Dear Editors:

Toraih EA et al.’s research [1] investigates the relationship between Roux-en-Y gastric bypass (RYGB) surgery and hypoglycemia risk in non-diabetic obese patients. It has value but also several areas for improvement.

The retrospective design has major limitations: subject to selection bias and unaccounted confounding factors. Unmeasured variables like patient history etc. could impact results. Propensity score matching didn't remove all confounding. Variable selection had issues. Just comparing baseline characteristics superficially. Deeper analyses could strengthen internal validity. The hypoglycemia definition is simplistic; a more comprehensive one is needed. Using current criteria may underestimate incidence. The study didn't consider real-world glucose measurement differences affecting event detection. The study showed an association between RYGB and increased hypoglycemia risk but didn’t establish causality. Other factors could confound the observed correlation, and experimental designs like randomized controlled trials are better for inferring causation. The subgroup analysis of hypoglycemic patients had limited scope. It focused only on short-term outcomes (30-day hospitalization and mortality) and ignored long-term effects like quality of life, recurrence, and related complications. The small number of subgroup events (e.g., 20 deaths) might limit detecting associations with other variables. Relying on the TriNetX database with aggregated data restricts generalizability. The study population may not represent all RYGB patients due to database limitations. Inability to access individual patient data also hampered exploring patient heterogeneity and its impact on outcomes. The study highlights hypoglycemia management importance but lacks specific, evidence-based clinical guidelines. Given the lack of defined treatment strategies in the literature, this is a missed chance to aid clinical practice. Future research should focus on developing and evaluating hypoglycemia prevention and treatment interventions in this patient group.

In conclusion, the study is important but future research needs to overcome its limitations for conclusive evidence and better clinical guidance.