Title: Analysis of the Correlation between Defunctioning Stoma and Postoperative Low
Anterior Resection Syndrome in Rectal Cancer#A prospective cohort study
Version: 2 Date: 07 Jul 2024
Reviewer's report:
This is an interesting paper, reporting risk factors for low anterior resection syndrome (LARS),
especially focusing on defunctioning stoma.
I should be grateful if could answer my comments shown below.
Major comments:
1.  Although it is claimed that defunctioning stoma was not an independent risk factor for LARS
as one of main results of this study, it is not demonstrated by binary logistic regression analysis.
It is certainly a risk factor for LARS, as is demonstrated by the univariate analysis in Table 3.
However, it might not be an independent risk factor due to other confounding factors. I agree
at your discussion that “Univariate analyses yielded that defunctioning stoma may be a risk
factor for LARS mainly due to other confounding factors. In a study by Croese AD, et al., it
was stated that the increased risk of LARS in patients with defunctioning stoma was not due to
the stoma per se, but to the underlying cause of the stoma.” However, to claim this, it must be
demonstrated by binary logistic regression analysis or multivariate analysis. No such data are
presented in this study.
2. It is also claimed that high BMI, tumor closer to dentate line, and ultra-low anterior resection
were independent risk factors for LARS. However, they are only demonstrated in the data at
3 months after surgery in Table 4 (their p values are less than 0.05), and not demonstrated in
the data at 6 months after surgery in Table 5, in which p value for BMI, distance from tumor
to dentate line and ULAR is 0.693, 0.136, and 0.110, respectively. At 12 months after surgery,
only tumor closer to dentate line is an independent risk factors for LARS according to Table 6.
These discrepancies should be stated in Results and summarized in Abstract.
Minor comment
1. The words of “urination urgency” in Abstract and in page 4 should be changed to “fecal
urgency”.
2. It is stated in page 5 as Methods that “In this study, a total of 190 patients received
neoadjuvant therapy, of which 4 (2.1%) patients opted for intermediate/long course neoadjuvant
chemotherapy combined with neoadjuvant radiotherapy, 46 (24.2%) patients opted for short
course neoadjuvant chemotherapy (1-2 cycles), 100 (52.6%) patients opted for intermediate
course neoadjuvant chemotherapy (3-4 cycles), 43 (22.6%) patients opted for long course
neoadjuvant chemotherapy (#5 cycles), and only 1 (0.5%) patient opted for short course
neoadjuvant radiotherapy (1 cycle).” However, these are not methods but one of results of this
study, and should be stated in Results.
3. The word of “mild LARS (21-29 points), and severe LARS (30-42 points)” stated in page 6
should be changed to “minor LARS (21-29 points), and major LARS (30-42 points)” as is used
in the original LARS paper.
Title: Analysis of the Correlation between Defunctioning Stoma and Postoperative Low
Anterior Resection Syndrome in Rectal Cancer#A prospective cohort study
Version: 2 Date: 07 Jul 2024
Reviewer's report:
This is an interesting paper, reporting risk factors for low anterior resection syndrome (LARS),
especially focusing on defunctioning stoma.
I should be grateful if could answer my comments shown below.
Major comments:
1.  Although it is claimed that defunctioning stoma was not an independent risk factor for LARS
as one of main results of this study, it is not demonstrated by binary logistic regression analysis.
It is certainly a risk factor for LARS, as is demonstrated by the univariate analysis in Table 3.
However, it might not be an independent risk factor due to other confounding factors. I agree
at your discussion that “Univariate analyses yielded that defunctioning stoma may be a risk
factor for LARS mainly due to other confounding factors. In a study by Croese AD, et al., it
was stated that the increased risk of LARS in patients with defunctioning stoma was not due to
the stoma per se, but to the underlying cause of the stoma.” However, to claim this, it must be
demonstrated by binary logistic regression analysis or multivariate analysis. No such data are
presented in this study.
