Correspondence to: Anyin Wang (email: Hospitalpwkedu@163.com)
Department of Gastrointestinal/Hernia Surgery
The People's Hospital of Liangping District
No. 16 Bigui Road
Liangping District
Chongqing
405200
China
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BJS, https://doi.org/10.1093/bjs/znaf043, published 28 March 2025
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Dear Editor
The authors are to be highly commended for successfully compiling a large and internationally representative dataset, and for employing the ‘population attributable fraction’ (PAF) to quantify the impact of specific postoperative complications on clinical outcomes following gastrectomy1.
The value of this study lies in identifying anastomotic leakage and pulmonary complications as major contributors to postoperative mortality, escalation of care and reoperations. Notably, anastomotic leak alone accounted for over one-quarter of all 30-day deaths, highlighting the urgent need for preventive strategies.
We would like to suggest further discussion in two areas: (1) while PAF is a robust epidemiological tool2, the study lacks time-sequence data linking complications with adverse outcomes, limiting causal inference. Future research that incorporates event timing could help determine whether certain complications precede poor outcomes or occur as a consequence of them2. The observed regional differences, particularly the greater impact of pulmonary complications in East Asia, suggest that health system-level factors may play a significant role. Exploring institutional data in more detail, such as ICU resource allocation3, nursing staff levels, and implementation of standardized care pathways4, may better explain these disparities and guide quality improvement initiatives.
Overall, this multicentre study sets an important benchmark for global quality standards in gastric cancer surgery. Prospective studies that integrate both clinical and system-level variables would further deepen our understanding of postoperative outcomes and ultimately improve patient prognosis.
References
van Hootegem SJM, van der Linde M, Schneider MA, Kim J, Berlth F, Sugita Y et al. Impact of postoperative complications on clinical outcomes after gastrectomy for cancer: multicentre study. BJS 2025;112, doi: https://doi.org/10.1093/bjs/znaf043.
Mansournia MA, Altman DG. Population attributable fraction. BMJ 2018;360:k757.
Murthy S, Adhikari NK. Global health care of the critically ill in low-resource settings. Ann Am Thorac Soc 2013;10:509-13.
Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148:740-5.
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