Letter to the Editor: Emergency surgery influences oncological outcome in small intestinal neuroendocrine tumors

Dear Editor

We read with great interest the article, “Emergency Surgery Influences Oncological Outcome in Small Intestinal Neuroendocrine Tumors” by Butz et al. ¹ We commend the authors’ insightful analysis and agree that emergency surgery impacts oncological outcomes in small intestinal neuroendocrine tumors (siNETs). However, we would like to raise a few additional points that could further enhance the discussion.

First, the study’s retrospective nature introduces potential selection bias, as patients undergoing emergency surgery often present with a more advanced disease. While the authors adjusted for confounders, fully accounting for all relevant variables remains challenging in a retrospective analysis. Folkestad et al. ² also noted that patients requiring emergency surgery frequently have severe baseline characteristics, which could contribute to poorer outcomes. Future studies could reduce this bias by incorporating multicenter data or using propensity score matching.

Another aspect that could be further explored is the article’s consideration of pre-surgical factors. The article does not sufficiently explore pre-surgical factors, such as delays before emergency surgery and perioperative care, which are known to influence outcomes. For instance, Xu et al. ³ demonstrated that delays in emergency surgery for colorectal cancer are associated with reduced survival, suggesting that similar effects could potentially influence siNET outcomes. A more comprehensive exploration of these factors could provide a more nuanced understanding of the topic.

Third, tumor biology plays a critical role in prognosis. The study could have explored how tumor differentiation and aggressiveness impact outcomes, as Manguso et al. ⁴ noted that these factors significantly determine survival, irrespective of whether the surgery is elective or emergency. Finally, the study briefly mentions the importance of follow-up care but lacks detailed strategies for postoperative management. In patients with advanced neuroendocrine tumors, aggressive postoperative care, such as enhanced recovery after surgery (ERAS) protocols, has been associated with improved outcomes. Sackstein et al. ⁵ underscored the importance of individualized postoperative care and frequent monitoring to optimize survival and reduce complications.