Title: Analysis of the Correlation between Defunctioning Stoma and Postoperative Low
Anterior Resection Syndrome in Rectal Cancer#A prospective cohort study
Version: 4 Date: 14 Aug 2024
Reviewer's report:
Dear Authors
I’ve read your retrospective audit aimed at evaluation of relation between defunctioning  stoma
and LARS among rectal cancer  patients. In general, the study confirm that stoma per se is less
important in terms of LARS than the level of colorectal/anal anastomosis and other confounding
factor. Nevertheless, in my opinion some issues in presented analysis have to be specified.
1. In accordance to obtained results ‘high BMI ‘ was a risk factor of LARS in binary regression
and than in multivariate analysis. What is a definition of ‘high’? Is it a median or mean of  BMI
of the study population? May be another cut-off  point was chosen? Why? Please address in
discussion Is there any explanation why obesity lead to LARS?
2. The same concern about age. In binary regression less/more than age should be provided.
3. More details about anastomosis are needed? E.g. all anastomoses were end-to-end or.. any
pouches, side-to-end etc. “all ISR cases were resected using transanal TME and coloanal
anastomosis (CAA ) or colon-anal (CAAN) was performed for anastomosis” What is a difference
between  coloanal anastomosis (CAA ) or colon-anal (CAAN)?  Also no information about
anastomotic technique is provided, e.g. hand-sewn, stapler etc.
4. An excellent result was demonstrated concerning anastomotic complication, i.e. 0,4%(!) of
leak. (In this context details of anastomotic technique are even more important!). It is far better
than in overwhelming majority of published reports. How can you explain that? May be it is
a result of patient selection before stoma closure? In this context, please provide information
about work up which precede stoma closure? How anastomotic leak was ruled out?
5. Again my concern is about surgical technique. Did you mobilize splenic flexure of colon
routinely? If not, what was the rate of splenic mobilization? There is a sound data that this
surgical maneuver increases LARS.
6. Though information about neo-adjuvant treatment is provided there is no mention about post-
op chemo. About one-third of patients had Stage III-IV and should be administered to systemic
chemotherapy, which also has negative impact to bowel function dew to gastrointestinal toxicity.
Title: Analysis of the Correlation between Defunctioning Stoma and Postoperative Low
Anterior Resection Syndrome in Rectal Cancer#A prospective cohort study
Version: 4 Date: 14 Aug 2024
Reviewer's report:
Dear Authors
I’ve read your retrospective audit aimed at evaluation of relation between defunctioning  stoma
and LARS among rectal cancer  patients. In general, the study confirm that stoma per se is less
important in terms of LARS than the level of colorectal/anal anastomosis and other confounding
factor. Nevertheless, in my opinion some issues in presented analysis have to be specified.
1. In accordance to obtained results ‘high BMI ‘ was a risk factor of LARS in binary regression
and than in multivariate analysis. What is a definition of ‘high’? Is it a median or mean of  BMI
of the study population? May be another cut-off  point was chosen? Why? Please address in
discussion Is there any explanation why obesity lead to LARS?
2. The same concern about age. In binary regression less/more than age should be provided.
3. More details about anastomosis are needed? E.g. all anastomoses were end-to-end or.. any
pouches, side-to-end etc. “all ISR cases were resected using transanal TME and coloanal
anastomosis (CAA ) or colon-anal (CAAN) was performed for anastomosis” What is a difference
between  coloanal anastomosis (CAA ) or colon-anal (CAAN)?  Also no information about
anastomotic technique is provided, e.g. hand-sewn, stapler etc.
4. An excellent result was demonstrated concerning anastomotic complication, i.e. 0,4%(!) of
leak. (In this context details of anastomotic technique are even more important!). It is far better
than in overwhelming majority of published reports. How can you explain that? May be it is
a result of patient selection before stoma closure? In this context, please provide information
about work up which precede stoma closure? How anastomotic leak was ruled out?
5. Again my concern is about surgical technique. Did you mobilize splenic flexure of colon
routinely? If not, what was the rate of splenic mobilization? There is a sound data that this
surgical maneuver increases LARS.
6. Though information about neo-adjuvant treatment is provided there is no mention about post-
op chemo. About one-third of patients had Stage III-IV and should be administered to systemic
chemotherapy, which also has negative impact to bowel function dew to gastrointestinal toxicity.
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: 4 Date: 14 Aug 2024
Reviewer's report:
Dear Authors
I’ve read your retrospective audit aimed at evaluation of relation between defunctioning  stoma
and LARS among rectal cancer  patients. In general, the study confirm that stoma per se is less
important in terms of LARS than the level of colorectal/anal anastomosis and other confounding
factor. Nevertheless, in my opinion some issues in presented analysis have to be specified.
1. In accordance to obtained results ‘high BMI ‘ was a risk factor of LARS in binary regression
and than in multivariate analysis. What is a definition of ‘high’? Is it a median or mean of  BMI
of the study population? May be another cut-off  point was chosen? Why? Please address in
discussion Is there any explanation why obesity lead to LARS?
2. The same concern about age. In binary regression less/more than age should be provided.
3. More details about anastomosis are needed? E.g. all anastomoses were end-to-end or.. any
pouches, side-to-end etc. “all ISR cases were resected using transanal TME and coloanal
anastomosis (CAA ) or colon-anal (CAAN) was performed for anastomosis” What is a difference
between  coloanal anastomosis (CAA ) or colon-anal (CAAN)?  Also no information about
anastomotic technique is provided, e.g. hand-sewn, stapler etc.
4. An excellent result was demonstrated concerning anastomotic complication, i.e. 0,4%(!) of
leak. (In this context details of anastomotic technique are even more important!). It is far better
than in overwhelming majority of published reports. How can you explain that? May be it is
a result of patient selection before stoma closure? In this context, please provide information
about work up which precede stoma closure? How anastomotic leak was ruled out?
5. Again my concern is about surgical technique. Did you mobilize splenic flexure of colon
routinely? If not, what was the rate of splenic mobilization? There is a sound data that this
surgical maneuver increases LARS.
6. Though information about neo-adjuvant treatment is provided there is no mention about post-
op chemo. About one-third of patients had Stage III-IV and should be administered to systemic
chemotherapy, which also has negative impact to bowel function dew to gastrointestinal toxicity.
assistant