Outcomes before and after Implementation of the ERAS (Enhanced Recovery after Surgery) Protocol in Open and Laparoscopic Colorectal Surgery: A Comparative Real-World Study from Northern Italy

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The authors responded sufficiently to the points raised by the reviewer and the manuscript has largely improved.

There some minor points that need attention in the revised manuscript:

Line 163, rectus instead of rectum

Line 168, Hysterectomy instead of isterectomy

Table 1, Oral Macrogol assumption instead of consumption and Laparoscopy surgery instead of Laparoscopic surgery

Line 263, please remove “pulmonary thromboembolism”

Line 276, drainage instead of drenage

Lines 271-289, some editing is needed for proper language use and expressions

Comments on the Quality of English Language

Some language polishing is needed

Author Response

Thank you very much for the comments, we have corrected what you requested. Best regards, Isabella Bisceglia

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Questions are well answered.

Author Response

Thank you very much!

Best regards,

Isabella Bisceglia

Reviewer 3 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

I thank the authors to have made changes  according to  suggestions 

Author Response

Thank you very much! 

Best regards,

Isabella Bisceglia

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

There are several points of criticism on this manuscript:

1) The title of the manuscript should be accurate. It states ERAS in CRC management through laparoscopic surgery but from the materials and methods and the results it is apparent that both open and laparoscopic surgeries were used.

2) Results section

In the results section, the authors present lower proportion of male patients, higher incidence of ASA 3, more frequent tumor location in the descending colon, higher proportion for stage I tumors and increased number stage IV tumors during 2023 as compared to 2022. However, in Table 2 there are no statistical differences regarding these variables. The same applies to the proportions of neoadjuvant chemotherapy and radiotherapy. The absence of differences should be clear in the text.

The presentation of data from Tables S1 and S2 should be also comparative and critically presented in the results section of the manuscript.

Again data for postoperative outcome variables should be clearly presented and make sure that only postoperative hospital stay was significantly longer in the ERAS group (Table 3).

The same applies for reporting data of Table 4. Statistical significance should be also given.

3) Discussion

The statements “reduced postoperative pain and faster recovery” (discussion, lines 215-216) are not valid. There are no results on pain intensity/analgesic consumption or recovery time. The same applies for “pulmonary thromboembolism” (lines 241 and 248).

The statement “Our experience has revealed a notable …” (lines 285-280) is not supported by the findings of the study.

4) Conclusions

The conclusions should be based on the actual findings of the study.

5) Tables and Figures

The y-axis in Figure 1, presumably refers to the number of surgeries performed each month. Please clarify.

Pay also attention to the caption of Figure 1 to be more precise.

The title of Table 2 should be more inclusive of the presented variables.

Give MBP in full (lines 262, 266, 267).

6) Other comments

Please pay attention and correct: oral Macrogol Assumption, Laparoscopic tecnique, ketoralc in Table 1, and pneumatological complications, (line  276).

Comments on the Quality of English Language

Included in the comments to the authors

Author Response

Please see attached.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Major points

1) Table 4 and Table S3; Severe complications corresponding to Clavien-Dindo III and V will nearly double in 2023 compared to 2022. In terms of complications in 2023, three out of seven cases are bleeding related. Without discussing this, it cannot be suggested that ``ERAS protocol could effectively mitigate the adverse effects of surgery and promote faster recovery'' (page 9, second paragraph).

2) Table l, Urinary catheter removal; Both 2022 and 2023 include more than 20 cases of rectal cancer surgery. Is it appropriate to use the ERAS protocol to remove the urinary catheter immediately after awakening or on POD1 in cases of rectal cancer surgery?

Minor point

3) Table 1, Postoperative phase; Line break in right column is incorrect

Author Response

Please see attached. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for permitting me to review  this manuscript 

In this before and  study the authors compared  a series of patients  in colorectal  cancer surgery   after the start   of the   ERAS protocol

I have some concern for the statistics  ,  beside the low numer of patients as a simple t test was used to compare data , propensity score matching in this study could have been performed  , to better select patients , however if this method was not appropriate , some explanation could help the reader .

Secondly, our study revealed that despite treating a greater number of patients with an unfavorable prognosis in 2023, including more ASA 3 cases classifications, advanced stages, and older age, the activation of the ERAS procedure led to fewer complications and shorter hospital stays, suggesting that ERAS protocol could effectively mitigate the adverse effects of surgery and promote faster recovery, even in patients with more complex medical profiles. 

Although this paragraph is part of the discussion  ? I believe the results do not permit to be so optimistic mainly because of lack of power and therefore this  need to be rewritten .

same as the conclusion which need to be mitigateed in accordance to the results which are not cutting clear

Author Response

Please see attached.

Author Response File: Author Response.pdf