Reviewer ’s report  
 
Title:  Bowel obstruc tion associated with a feeding jejunostomy and its association to weight loss 
after thoracoscopic esophagectomy  
 
Version: 1 Date: 25 Apr 2019 
 
Reviewer:  Hiroshi  Ichikawa  
 
Reviewer’s report:  
 
Kitagawa H. and colleague retrospectively reviewed the clinical record of 100 consecutive 
patients who underwent thoracoscopic esophagectomy and placement of a jejunostomy feeding 
catheter. They investigated the incidence of bowel obstruction associated with a feeding 
jejunostomy, and compared the clinicopathological factors between bowel obstruction group and 
non-bowel obstructio n group. As a result, bowel obstruction developed in 17% of patients. 
Patients with bowel obstruction had higher preoperative body mass index and greater 
postoperative body weight loss rate. This study provides the intriguing finding about the risk 
factors  for feeding jejunostomy related bowel obstruction; however, there are several areas of 
concern which would need to be addressed:  
 
1. The authors should calculate the odds ratio for bowel obstruction by multivariate analysis and 
evaluate the cut -off value of preoperative BMI to predict the occurrence of bowel obstruction.  
 
2. The incidence of bowel obstruction associated with feeding jejunostomy in this study (17%) 
was higher than that of previous reports. The authors should discuss about the reason for the high 
incidence of it.  
 
3. Mechanical bowel obstruction is a well -known complication after the placement of feeding 
jejunostomy in patients who underwent esophagectomy for esophageal cancer. How about the 
previous report about the risk factors for this severe complication? The authors should discuss 
this issue.  
 
4.  The aut hors mentioned the informed consent as follows; "Informed consent was obtained in 
the form of opt -out our hospital website." However, written informed consent is usually omitted 
and not obtained in the opt -out method. The opt -out method is to disclose the information about 
the study on the website to guarantee an opportunity for refusal of participation without written 
informed consent. Please revise the description of the informed consent for enrolled patients in 
this study.  
 
5. Reference No. 8 is not the Japanese guideline. Please revise the description in the last line of 
page 6.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would yo u recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization tha t 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, wri te 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understand that my name will be include d 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open A ccess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title:  Bowel obstruc tion associated with a feeding jejunostomy and its association to weight loss 
after thoracoscopic esophagectomy  
 
Version: 1 Date: 25 Apr 2019 
 
Reviewer:  Hiroshi  Ichikawa  
 
Reviewer’s report:  
 
Kitagawa H. and colleague retrospectively reviewed the clinical record of 100 consecutive 
patients who underwent thoracoscopic esophagectomy and placement of a jejunostomy feeding 
catheter. They investigated the incidence of bowel obstruction associated with a feeding 
jejunostomy, and compared the clinicopathological factors between bowel obstruction group and 
non-bowel obstructio n group. As a result, bowel obstruction developed in 17% of patients. 
Patients with bowel obstruction had higher preoperative body mass index and greater 
postoperative body weight loss rate. This study provides the intriguing finding about the risk 
factors  for feeding jejunostomy related bowel obstruction; however, there are several areas of 
concern which would need to be addressed:  
 
1. The authors should calculate the odds ratio for bowel obstruction by multivariate analysis and 
evaluate the cut -off value of preoperative BMI to predict the occurrence of bowel obstruction.  
 
2. The incidence of bowel obstruction associated with feeding jejunostomy in this study (17%) 
was higher than that of previous reports. The authors should discuss about the reason for the high 
incidence of it.  
 
3. Mechanical bowel obstruction is a well -known complication after the placement of feeding 
jejunostomy in patients who underwent esophagectomy for esophageal cancer. How about the 
previous report about the risk factors for this severe complication? The authors should discuss 
this issue.  
 
4.  The aut hors mentioned the informed consent as follows; "Informed consent was obtained in 
the form of opt -out our hospital website." However, written informed consent is usually omitted 
and not obtained in the opt -out method. The opt -out method is to disclose the information about 
the study on the website to guarantee an opportunity for refusal of participation without written 
informed consent. Please revise the description of the informed consent for enrolled patients in 
this study.  
 
5. Reference No. 8 is not the Japanese guideline. Please revise the description in the last line of 
page 6.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would yo u recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization tha t 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, wri te 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understand that my name will be include d 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open A ccess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title:  Bowel obstruc tion associated with a feeding jejunostomy and its association to weight loss 
after thoracoscopic esophagectomy  
 
Version: 1 Date: 25 Apr 2019 
 
Reviewer:  Hiroshi  Ichikawa  
 
Reviewer’s report:  
 
Kitagawa H. and colleague retrospectively reviewed the clinical record of 100 consecutive 
patients who underwent thoracoscopic esophagectomy and placement of a jejunostomy feeding 
catheter. They investigated the incidence of bowel obstruction associated with a feeding 
jejunostomy, and compared the clinicopathological factors between bowel obstruction group and 
non-bowel obstructio n group. As a result, bowel obstruction developed in 17% of patients. 
Patients with bowel obstruction had higher preoperative body mass index and greater 
postoperative body weight loss rate. This study provides the intriguing finding about the risk 
factors  for feeding jejunostomy related bowel obstruction; however, there are several areas of 
concern which would need to be addressed:  
 
1. The authors should calculate the odds ratio for bowel obstruction by multivariate analysis and 
evaluate the cut -off value of preoperative BMI to predict the occurrence of bowel obstruction.  
 
2. The incidence of bowel obstruction associated with feeding jejunostomy in this study (17%) 
was higher than that of previous reports. The authors should discuss about the reason for the high 
incidence of it.  
 
3. Mechanical bowel obstruction is a well -known complication after the placement of feeding 
jejunostomy in patients who underwent esophagectomy for esophageal cancer. How about the 
previous report about the risk factors for this severe complication? The authors should discuss 
this issue.  
 
4.  The aut hors mentioned the informed consent as follows; "Informed consent was obtained in 
the form of opt -out our hospital website." However, written informed consent is usually omitted 
and not obtained in the opt -out method. The opt -out method is to disclose the information about 
the study on the website to guarantee an opportunity for refusal of participation without written 
informed consent. Please revise the description of the informed consent for enrolled patients in 
this study.  
 
5. Reference No. 8 is not the Japanese guideline. Please revise the description in the last line of 
page 6.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would yo u recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization tha t 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, wri te 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understand that my name will be include d 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open A ccess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant