The association of preoperative psychological assessments with long-term sleeve gastrectomy surgery outcomes

Sofia Yeremian; Ara Keshishian; Robert Mardirosian

doi:10.1371/journal.pone.0344917

Peer Review History

Original SubmissionAugust 9, 2025
9 Aug 2025 Author Response Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. https://doi.org/10.1371/journal.pone.0344917.r001
10 Dec 2025 Decision Letter - Kwang-Sig Lee, Editor Dear Dr. Keshishian, 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 Jan 24 2026 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.. 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.. 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Study Design and Bias - The grouping criterion (having or not having a psychological evaluation) overlaps strongly with the presence or absence of psychiatric history, which introduces potential selection bias. - Please acknowledge this explicitly in the Limitations section and clarify that the study's findings are hypothesis-generating rather than conclusive. 2. Interpretation of "No Significant Difference" - The statement that "no significant difference was found" should not be interpreted as evidence that psychological evaluations are unnecessary. - Consider rephrasing to: "In this retrospective cohort, no statistically significant association was observed between preoperative psychological evaluation and long-term weight loss outcomes. However, the study was not powered to exclude a clinically meaningful difference." 3. Clinical and Ethical Role of Psychological Evaluation - Beyond predicting weight loss, psychological assessment in bariatric surgery serves an ethical and preventive function — ensuring that patients understand the irreversible nature of surgery, are psychologically ready for lifestyle changes, and minimizing postoperative regret or maladaptation. - A short paragraph reflecting this broader purpose would make the Discussion more comprehensive and clinically grounded. 4. Conclusion Section - Consider tempering the conclusion's tone. For example: "While no significant difference was observed in this dataset, the role of psychological evaluation may need refinement and better targeting rather than elimination." - This phrasing preserves the originality of your message while avoiding overgeneralization. ****** what does this mean?). If published, this will include your full peer review and any attached files.). 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Revision 1
7 Jan 2026 Author Response Response to Reviewers Manuscript ID: PONE-D-25-37468 Title: The association of preoperative psychological assessments with long-term sleeve gastrectomy surgery outcomes Dear Academic Editor and Reviewers, We thank the Academic Editor and Reviewer #1 for their thoughtful and constructive comments, which have helped improve the clarity, balance, and methodological transparency of our manuscript. We have carefully addressed each point raised and revised the manuscript accordingly. Our point-by-point responses are provided below. Academic Editor Comments Data Availability and Ethics Statement Comment: PLOS ONE requires clarification regarding ethical or legal restrictions on data sharing, including who imposed them and how data may be accessed. The ethics statement should appear only in the Methods section. Response: We have revised the Methods section to include a dedicated subsection describing data governance, de-identification procedures, and access restrictions. We clarify that the dataset was fully de-identified before analysis, with all direct patient identifiers removed, and that the data are governed by third-party data use agreements (MBSAQIP/SRC), which preclude unrestricted public sharing. We further specify that an Institutional Review Board imposed no additional ethical or legal restrictions, as IRB approval was not required for analysis of anonymized data. Access to the de-identified dataset is available upon reasonable request through the corresponding author. The ethics statement now appears exclusively within the “Methods” section, in accordance with journal requirements. Reviewer #1 Comments 1. Study Design and Bias Comment: The grouping criterion overlaps with psychiatric history, introducing potential selection bias. This should be acknowledged in the “Limitations,” and the findings should be framed as hypothesis-generating. Response: We acknowledged this potential source of selection bias in the “Limitations” section. We now clarify that the non-random assignment to psychological evaluation groups overlaps with psychiatric history and insurance requirements, which may introduce residual confounding and limit causal inference. 2. Interpretation of “No Significant Difference” Comment: The absence of a statistically significant difference should not be interpreted as evidence that psychological evaluations are unnecessary. The reviewer suggests rephrasing to note that the study was not powered to exclude a clinically meaningful difference. Response: We have revised the language to adopt the suggested phrasing. The manuscript now states that no statistically significant association was observed between preoperative psychological evaluation and weight loss outcomes in this retrospective cohort, while explicitly acknowledging that the study was not powered to exclude a clinically meaningful difference. This revision avoids overinterpretation while preserving the integrity of our findings. 3. Clinical and Ethical Role of Psychological Evaluation Comment: Psychological assessment serves ethical and preventive functions beyond predicting weight loss. A short paragraph reflecting this broader role should be added to the “Discussion.” Response: We have added a concise paragraph to the “Discussion” acknowledging the ethical and preventive role of psychological evaluation in bariatric surgery, including assessment of patient readiness, understanding of the irreversible nature of surgery, and capacity to adapt to long-term behavioral and psychosocial changes. This addition clarifies that our findings relate specifically to weight loss outcomes and do not negate the broader clinical relevance of psychological assessment, particularly in patients with known or suspected mental health vulnerabilities. 4. Conclusion Section Comment: The conclusion should be tempered to suggest refinement and better targeting of psychological evaluation rather than elimination. Response: We have revised the “Conclusion” accordingly. The updated language emphasizes that, while no significant association was observed in this dataset, the role of psychological evaluation may warrant refinement and more targeted application rather than universal implementation. This phrasing preserves the originality of our findings while avoiding overgeneralization. Additional Revisions • We reviewed the manuscript for consistency with PLOS ONE style requirements and corrected minor formatting issues. • References were reviewed for accuracy and completeness; no retracted articles were cited. • All revisions are highlighted in the marked-up manuscript submitted with track changes. We appreciate the opportunity to revise our manuscript and believe that these changes have strengthened its methodological rigor and clinical balance. We thank the Academic Editor and Reviewer for their valuable feedback and hope the revised manuscript is now suitable for publication in PLOS ONE. Sincerely, Ara Keshishian, MD, MPH, FACS, FASMBS (on behalf of all authors) Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0344917.r003
26 Feb 2026 Decision Letter - Kwang-Sig Lee, Editor The association of preoperative psychological assessments with long-term sleeve gastrectomy surgery outcomes PONE-D-25-37468R1 Dear Dr. Keshishian, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.... 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, Kwang-Sig Lee Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0344917.r004
Formally Accepted
Acceptance Letter - Kwang-Sig Lee, Editor PONE-D-25-37468R1 PLOS One Dear Dr. Keshishian, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@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 Professor Kwang-Sig Lee Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0344917.r005

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