Author response: Impact of postoperative complications on clinical outcomes after gastrectomy for cancer: multicentre study

Correspondence to: Sander J. M. van Hootegem (e-mail: s.vanhootegem@erasmusmc.nl)

Department of Surgery

Erasmus Medical Centre

PO Box 2040

Rotterdam

3000 CA

The Netherlands

BJS, https://doi.org/10.1093/bjs/znaf043, published 28 March 2025

We sincerely thank Drs Wang, Fu, and Tian for their comments on our study1. While we are unable to answer with the present data, the points raised are valid and may direct future research.

As acknowledged in our discussion, postoperative complications often have multifactorial origins and overlapping pathways. Prospective studies incorporating event timing would be valuable to delineate causality and better understand whether complications such as pulmonary events develop independently or secondary to other complications. However, it is often difficult to define the sentinel complication that may lead to a chain of adverse events.

Second, we also highlighted in our paper that healthcare system factors, including resource availability and rescue capacity, likely contribute to disparities2. In an additional analysis on global hospital variation using the same dataset, we found that case-mix and treatment factors explained only a minor proportion of variance for most surgical outcomes following gastrectomy (personal communication, EGCC 2024 Siena). This further supports the notion that (often unmeasured) organizational and system-level factors contribute substantially​. We agree that further exploration of these factors is therefore necessary to provide actionable targets and guide quality improvement initiatives.