Reviewer ’s report  
 
Title: Safety and outcome of gastrostomy tube placement in patients with Loeys -Dietz 
Syndrome  
 
Version: 2 Date: 24 Dec 2019  
 
Reviewer: Riad Rah hal 
 
Reviewer's report:  
Dear authors,  
Thank you for the submission. This work presents findings from a descriptive retrospective 
cohort of patients with Loeys -Dietz syndrome which is a systemi c connective tissue disease 
frequently associated with growth and feeding difficulties.  
 
The manuscript would serve as an addition to the literature in this relatively uncommon patient 
population. The authors can better describe the complications noted (b uried bumper syndrome 
and gastrostomy site expansion) to highlight the presentation and surgical/endoscopic 
intervention needed as these complications are likely related to the underlying connective tissue 
disease and should be seriously considered in this  population. In addition, the authors can better 
present growth data graphically instead of just in text form. The following are the specific points 
to address:  
 
-In the abstract and manuscript, should refer to the study design as "retrospective cohort stu dy" 
instead of "retrospective chart review"  
-With connective tissue disease, expected complications would potentially include bleeding so 
such complication (presence or absence) should be clearly described as part of the procedural 
outcomes  
-In 2 out of t he 10 patients, a second gastrostomy tube was placed. It would be relevant to 
describe if the same or different location was chosen in these two patients to place the new 
gastrostomy tubes compared to the previous site  
-It is better to graphically demonst rate the change in BMI Z -score overtime for each patient and 
include a line summarizing the change for the entire cohort  
 
-Since the indication gastrostomy tube placement was poor growth/poor intake, one outcome 
measure to be reported should be % success in  nutritional rehabilitation/benefit for having the 
tube placed as it is relevant to physicians and patients to discuss and recognize all potential risks 
and benefits and not simply the immediate post -operative complications. This is especially 
important as  some patients did not adhere to prescribed diet or removed the tube soon after 
placement  
-How did the patient with the complication of buried bumper syndrome present and how was it 
addressed (did it require surgical or endoscopic intervention)  
-The patie nt who had the complication of the expansion of the gastrostomy site, this sounds like 
gastric prolapse or poor wound healing and should be stated as such. Should also report the time 
from initial gastrostomy tube placement to surgical closure.  
 
Thank you   
 
 
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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional  statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate 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, f ees, funding, or salary from an 
organisation that may in any way gain  or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat 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 that 
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 inte rests in relation to this paper?  
 
If you can answer no to al l of the above, write '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' below  
 
I agree to the open peer review policy of the jo urnal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree fo r my report to be made available under an Open Access 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 in cluded 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: Safety and outcome of gastrostomy tube placement in patients with Loeys -Dietz 
Syndrome  
 
Version: 2 Date: 24 Dec 2019  
 
Reviewer: Riad Rah hal 
 
Reviewer's report:  
Dear authors,  
Thank you for the submission. This work presents findings from a descriptive retrospective 
cohort of patients with Loeys -Dietz syndrome which is a systemi c connective tissue disease 
frequently associated with growth and feeding difficulties.  
 
The manuscript would serve as an addition to the literature in this relatively uncommon patient 
population. The authors can better describe the complications noted (b uried bumper syndrome 
and gastrostomy site expansion) to highlight the presentation and surgical/endoscopic 
intervention needed as these complications are likely related to the underlying connective tissue 
disease and should be seriously considered in this  population. In addition, the authors can better 
present growth data graphically instead of just in text form. The following are the specific points 
to address:  
 
-In the abstract and manuscript, should refer to the study design as "retrospective cohort stu dy" 
instead of "retrospective chart review"  
-With connective tissue disease, expected complications would potentially include bleeding so 
such complication (presence or absence) should be clearly described as part of the procedural 
outcomes  
-In 2 out of t he 10 patients, a second gastrostomy tube was placed. It would be relevant to 
describe if the same or different location was chosen in these two patients to place the new 
gastrostomy tubes compared to the previous site  
-It is better to graphically demonst rate the change in BMI Z -score overtime for each patient and 
include a line summarizing the change for the entire cohort  
 
-Since the indication gastrostomy tube placement was poor growth/poor intake, one outcome 
measure to be reported should be % success in  nutritional rehabilitation/benefit for having the 
tube placed as it is relevant to physicians and patients to discuss and recognize all potential risks 
and benefits and not simply the immediate post -operative complications. This is especially 
important as  some patients did not adhere to prescribed diet or removed the tube soon after 
placement  
-How did the patient with the complication of buried bumper syndrome present and how was it 
addressed (did it require surgical or endoscopic intervention)  
-The patie nt who had the complication of the expansion of the gastrostomy site, this sounds like 
gastric prolapse or poor wound healing and should be stated as such. Should also report the time 
from initial gastrostomy tube placement to surgical closure.  
 
Thank you   
 
 
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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional  statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate 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, f ees, funding, or salary from an 
organisation that may in any way gain  or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat 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 that 
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 inte rests in relation to this paper?  
 
If you can answer no to al l of the above, write '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' below  
 
I agree to the open peer review policy of the jo urnal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree fo r my report to be made available under an Open Access 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 in cluded 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: Safety and outcome of gastrostomy tube placement in patients with Loeys -Dietz 
Syndrome  
 
Version: 2 Date: 24 Dec 2019  
 
Reviewer: Riad Rah hal 
 
Reviewer's report:  
Dear authors,  
Thank you for the submission. This work presents findings from a descriptive retrospective 
cohort of patients with Loeys -Dietz syndrome which is a systemi c connective tissue disease 
frequently associated with growth and feeding difficulties.  
 
The manuscript would serve as an addition to the literature in this relatively uncommon patient 
population. The authors can better describe the complications noted (b uried bumper syndrome 
and gastrostomy site expansion) to highlight the presentation and surgical/endoscopic 
intervention needed as these complications are likely related to the underlying connective tissue 
disease and should be seriously considered in this  population. In addition, the authors can better 
present growth data graphically instead of just in text form. The following are the specific points 
to address:  
 
-In the abstract and manuscript, should refer to the study design as "retrospective cohort stu dy" 
instead of "retrospective chart review"  
-With connective tissue disease, expected complications would potentially include bleeding so 
such complication (presence or absence) should be clearly described as part of the procedural 
outcomes  
-In 2 out of t he 10 patients, a second gastrostomy tube was placed. It would be relevant to 
describe if the same or different location was chosen in these two patients to place the new 
gastrostomy tubes compared to the previous site  
-It is better to graphically demonst rate the change in BMI Z -score overtime for each patient and 
include a line summarizing the change for the entire cohort  
 
-Since the indication gastrostomy tube placement was poor growth/poor intake, one outcome 
measure to be reported should be % success in  nutritional rehabilitation/benefit for having the 
tube placed as it is relevant to physicians and patients to discuss and recognize all potential risks 
and benefits and not simply the immediate post -operative complications. This is especially 
important as  some patients did not adhere to prescribed diet or removed the tube soon after 
placement  
-How did the patient with the complication of buried bumper syndrome present and how was it 
addressed (did it require surgical or endoscopic intervention)  
-The patie nt who had the complication of the expansion of the gastrostomy site, this sounds like 
gastric prolapse or poor wound healing and should be stated as such. Should also report the time 
from initial gastrostomy tube placement to surgical closure.  
 
Thank you   
 
 
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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional  statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate 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, f ees, funding, or salary from an 
organisation that may in any way gain  or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat 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 that 
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 inte rests in relation to this paper?  
 
If you can answer no to al l of the above, write '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' below  
 
I agree to the open peer review policy of the jo urnal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree fo r my report to be made available under an Open Access 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 in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant