Dear Editor, We have reviewed the article by Carandina et al1, which provides valuable clinical evidence for salvage surgery following failed sleeve gastrectomy and is most impressive. Through extensive data analysis, the authors illustrate the significant effectiveness of single anastomosis sleeve ileal bypass (SASIB) in mid-term weight loss and improvement of metabolic obesity-related comorbidities. This preliminary investigation establishes a robust basis for future research in this area. Nonetheless, being an observational study, it possesses methodological aspects that require thorough consideration. Here, we outline the following key observations to enhance scholarly discussion. First, concerning retrospective design bias, the study’s dependence on historical data without a control group limits the ability to control for confounding variables (e.g., variations in patient baseline characteristics or surgical timing) and undermines the accuracy of results. We suggest that the authors, in their revision, incorporate thorough explanations of bias mitigation strategies – like multivariate adjustment or sensitivity analyses – to assess the influence of potential biases. Moreover, clearly delineating the patient screening procedures and ensuring consistent application of inclusion/exclusion criteria will bolster the study’s transparency and internal validity. Additionally, other studies have also highlighted the need to be mindful of methodological limitations in single anastomosis sleeve ileal (SASI) surgical assessments2,3. Secondly, concerning the insufficient sample size, the cohort of 44 patients may not adequately represent the diversity of surgical complications (e.g., an 11.3% incidence of gastroesophageal reflux disease within this cohort) or the range of metabolic improvements4,5. We recommend that the authors enhance the methodology section by providing a justification for the sample size calculation. This should include a statistical power analysis based on primary outcome measures, such as percent total weight loss, and an evaluation of the current sample’s ability to detect significant differences. In future studies, if possible, increasing sample sizes through collaboration across multiple centers is advised to enhance the robustness and generalizability of the results. As some studies4,6 indicate, small samples may overestimate or underestimate risks. Last, regarding follow-up duration, while 24-month data provide valuable insights into intermediate-term efficacy, extended observation periods may further facilitate the assessment of weight maintenance, metabolic stability, and changes in nutritional status3,4. Incorporating follow-up data spanning 5 years in future studies, supplemented by patient-reported outcomes such as quality-of-life questionnaires, would more comprehensively reflect the long-term benefits and risks of SASI surgery5,7. We recommend that the authors elaborate on this point in their discussion to facilitate ongoing exploration of the long-term safety and efficacy of this procedure. In conclusion, this study provides a valuable reference for the clinical utilization of SASIB and illustrates significant clinical relevance. Nevertheless, addressing limitations concerning bias control, sample size, and follow-up duration is imperative. Improving these facets will significantly bolster the scientific rigor of the research. We contend that these enhancements will not only fortify the scientific and clinical merit of the study but also furnish more dependable evidence for evidence-based decision-making in bariatric surgery, thereby propelling research in this field toward elevated quality benchmarks. This correspondence was conducted without using artificial intelligence tools in accordance with the TITAN Guidelines 20258.
Liu et al. (Wed,) studied this question.