1186/s12876-025-03729-x (2025)

Title: A prospective randomized study of the efficacy of continuous active warming in patients
undergoing laparoscopic gastrectomy
Version: 4 Date: 06 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the sample size is based on prior observational data, a clearer explanation of the power
analysis would help justify the study's statistical rigor. It would be helpful to see the exact
calculations for alpha, power, and expected effect size in the context of detecting differences in
temperature between the two groups.
-While randomization is mentioned, further detail on the randomization process would be
beneficial. Specifically, it would be helpful to know how patients were assigned to the two
groups (e.g., using a random number generator, or blocked randomization). Additionally, while
patients are blinded, it would be useful to confirm whether the surgical staff and outcome
assessors were also blinded to group assignment to prevent bias in the intervention or outcome
assessment.
-The bladder temperature is used as a proxy for core temperature. While bladder temperature is
commonly used, a brief justification for using this method, including its accuracy and potential
limitations in reflecting core temperature, would improve the study’s transparency. Furthermore,
explaining the use of a specific catheter type (No. 14 urethral catheter) could help replicate the
process in other settings.
-The temperature settings for the heating machines (44°C) and the stopping criteria (37.5°C)
are provided for the CAW group. However, a more detailed description of the specific devices
used for warming (e.g., the thermal blanket and its technical characteristics) would increase the
reproducibility and transparency of the intervention.
-The study mentions that patients will be transferred to the Post-Anesthesia Care Unit (PACU)
after surgery, but more detail on the postoperative care protocol—specifically, how temperature
is monitored postoperatively and how shivering or other complications are addressed—would
add value to the protocol.
-The description of the three stages of temperature reduction (Redistribution Period, Linear
Reduction Period, and Plateau Period) is important but could benefit from more detail or
clarification. For example, it would help to explain why the core temperature stabilizes during
the Plateau Period despite continuing heat loss in the other stages.
-Additionally, a diagram or figure summarizing these stages could be helpful to enhance
understanding for readers who are not familiar with the terminology.
-The comparison with some studies, such as those by Reynolds et al. [28] and Persson et al.
[31], is insightful but could benefit from a clearer explanation of why certain differences in
outcomes were observed between studies. For example, the authors state that Luke Reynolds et
al. found a significant association between hypothermia and wound infection, but the authors
did not find such an association. An exploration of potential reasons for this discrepancy, such
as differences in patient demographics, surgical techniques, or statistical methods, would make
the comparison more meaningful.