Title: Risk Factors for Perioperative Blood Transfusion in Patients Undergoing Total
Laparoscopic Hysterectomy
Version: 2 Date: 29 Nov 2023
Reviewer:  Phuc Nhon Nguyen
Reviewer's report:
Dear authors,
Thank you for the insight paper. The study has addressed some factors in relation to
perioperatibve blood transfusion in laparoscopic total hysterectomy with large number of
patients. After reading carefully the manuscript, I suggest some points needed to be revised as
below:
- Laparoscopic total hysterectomy (LTH) is importantly operative technique in this research.
LTH should be described in “materials and  methods” section.
- Some variables needed to be defined in Table 1.
- The bed size of hospital (small, medium, large) should be replaced by type of room/prize of
room. It’s difficult to understand the meaning of this variable.
- Type of insure needed to be defined. The readers can not differentiate medicare with medicaid.
-Please explain the type of elective admission. Did the authors mean that “no transfusion” in
planned surgery group is significantly greater than “transfusion” in scheduled surgery group
which is different from the emergency surgery? The term should be reflected.
-Why the “transfusion” case related significantly to type of teaching hospital compared to “no
transfusion” (Table 1) ? Please discuss more about it.
- In Table 2, location of hospital variable is necessary. But, region of hospital is unnecessary.
- Please include the number of death patient (n) along with percentage (%). The number is easier
to understand.
- The estimated blood loss and blood transfusion is necessary to describe the measurement
method and the mean/median value. Unfortunately, the data is missed as the authors mentioned
in limitations.
- Please include the duration time of surgery in both groups of Table 2. Moreover, some surgical
indications (endometrial cancer, abnormal uterine bleeding, uterine intracavitary pathologies,
etc) relating to LTH should be included. Similarly, the uterine size and fibroid size (by surgical
evaluation/ultrasound findings) could be revealed.
- Regardless of Fig 2, I see that the incidence of transfusion in 2019 is greater than that of
previous years. Meanwhile, 2019 was associated with the COVID-19 pandemic, thus, the blood
donation in blood bank may be decreased. Similarly, in the first paragraph of discussion, besides
the issue of ICD code, could you please explain why the authors mentioned that ”It is worth
noting that the rate of blood transfusion showed a gradual rise over the years”.
-In Fig 3, why the “self-pay/medicare” related to more transfusion than “no charge/medicare”?
The transfusion is associated with medical indication or by the patient requirement?
-In Figure 4, some preoperative factors such as chronic blood loss anemia, deficiency anemia,
metastatic cancer, and coagulopathy are surely related to perioperative blood transfusion
following LTH. I thought that these factors do not contribute to the literature in this study. The
Fig 4 should described as the baseline characteristic of the study population instead of related
factors (OR).
- The factors related to comorbidities and complications in blood transfusion were present in all
patient data in study? Since I see so many medical diseases were well recorded. The analysis
did not include missing value?
-In Fig 5, why OR of sepsis was greater significantly than that of wound infection? Did the
sepsis appear before wound infection and later?
- Figure 5 should include additionally the variables following the early complication and long-
term outcomes since medical/surgical complications may be all factors related to LTH.
- The discussion is not well written. More data and the different results of the similar studies
should be added to compare with the finding results.
- The typing errors and English editing are required. For example, the third paragraph in
discussion, “Patients with fliud and electrolyte disorders, metastatic cancer, renal failure, or
weight loss carry the highest risks of requiring transfusions probably due to the iron deficiency
anemia, vitamin deficiency anemia (B12 or folic acid), protein deficiency anemia, nutrient loss
or anemia of chronic disease.”
- Conclusion needed to be more clarified. “Women with higher chances of needing a
perioperative blood transfusion, as determined by the factors mentioned above, should receive
appropriate counseling and sufficient preparation for surgery.” The authors must refer to detailed
factors. The readers may not read the entire paper to understand which factors mentioned above.
Best regards,