2. It is also claimed that high BMI, tumor closer to dentate line, and ultra-low anterior resection
were independent risk factors for LARS. However, they are only demonstrated in the data at
3 months after surgery in Table 4 (their p values are less than 0.05), and not demonstrated in
the data at 6 months after surgery in Table 5, in which p value for BMI, distance from tumor
to dentate line and ULAR is 0.693, 0.136, and 0.110, respectively. At 12 months after surgery,
only tumor closer to dentate line is an independent risk factors for LARS according to Table 6.
These discrepancies should be stated in Results and summarized in Abstract.
Minor comment
1. The words of “urination urgency” in Abstract and in page 4 should be changed to “fecal
urgency”.
2. It is stated in page 5 as Methods that “In this study, a total of 190 patients received
neoadjuvant therapy, of which 4 (2.1%) patients opted for intermediate/long course neoadjuvant
chemotherapy combined with neoadjuvant radiotherapy, 46 (24.2%) patients opted for short
course neoadjuvant chemotherapy (1-2 cycles), 100 (52.6%) patients opted for intermediate
course neoadjuvant chemotherapy (3-4 cycles), 43 (22.6%) patients opted for long course
neoadjuvant chemotherapy (#5 cycles), and only 1 (0.5%) patient opted for short course
neoadjuvant radiotherapy (1 cycle).” However, these are not methods but one of results of this
study, and should be stated in Results.
3. The word of “mild LARS (21-29 points), and severe LARS (30-42 points)” stated in page 6
should be changed to “minor LARS (21-29 points), and major LARS (30-42 points)” as is used
in the original LARS paper.
Please review this paper.
user
Title: Analysis of the Correlation between Defunctioning Stoma and Postoperative Low
Anterior Resection Syndrome in Rectal Cancer#A prospective cohort study
Version: 2 Date: 07 Jul 2024
Reviewer's report:
This is an interesting paper, reporting risk factors for low anterior resection syndrome (LARS),
especially focusing on defunctioning stoma.
I should be grateful if could answer my comments shown below.
Major comments:
1.  Although it is claimed that defunctioning stoma was not an independent risk factor for LARS
as one of main results of this study, it is not demonstrated by binary logistic regression analysis.
It is certainly a risk factor for LARS, as is demonstrated by the univariate analysis in Table 3.
However, it might not be an independent risk factor due to other confounding factors. I agree
at your discussion that “Univariate analyses yielded that defunctioning stoma may be a risk
factor for LARS mainly due to other confounding factors. In a study by Croese AD, et al., it
was stated that the increased risk of LARS in patients with defunctioning stoma was not due to
the stoma per se, but to the underlying cause of the stoma.” However, to claim this, it must be
demonstrated by binary logistic regression analysis or multivariate analysis. No such data are
presented in this study.
2. It is also claimed that high BMI, tumor closer to dentate line, and ultra-low anterior resection
were independent risk factors for LARS. However, they are only demonstrated in the data at
3 months after surgery in Table 4 (their p values are less than 0.05), and not demonstrated in
the data at 6 months after surgery in Table 5, in which p value for BMI, distance from tumor
to dentate line and ULAR is 0.693, 0.136, and 0.110, respectively. At 12 months after surgery,
only tumor closer to dentate line is an independent risk factors for LARS according to Table 6.
These discrepancies should be stated in Results and summarized in Abstract.
Minor comment
1. The words of “urination urgency” in Abstract and in page 4 should be changed to “fecal
urgency”.
2. It is stated in page 5 as Methods that “In this study, a total of 190 patients received
neoadjuvant therapy, of which 4 (2.1%) patients opted for intermediate/long course neoadjuvant
chemotherapy combined with neoadjuvant radiotherapy, 46 (24.2%) patients opted for short
course neoadjuvant chemotherapy (1-2 cycles), 100 (52.6%) patients opted for intermediate
course neoadjuvant chemotherapy (3-4 cycles), 43 (22.6%) patients opted for long course
neoadjuvant chemotherapy (#5 cycles), and only 1 (0.5%) patient opted for short course
neoadjuvant radiotherapy (1 cycle).” However, these are not methods but one of results of this
study, and should be stated in Results.
3. The word of “mild LARS (21-29 points), and severe LARS (30-42 points)” stated in page 6
should be changed to “minor LARS (21-29 points), and major LARS (30-42 points)” as is used
in the original LARS paper.
assistant