Title: Incidence and risk factors of nasogastric feeding intolerance in moderately-severe to
severe acute pancreatitis
Version: 1 Date: 11 Mar 2022
Reviewer's report:
The authors conducted the retrospective study to investigate the incidence and risk factors
for gastric feeding intolerance (GFI) in moderate-severe to severe acute pancreatitis (AP) in
the Centre of Severe Acute Pancreatitis of Jinling Hospital in China. Patients diagnosed with
moderate-severe to severe AP and admitted within seven days from the onset of abdominal pain
were assessed for eligibility. A total of 561 patients were hospitalized with AP during the study
period and 93 (16.5%) patients were enrolled in the analysis; 73.1% of the enrolled patients had
moderately severe AP. They found that 24 (25.8%) patients had GFI and respiratory failure was
an independent risk factor of developing GFI. They concluded that GFI is common in moderate-
severe to severe AP patients, and the presence of respiratory failure is a risk factor of GFI. The
study is of clinical interest; however, the results may be unreliable due to referral and selection
biases. Major comments are shown below.
Major comments
1. The study hospital seems to be a referral center for severe AP. Therefore, a referral bias is
likely and may lead to underestimate the incidence of GFI if patients referred to the hospital
were predominantly moderately severe cases (73.1%, Table 1). Moreover, the timing of referral
can also influence the estimate of GFI incidence. For example, of the 468 excluded patients,
346 (71%) were more than seven days from onset of AP at hospital admission (Figure 1). The
distribution of AP severity among the excluded patients is unclear. If these patients were referred
to the hospital earlier, the case mix may be different.
2. The classification of AP severity is questionable. In Table 1, 39 patients had respiratory failure,
but only 26 were classified as severe AP.
3. The definition of GFI is unclear. “Patients who showed signs of intolerance to gastric
feeding and required switching to NJ feeding were deemed GFI.” However, “The final decision
regarding the requirement of NJ feeding depends on the physician in charge.” Therefore, it is
likely that some patients may not be classified as GFI if they showed signs of intolerance to
gastric feeding, but the physician in charge was reluctant to switch to NJ feeding.
Title: Incidence and risk factors of nasogastric feeding intolerance in moderately-severe to
severe acute pancreatitis
Version: 1 Date: 11 Mar 2022
Reviewer's report:
The authors conducted the retrospective study to investigate the incidence and risk factors
for gastric feeding intolerance (GFI) in moderate-severe to severe acute pancreatitis (AP) in
the Centre of Severe Acute Pancreatitis of Jinling Hospital in China. Patients diagnosed with
moderate-severe to severe AP and admitted within seven days from the onset of abdominal pain
were assessed for eligibility. A total of 561 patients were hospitalized with AP during the study
period and 93 (16.5%) patients were enrolled in the analysis; 73.1% of the enrolled patients had
moderately severe AP. They found that 24 (25.8%) patients had GFI and respiratory failure was
an independent risk factor of developing GFI. They concluded that GFI is common in moderate-
severe to severe AP patients, and the presence of respiratory failure is a risk factor of GFI. The
study is of clinical interest; however, the results may be unreliable due to referral and selection
biases. Major comments are shown below.
Major comments
1. The study hospital seems to be a referral center for severe AP. Therefore, a referral bias is
likely and may lead to underestimate the incidence of GFI if patients referred to the hospital
were predominantly moderately severe cases (73.1%, Table 1). Moreover, the timing of referral
can also influence the estimate of GFI incidence. For example, of the 468 excluded patients,
346 (71%) were more than seven days from onset of AP at hospital admission (Figure 1). The
distribution of AP severity among the excluded patients is unclear. If these patients were referred
to the hospital earlier, the case mix may be different.
2. The classification of AP severity is questionable. In Table 1, 39 patients had respiratory failure,
but only 26 were classified as severe AP.
3. The definition of GFI is unclear. “Patients who showed signs of intolerance to gastric
feeding and required switching to NJ feeding were deemed GFI.” However, “The final decision
regarding the requirement of NJ feeding depends on the physician in charge.” Therefore, it is
likely that some patients may not be classified as GFI if they showed signs of intolerance to
gastric feeding, but the physician in charge was reluctant to switch to NJ feeding.
Please review this paper.
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Title: Incidence and risk factors of nasogastric feeding intolerance in moderately-severe to
severe acute pancreatitis
Version: 1 Date: 11 Mar 2022
Reviewer's report:
The authors conducted the retrospective study to investigate the incidence and risk factors
for gastric feeding intolerance (GFI) in moderate-severe to severe acute pancreatitis (AP) in
the Centre of Severe Acute Pancreatitis of Jinling Hospital in China. Patients diagnosed with
moderate-severe to severe AP and admitted within seven days from the onset of abdominal pain
were assessed for eligibility. A total of 561 patients were hospitalized with AP during the study
period and 93 (16.5%) patients were enrolled in the analysis; 73.1% of the enrolled patients had
moderately severe AP. They found that 24 (25.8%) patients had GFI and respiratory failure was
an independent risk factor of developing GFI. They concluded that GFI is common in moderate-
severe to severe AP patients, and the presence of respiratory failure is a risk factor of GFI. The
study is of clinical interest; however, the results may be unreliable due to referral and selection
biases. Major comments are shown below.
Major comments
1. The study hospital seems to be a referral center for severe AP. Therefore, a referral bias is
likely and may lead to underestimate the incidence of GFI if patients referred to the hospital
were predominantly moderately severe cases (73.1%, Table 1). Moreover, the timing of referral
can also influence the estimate of GFI incidence. For example, of the 468 excluded patients,
346 (71%) were more than seven days from onset of AP at hospital admission (Figure 1). The
distribution of AP severity among the excluded patients is unclear. If these patients were referred
to the hospital earlier, the case mix may be different.
2. The classification of AP severity is questionable. In Table 1, 39 patients had respiratory failure,
but only 26 were classified as severe AP.
3. The definition of GFI is unclear. “Patients who showed signs of intolerance to gastric
feeding and required switching to NJ feeding were deemed GFI.” However, “The final decision
regarding the requirement of NJ feeding depends on the physician in charge.” Therefore, it is
likely that some patients may not be classified as GFI if they showed signs of intolerance to
gastric feeding, but the physician in charge was reluctant to switch to NJ feeding.
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