Enhanced recovery programmes versus conventional care in bariatric surgery: A systematic literature review and meta-analysis

Khalid Al-Rubeaan; Cindy Tong; Hannah Taylor; Karl Miller; Thao Nguyen Phan Thanh; Christian Ridley; Sara Steeves; William Marsh

doi:10.1371/journal.pone.0243096

Peer Review History

Original SubmissionJune 5, 2020
10 Aug 2020 Decision Letter - Ahmed Negida, Editor PONE-D-20-17131 Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis PLOS ONE Dear Dr. Steeves, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 24 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Ahmed Negida, MD Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following in the Competing Interests section: "I have read the journal's policy and the authors of this manuscript have the following competing interests: CT, HT, KM and TN: Employees of Johnson & Johnson KA: Employee of Sultan Bin Abdulaziz Humanitarian City at the time this study was conducted, and paid consultant for Johnson & Johnson CR, SS and WM: Employees of Costello Medical at the time this study was conducted and have served as paid consultants for Johnson & Johnson" We note that one or more of the authors have an affiliation to the commercial funders of this research study : Johnson & Johnson Medical NV. We also note that one or more of the authors are employed by a commercial company: Costello Medical Consulting Limited. 2.1. Please provide an amended Funding Statement declaring these commercial affiliations, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form. Please also include the following statement within your amended Funding Statement. “The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.” If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement. 2.2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc. Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If this adherence statement is not accurate and there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests 3. Please include captions for figure 4 and 5. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. We note that this manuscript is a systematic review or meta-analysis; our author guidelines therefore require that you use PRISMA guidance to help improve reporting quality of this type of study. Please upload copies of the completed PRISMA checklist as Supporting Information with a file name “PRISMA checklist”. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No Reviewer #4: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This meta-analysis aims to assess the utility of enhanced recovery programs (ERAS) following bariatric surgery. Bariatric surgery is indicated in certain cases of type 2 diabetes and metabolic syndrome, and enhanced recovery programs may play a critical role in improving the post-operative experience of the patient. Given the degree of importance & prevalence of the aforementioned conditions, the authors’ choice of topic is strongly commended. There are already two recent meta analyses covering this topic by Malczak and Ahmed et al. published in 2017 and 2018 respectively. The present review corroborates the findings of the previous two meta-analyses, though it does not add a significant novel finding of its own, with all 3 reviews finding a significant reduction in hospitalization duration but non-significant differences with respect to complications/readmission rate. The authors state that the novel aspect of this review is that it aims to stratify by type of bariatric procedure; unfortunately, the only procedure for which multiple (six) studies were available was Roux-en-Y bypass, and was thus the only procedure to undergo meta-analysis. The other two procedures (sleeve gastrectomy and one anastomosis gastric bypass) each had one study and were not further discussed in the manuscript as per the authors. Given the existing limitation within the literature, the primary promise of the meta-analysis (investigating the effect of recovery programs stratified by type of procedure) could not be achieved. I believe the quality of the methods section, and therefore of the review as a whole, would improve by addressing the following points: • The authors referenced the paper by Hozo et al. in estimating the SD from the range (Range / 6); however, they did not clarify the sample sizes to which this formula would be applied, as it was recommended by Hozo et al. in cases where N > 70. I believe the manuscript would benefit from an increased degree of clarity if the authors were to clarify this. • The authors state that they used the median as an estimate for mean values in some studies. It would be ideal if the authors were to specify exactly which studies used the median as well as conduct a sensitivity analysis excluding said studies. This is because the median may have been used by the authors of the original studies because of a skewed -rather than normal- distribution of data; therefore, simply replacing it by the mean may not be appropriately representative of the study’s results. This is especially likely to be an issue if included studies had a small sample size. Conducting a sensitivity analysis will likely improve the robustness of the findings and improve the overall quality of the manuscript. • One concern is the focus on studies conducted in Europe, the Middle East and Africa while excluding non-English studies. Due to the linguistic variation in the aforementioned regions, this may well be a significant limitation in the findings of the review (though this limitation is acknowledged by the reviewers). Had the language restriction been removed, this may have aided the authors in finding a sufficient number of studies to perform a meta-analysis for the other two procedures (though this is difficult to ascertain since the PRISMA diagram does not specify the number of studies excluded due to the English-only limitation). If it is possible to retrieve such studies, I believe this would enhance the credibility of the review. • Though standardized checklists are often modified to fit the purposes of each individual review, it would probably be beneficial if the authors were to clarify what modifications were done to the Downs and Blacks checklist, as this may impact the quality assessment of the included studies and quell any concerns other reviewers may have. • The study is otherwise well-written and structured, and the PRISMA diagram is especially well-done. Two previous meta-analyses: 1. Ahmed OS, Rogers AC, Bolger JC, Mastrosimone A, Robb WB. Meta-analysis of enhanced recovery protocols in bariatric surgery. J Gastrointest Surg. 2018;22(6):964-972. 2. Małczak P, Pisarska M, Piotr M, Wysocki M, Budzynski A, Pedziwiatr M. Enhanced Recovery after Bariatric Surgery: Systematic Review and Meta-Analysis. Obes Surg. 2017;27(1):226-235. Epub 2016/11/07. doi: 10.1007/s11695-016-2438- z. PubMed PMID: 27817086; PubMed Central PMCID: PMCPMC5187372. Reviewer #2: This is a systematic review and meta-analysis in which the authors compare the efficacy of Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery. This is considered an updated review which supports the enhanced recovery programmes which allow shorter hospital stay. Although the study is inconclusive, it enhances the future research to fill the current data gaps. The manuscript is well-written and structure and the quality of research is scientifically sound. Reviewer #3: The authors performed a systematic review with meta-analysis to evaluate the effects of enhanced recovery programmes after three common bariatric procedures: laparoscopic Roux en-Y gastric bypass, laparoscopic sleeve gastrectomy, and one anastomosis gastric bypass. Although the overall approach to the review is proper, I have few comments: 1. Abstract - Replace (Method) with (Methods). Also, replace (papers) with (studies). - Insert the software used for analysis. - Insert the total number of included patients. - P-values should be reported. 2. Introduction - Line 65: insert citation for the previous meta-analyses, and highlight the unique data reported in this systematic review as well as any controversies. 3. Methods - The databases were searched up to 2019; please consider updating it. - Insert the software used for analysis. 4. Results - line 141: insert reference of the included studies. - Line 174-176: mention that the sensitivity analysis did not resolve the heterogeneity. Was the subgroup analysis performed? 5. Language: The entire manuscript needs professional revision for grammatical errors and stylistic editing. For example, - Line 2: (it is likely the demand), Squinting modifier!! - Line 4: (XX and more efficient use) & (XX and one anastomosis gastric), insert a comma before (and). - Line 15: (outcomes, however as) should be (outcomes; however, as). - (Meta-analysis revealed), consider adding an article (The). - Line 48, 51, etc.: The comma before the reference number should be replaced with a dot. Reviewer #4: Review of the manuscript “Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis” Since the end of the 90s of the last century, there have been many reports describing a method defined as ERPs. The strategy of fast track gathers various elements of perioperative procedure. It takes into account the pathophysiology of operation injury and eliminates surgery procedures that are not justified in the perspective of evidence-based medicine. Optimal preparation of a patient for the operation connected with oral and written information about the surgical procedure and postoperative course, early feeding and rehabilitation on the day of surgery and optimal pain control make up the most important elements of pre- and post-operative procedures based on fast track surgery. The intraoperative factors include minimal-access surgery, thoracic epidural anesthesia and no routine use of nasogastric tube and abdominal drains. The effect of such a procedure is a decrease of postoperative complications, improvement of patient’s comfort and satisfaction, and shortening of hospital stay, and at the same time, reduction of hospitalization costs. The authors presented systematic literature review aimed to evaluate the effects of enhanced recovery programmes after LRYGB. The results can be drawn that using ERP in the obese patients qualified to LRYGB shortens length of hospital stay. The study design is clear and well described. The used methods are generally acceptable. The topic of article is interesting, methods of the study are presented concisely. My remarks: 1. In figure 2 authors characterised of ERP implementation for included studies. Analysis of fig 2 suggest that data about important elements of ER programme are unable to determine in most analysed articles. It is difficult to compare the results precisely since the trials applied variable protocols of enhanced recovery programs and each study assumed various final points. In my opinion it should be cleary described and highlights in the manuscript. 2. Although we have an access to a few study on ERPs, it is difficult to prove, in an unambiguous manner, an advantage of one of the methods. It seems that relaying on the presented results, a conclusion can be drawn that using ERPs shortens length of hospital stay, but further RCTs study are necessary. Authors concluded that “…results of this review support the use of ERPs in terms of faster time to discharge…”. What was criteria of discharging a patient from hospital in analyzed study? There are same or differ in these study, it can impacts of obtained results. 3.References should be checked according to submission guidelines ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: No Reviewer #4: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: REVIEW.docx https://doi.org/10.1371/journal.pone.0243096.r001
Revision 1
21 Sep 2020 Author Response We thank the reviewers for their helpful feedback on the manuscript. Below are the changes we have made to address their comments. Please note that line numbers refer to the ‘Track Changes’ version of the manuscript. Reviewer #1: COMMENT - The authors referenced the paper by Hozo et al. in estimating the SD from the range (Range / 6); however, they did not clarify the sample sizes to which this formula would be applied, as it was recommended by Hozo et al. in cases where N > 70. I believe the manuscript would benefit from an increased degree of clarity if the authors were to clarify this. RESPONSE - Thank you, we have clarified that the N>70 version was applicable to the studies included in the analysis. [L137-139] COMMENT - The authors state that they used the median as an estimate for mean values in some studies. It would be ideal if the authors were to specify exactly which studies used the median as well as conduct a sensitivity analysis excluding said studies. This is because the median may have been used by the authors of the original studies because of a skewed -rather than normal- distribution of data; therefore, simply replacing it by the mean may not be appropriately representative of the study’s results. This is especially likely to be an issue if included studies had a small sample size. Conducting a sensitivity analysis will likely improve the robustness of the findings and improve the overall quality of the manuscript. RESPONSE - Thank you for these suggestions. We have added citations for the studies where the mean and standard deviation needed to be estimated to the Methods section. A sensitivity analysis excluding these studies has also been performed and is included as Supplementary Figure 1; the results are the same as the primary analysis including all studies. [L140-141] COMMENT - One concern is the focus on studies conducted in Europe, the Middle East and Africa while excluding non-English studies. Due to the linguistic variation in the aforementioned regions, this may well be a significant limitation in the findings of the review (though this limitation is acknowledged by the reviewers). Had the language restriction been removed, this may have aided the authors in finding a sufficient number of studies to perform a meta-analysis for the other two procedures (though this is difficult to ascertain since the PRISMA diagram does not specify the number of studies excluded due to the English-only limitation). If it is possible to retrieve such studies, I believe this would enhance the credibility of the review. RESPONSE - Thank you for raising this. The review included publications in any European language rather than using an English language limit, which we have clarified in the Methods section. No articles were ultimately excluded as a result of the language limit however, which we have now mentioned in the Discussion section. [L109-114; L303-305] COMMENT - Though standardized checklists are often modified to fit the purposes of each individual review, it would probably be beneficial if the authors were to clarify what modifications were done to the Downs and Blacks checklist, as this may impact the quality assessment of the included studies and quell any concerns other reviewers may have. RESPONSE - Thank you for this suggestion. We have added more information about how the checklist was modified to the Methods section and included the modified version of the checklist as Supplementary Table 9. [L126-128] COMMENT - The study is otherwise well-written and structured, and the PRISMA diagram is especially well-done. RESPONSE - We thank the reviewer for their feedback. Reviewer #2: COMMENT - This is a systematic review and meta-analysis in which the authors compare the efficacy of Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery. This is considered an updated review which supports the enhanced recovery programmes which allow shorter hospital stay. Although the study is inconclusive, it enhances the future research to fill the current data gaps. The manuscript is well-written and structure and the quality of research is scientifically sound. RESPONSE - We thank the reviewer for their feedback. Reviewer #3: COMMENT - Replace (Method) with (Methods). Also, replace (papers) with (studies). RESPONSE - Thank you, these changes have been made [L9-10] COMMENT - Insert the software used for analysis. RESPONSE - We have added that analyses were conducted in R [L14] COMMENT - Insert the total number of included patients. RESPONSE - We have added this information [L15-17] COMMENT - P-values should be reported. RESPONSE - We have added this information [L21-24] COMMENT - Line 65: insert citation for the previous meta-analyses, and highlight the unique data reported in this systematic review as well as any controversies. RESPONSE - Thank you for this suggestion, we have added the citations to this sentence and provided the rationale for conducting a new review in the context of these previous meta-analyses. [L68-69] COMMENT - The databases were searched up to 2019; please consider updating it. RESPONSE - Thank you for this suggestion. We have conducted targeted searches over the past year and do not believe that any major new data that would change the review’s conclusions have been published since the searches were last updated. COMMENT - Insert the software used for analysis. RESPONSE - We have added that analyses were conducted in R [L136] COMMENT - line 141: insert reference of the included studies. RESPONSE - We have added the citations COMMENT - Line 174-176: mention that the sensitivity analysis did not resolve the heterogeneity. Was the subgroup analysis performed? RESPONSE - We have added that the high level of heterogeneity remained in the sensitivity analysis. No subgroup analyses beyond the sensitivity analyses described in the Methods section were performed, and all results of the sensitivity analyses are reported in full in the Supplementary material (Figures S1-S3). [L188] COMMENT - Line 2: (it is likely the demand), Squinting modifier!! RESPONSE - We have removed this from the abstract [L2] COMMENT - Line 4: (XX and more efficient use) & (XX and one anastomosis gastric), insert a comma before (and). RESPONSE - We have added commas in these places [L4-7] COMMENT - Line 15: (outcomes, however as) should be (outcomes; however, as). RESPONSE - We have made this change [L17] COMMENT - (Meta-analysis revealed), consider adding an article (The). RESPONSE - We have made this change [L19] COMMENT - Line 48, 51, etc.: The comma before the reference number should be replaced with a dot. RESPONSE - We have moved all references in the manuscript to the end of the sentences they are in. Reviewer #4: COMMENT - In figure 2 authors characterised of ERP implementation for included studies. Analysis of fig 2 suggest that data about important elements of ER programme are unable to determine in most analysed articles. It is difficult to compare the results precisely since the trials applied variable protocols of enhanced recovery programs and each study assumed various final points. In my opinion it should be cleary described and highlights in the manuscript. RESPONSE - We have added further details to the Results section discussing Figure 2 to highlight the difficulty of making comparisons between the studies due to the lack of clear reporting. [L170-172] COMMENT - Although we have an access to a few study on ERPs, it is difficult to prove, in an unambiguous manner, an advantage of one of the methods. It seems that relaying on the presented results, a conclusion can be drawn that using ERPs shortens length of hospital stay, but further RCTs study are necessary. RESPONSE - We have updated the Conclusions section to reflect the fact that there remains some uncertainty in the length of stay results, and that it would be beneficial to have additional studies to support the conclusion. [L312-320] COMMENT - Authors concluded that “…results of this review support the use of ERPs in terms of faster time to discharge…”. RESPONSE - COMMENT - What was criteria of discharging a patient from hospital in analyzed study? There are same or differ in these study, it can impacts of obtained results. RESPONSE - Although not reported in one study, the discharge criteria used in the other studies were broadly similar. This was aligned with our expectations as the focus of the analyses was on a specific surgical procedure which should have generally universal discharge criteria. We have added a statement to the discussion section mentioning this as a possible source of variation and provided the criteria that were reported in each study in the supplementary material (Table S11). [L253-256] COMMENT - References should be checked according to submission guidelines. RESPONSE - All of the references have been checked against the submission guidance Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0243096.r002
19 Oct 2020 Decision Letter - Ahmed Negida, Editor PONE-D-20-17131R1 Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis PLOS ONE Dear Dr. Steeves, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Dec 03 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Ahmed Negida, MD Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #3: All comments have been addressed Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #3: Yes Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #3: Yes Reviewer #4: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Abstract 1- Remove the number of words 2- The study objectives is different from the final conclusion; the authors aimed to evaluate the effects of enhanced recovery programmes on three types of bariatric surgeries; however, in the final conclusion they mentioned only the laparoscopic Roux-en-Y gastric bypass surgery. Even if you couldn't include other surgeries in the analysis, you have to highlight the current evidence regarding these surgeries in the conclusion, or you can adjust your objectives. 3- Line 16: add "comma" after "however". 4- Line 18: add "hospital" to be "duration of hospital-stay". 5- Add up to 6 keywords related to your study. Introduction 6- Line 35: Cite each mentioned guidelines. 7- The authors highlighted the association between obesity and T2DM, I suggest adding a hint about the overall morbidity and mortality associated with obesity before talking about T2DM. 8- Line 47: I suggest adding one sentence about the impact of bariatric surgery on insulin resistance here. 9- The authors need to clearly present their rationale to conduct this study, as the previous two meta-analysis has similar objectives with larger sample and similar findings. Methods 10- Please cite the protocol of this study, if you registered it in PROSPERO, or published it on an online repository. 11- The last update of the study search was 15 months ago, I strongly recommend updating this search and preferably include Scopus database in your search to ensure including all potential studies. 12- Did you exclude the seventh study that includes data regarding the other surgeries? If yes (I think so), you have to adjust the objectives to include only reported surgery (as I mentioned before). If no, you have to report it's data and include it in the tables of summary. Moreover, the PRISMA flow diagram should be adjusted to include only 6 studies in the final stage. The number of included studies in the PRISMA should match the exact number of studies in the summary tables and Quality assessment. 13- The PRISMA flow diagram should be adjusted to include the reasons of exclusion of the last 11 and 4 studies. 14- Do you have any explanation for using RR instead of OR in readmission? 15- Consider to conduct a subgroup analysis in the LOS outcome according to the study design to solve the heterogeneity. Discussion 16- "This review explored the evidence available for the impact that ERPs have on outcomes in patients undergoing three common bariatric procedures". You evaluated the impact of ERPs on only one surgery not three, please correct. 17- "As only one relevant study was identified for each of LSG and OAGB, meta-analysis was not possible, and results are therefore not discussed for these procedures." State clearly that you exclude the study from your review, as you did not report and data regarding it. 18- Line 258 "reporting recent clinical and economic evidence related to ERPs in LRYGB, OAGB and LSG within EMEA" You cannot consider this as a strength point as you did not report any data regarding OAGB and LSG. 19- Significant heterogeneity and the relatively small number of studies should be added to the section of limitations. 20- The manuscript needs language editing to eliminate any mistakes. Reviewer #3: The authors have addressed all my comments/suggestions. Reviewer #4: I have no comments. I accepted author response to manuscripte Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: No Reviewer #4: Yes:** Maciej Wiewiora [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0243096.r003
Revision 2
3 Nov 2020 Author Response We thank the reviewers for their helpful feedback on the manuscript. Below are the changes we have made to address their comments. Please note that line numbers refer to the ‘Track Changes’ version of the manuscript. Reviewer #1: COMMENT - [Abstract] 1- Remove the number of words. RESPONSE - Thank you, this change has been made [L1] COMMENT - [Abstract] 2- The study objectives is different from the final conclusion; the authors aimed to evaluate the effects of enhanced recovery programmes on three types of bariatric surgeries; however, in the final conclusion they mentioned only the laparoscopic Roux-en-Y gastric bypass surgery. Even if you couldn't include other surgeries in the analysis, you have to highlight the current evidence regarding these surgeries in the conclusion, or you can adjust your objectives. RESPONSE - Thank you for this comment. We have adjusted the wording of the objectives to clarify the objective was to evaluate the available evidence on the effects of enhanced recovery programmes in all three procedures, and then updated the conclusions to state that the data gaps identified by the review include the lack of data for OAGB and LSG. [L5; L32] COMMENT [Abstract] 3- Line 16: add "comma" after "however". RESPONSE - Thank you, this change has been made [L16] COMMENT [Abstract] 4- Line 18: add "hospital" to be "duration of hospital-stay". RESPONSE - Thank you, this change has been made [L19] COMMENT [Abstract] 5- Add up to 6 keywords related to your study. RESPONSE - These have been added after the abstract [L33-35] COMMENT [Introduction] 6- Line 35: Cite each mentioned guidelines. RESPONSE - Thank you, we have added the missing citations [L41-42] COMMENT [Introduction] 7- The authors highlighted the association between obesity and T2DM, I suggest adding a hint about the overall morbidity and mortality associated with obesity before talking about T2DM. RESPONSE - Thank you, we have added the following sentences before the association with T2DM is introduced: “Severe obesity can increase the risk of hypertension, hyperlipidaemia, heart disease and ischaemic stroke, as well as a number of cancers including cancer of the colon, gall bladder, rectum and liver. Obesity is also closely linked to the development of T2DM due to a progressive decrease in insulin secretion alongside a rise in insulin resistance.” [L44-48] COMMENT [Introduction] 8- Line 47: I suggest adding one sentence about the impact of bariatric surgery on insulin resistance here. RESPONSE - Thank you for this suggestion, we have added a sentence that bariatric surgery has been shown to improve insulin resistance, referencing Schauer et al. 2012 [L55-56] COMMENT [Introduction] 9- The authors need to clearly present their rationale to conduct this study, as the previous two meta-analysis has similar objectives with larger sample and similar findings. RESPONSE - We have added that the literature reviews to inform the previous meta-analyses were conducted several years ago (May 2017 and April 2016) to clarify that the rationale for our study was to review whether the evidence limitations noted in these original analyses are still present despite additional studies having since been published. [L77-78] COMMENT [Methods] 10- Please cite the protocol of this study, if you registered it in PROSPERO, or published it on an online repository. RESPONSE - Thank you for this suggestion. Our protocol was not registered in an online repository therefore we are unable to cite it. COMMENT [Methods] 11- The last update of the study search was 15 months ago, I strongly recommend updating this search and preferably include Scopus database in your search to ensure including all potential studies. RESPONSE - Thank you for this suggestion. We have conducted targeted searches over the past year and do not believe that any major new data that would change the review’s conclusions have been published since the searches were last updated. While we did not search the Scopus database, we think it would be unlikely to yield additional relevant studies in this case as we searched multiple electronic databases (including CENTRAL, MEDLINE and Embase as recommended by the Cochrane Handbook for Systematic Reviews of Interventions) and performed hand searches of citations in included studies, which is the suggested use of Scopus by the Cochrane Handbook (Section 4). COMMENT [Methods] 12- Did you exclude the seventh study that includes data regarding the other surgeries? If yes (I think so), you have to adjust the objectives to include only reported surgery (as I mentioned before). If no, you have to report it's data and include it in the tables of summary. Moreover, the PRISMA flow diagram should be adjusted to include only 6 studies in the final stage. The number of included studies in the PRISMA should match the exact number of studies in the summary tables and Quality assessment. RESPONSE - Yes, we excluded the seventh study from the analyses as it was the only study to report data for OAGB, however it was included in the review itself due to fulfilling the eligibility criteria. We have updated the PRISMA flow diagram to make this distinction clearer and now refer only to the studies that were ultimately included in the analyses as the final level of the diagram. [Fig 1] As the seventh study was not included in the analyses, we have added the characteristics and outcomes extracted from this study together with the data from the study reporting outcomes following LSG as a separate table in the data supplement (S10 Table). COMMENT [Methods] 13- The PRISMA flow diagram should be adjusted to include the reasons of exclusion of the last 11 and 4 studies. RESPONSE - Thank you for this suggestion, we have updated the diagram to include these reasons. [Fig 1] COMMENT [Methods] 14- Do you have any explanation for using RR instead of OR in readmission? RESPONSE - We used RR as this measure is more easily interpretable than OR, as per the Cochrane Handbook for Systematic Reviews of Interventions (Section 6.4.1.2). COMMENT [Methods] 15- Consider to conduct a subgroup analysis in the LOS outcome according to the study design to solve the heterogeneity. RESPONSE - A subgroup analysis was conducted to explore this (please see Fig S2), however it was not found to account fully for the heterogeneity. COMMENT [Discussion] 16- "This review explored the evidence available for the impact that ERPs have on outcomes in patients undergoing three common bariatric procedures". You evaluated the impact of ERPs on only one surgery not three, please correct. RESPONSE - The objective of the review was not purely to evaluate the impact but to examine what evidence was available to inform such an evaluation, therefore the confirmation of a lack of evidence for these procedures was part of the findings of the review. We have updated the wording of the opening sentence in the discussion to make this clearer: “This review explored what evidence was available for the impact that ERPs have on outcomes in patients undergoing three common bariatric procedures” [L237] COMMENT [Discussion] 17- "As only one relevant study was identified for each of LSG and OAGB, meta-analysis was not possible, and results are therefore not discussed for these procedures." State clearly that you exclude the study from your review, as you did not report and data regarding it. RESPONSE - As per the previous comment we have updated the PRISMA flow diagram to make the distinction between studies included in the review versus the analysis clearer. We have also updated the results section to refer to the data supplement where characteristics and outcomes for these studies are presented. [ L162-163] COMMENT [Discussion] 18- Line 258 "reporting recent clinical and economic evidence related to ERPs in LRYGB, OAGB and LSG within EMEA" You cannot consider this as a strength point as you did not report any data regarding OAGB and LSG. RESPONSE - This sentence has been rephrased to clarify that the review methodology was designed to identify these data as the inability to report analyses is a product of the lack of published data rather than a strength or weakness of the review methodology. [L305] COMMENT [Discussion] 19- Significant heterogeneity and the relatively small number of studies should be added to the section of limitations. RESPONSE - Thank you for this suggestion, we have added further details of the heterogeneity and the small number of studies to the paragraph discussing evidence gaps. [L297-300] COMMENT [Discussion] 20- The manuscript needs language editing to eliminate any mistakes. RESPONSE - Thank you, we have performed a full review of the manuscript and updated wording throughout. Reviewer #3: COMMENT - The authors have addressed all my comments/suggestions. RESPONSE - Thank you very much for your review of the revised manuscript Reviewer #4: COMMENT - I have no comments. I accepted author response to manuscripte Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis. RESPONSE - Thank you very much for your review of the revised manuscript Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0243096.r004
16 Nov 2020 Decision Letter - Ahmed Negida, Editor Enhanced Recovery Programmes Versus Conventional Care in Bariatric Surgery: A Systematic Literature Review and Meta-Analysis PONE-D-20-17131R2 Dear Dr. Steeves, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Ahmed Negida, MD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0243096.r005
Formally Accepted
17 Dec 2020 Acceptance Letter - Ahmed Negida, Editor PONE-D-20-17131R2 Enhanced recovery programmes versus conventional care in bariatric surgery: A systematic literature review and meta-analysis Dear Dr. Taylor: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Ahmed Negida Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0243096.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .