Reviewer ’s report  
 
Title:  Bowel obstruc tion associated with a feeding jejunostomy and its association to weight loss 
after thoracoscopic esophagectomy  
 
Version: 1 Date: 23 Apr 2019 
 
Reviewer:  C Gutschow  
 
Reviewer’s report:  
 
Namikawa T et al.: Bowel obstruction associated with a feeding jejunostomy and its association 
to weight loss after thoracoscopic esophagectomy  
 
This retr ospective monocentric study analyzes bowel obstruction due to jejunal feeding catheters 
after thoracoscopic esophagectomy. One hundred consecutive patients that underwent surgery 
between 2009 and 2017 were included. The study shows a high rate of revisiona l surgery (17%) 
due to acute (n=9) or chronic (n=8) symptoms of bowel obstruction. Further analysis of the 
dataset revealed a higher preoperative weight and BMI and a greater postoperative weight loss in 
patients needing surgical revision for bowel obstruc tion.  
 
This trial looks at a relevant topic in esophageal surgery, as feeding jejunostomies are frequently 
used in this group of patients. The study design - although retrospective - is clear and the 
statistics seem sound, and all in all I think that this work is a valuable contribution to an ongoing 
scientific debate. However, I have a few remarks:  
 
* The main message of the paper is that in the univariate analysis, bowel obstruction after 
feeding jejunostomy is more frequent in patients with higher preop body weight and BMI 
and greater postop weight loss. Also, although not significant, patients undergoing a 
laparoscopic procedure were also at risk. Why didn´t the authors perform a multivariate 
analysis of all potential factors? This would certainly improv e the message of this paper.  
 
* The authors describe a technique for jejunal catheter insertion that includes a Witzel 
maneuver, which is unusual for laparoscopic procedures but commonly performed in 
open feeding tube placement. Also, the manufacturer of th e tube and the surgical thread is 
not mentioned. Moreover, no anti -rotation stitches are described, which are generally 
used by most surgeons performing this procedure. Given the extremely high reoperation 
rate - did the authors consider modifying their te chnique at some point of their 
experience? Fixation of the jejunal loop to the abdominal wall over a longer distance 
could possibly avoid rotation and twisting of the jejunum as shown in Figure 2. 
Consequently, it needs to be discussed that the main reason  for the exceptionally high 
rate of BOFJ in this study may be the technique used by the authors and not the preop 
BMI.  
 
* How many patients had other complications of feeding jejunostomy than bowel 
obstruction (leakage, infection, accidental removal needing  reinsertion, luminal 
obstruction of the catheter, kinking)? A thorough analysis of all potential complications 
attributable to feeding catheters would be interesting here.  
 
* Please include detailed information on other previous abdominal surgeries. This i s an 
important issue, as postoperative bowel obstruction could also be caused by adhesions 
other than from the jejunostomy site. Also, please state whether there were other reasons 
for bowel obstruction, i.e. other regions of the small bowel that actually needed 
adhesiolysis.  
 
* Please describe the surgical procedure for esophagectomy correctly. Did all patients 
undergo a McKeown esophagectomy with a thoracoscopic esophagectomy first, followed 
by a cervico -abdominal reconstruction phase?  
 
* Epigastric pain i s a frequent symptom after esophagectomy. How many patients 
presented with this symptom, how many patients underwent a diagnostic work -up 
including CT scan, and how many of them were finally diagnosed with bowel 
obstruction? Was the whirl sign a specific d iagnostic parameter in all patients and could 
this be verified during revisional surgery? Did all patients with unclear upper abdominal 
crampy pain undergo surgery or were some of the patients treated conservatively?  
 
* Higher weight loss may be due to (chr onic) bowel obstruction and therefore, rather a 
consequence of BOFJ than its cause.  
 
* Please explain the units used in the tables (n,% or mean/median range /IQR etc.)  
 
In summary, the manuscript needs revision but may be suitable for publication in the BM C 
Gastroenterology.  
 
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 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 am able to assess the statistics  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
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: 23 Apr 2019 
 
Reviewer:  C Gutschow  
 
Reviewer’s report:  
 
Namikawa T et al.: Bowel obstruction associated with a feeding jejunostomy and its association 
to weight loss after thoracoscopic esophagectomy  
 
This retr ospective monocentric study analyzes bowel obstruction due to jejunal feeding catheters 
after thoracoscopic esophagectomy. One hundred consecutive patients that underwent surgery 
between 2009 and 2017 were included. The study shows a high rate of revisiona l surgery (17%) 
due to acute (n=9) or chronic (n=8) symptoms of bowel obstruction. Further analysis of the 
dataset revealed a higher preoperative weight and BMI and a greater postoperative weight loss in 
patients needing surgical revision for bowel obstruc tion.  
 
This trial looks at a relevant topic in esophageal surgery, as feeding jejunostomies are frequently 
used in this group of patients. The study design - although retrospective - is clear and the 
statistics seem sound, and all in all I think that this work is a valuable contribution to an ongoing 
scientific debate. However, I have a few remarks:  
 
* The main message of the paper is that in the univariate analysis, bowel obstruction after 
feeding jejunostomy is more frequent in patients with higher preop body weight and BMI 
and greater postop weight loss. Also, although not significant, patients undergoing a 
laparoscopic procedure were also at risk. Why didn´t the authors perform a multivariate 
analysis of all potential factors? This would certainly improv e the message of this paper.  
 
* The authors describe a technique for jejunal catheter insertion that includes a Witzel 
maneuver, which is unusual for laparoscopic procedures but commonly performed in 
open feeding tube placement. Also, the manufacturer of th e tube and the surgical thread is 
not mentioned. Moreover, no anti -rotation stitches are described, which are generally 
used by most surgeons performing this procedure. Given the extremely high reoperation 
rate - did the authors consider modifying their te chnique at some point of their 
experience? Fixation of the jejunal loop to the abdominal wall over a longer distance 
could possibly avoid rotation and twisting of the jejunum as shown in Figure 2. 
Consequently, it needs to be discussed that the main reason  for the exceptionally high 
rate of BOFJ in this study may be the technique used by the authors and not the preop 
BMI.  
 
* How many patients had other complications of feeding jejunostomy than bowel 
obstruction (leakage, infection, accidental removal needing  reinsertion, luminal 
obstruction of the catheter, kinking)? A thorough analysis of all potential complications 
attributable to feeding catheters would be interesting here.  
 
* Please include detailed information on other previous abdominal surgeries. This i s an 
important issue, as postoperative bowel obstruction could also be caused by adhesions 
other than from the jejunostomy site. Also, please state whether there were other reasons 
for bowel obstruction, i.e. other regions of the small bowel that actually needed 
adhesiolysis.  
 
* Please describe the surgical procedure for esophagectomy correctly. Did all patients 
undergo a McKeown esophagectomy with a thoracoscopic esophagectomy first, followed 
by a cervico -abdominal reconstruction phase?  
 
* Epigastric pain i s a frequent symptom after esophagectomy. How many patients 
presented with this symptom, how many patients underwent a diagnostic work -up 
including CT scan, and how many of them were finally diagnosed with bowel 
obstruction? Was the whirl sign a specific d iagnostic parameter in all patients and could 
this be verified during revisional surgery? Did all patients with unclear upper abdominal 
crampy pain undergo surgery or were some of the patients treated conservatively?  
 
* Higher weight loss may be due to (chr onic) bowel obstruction and therefore, rather a 
consequence of BOFJ than its cause.  
 
* Please explain the units used in the tables (n,% or mean/median range /IQR etc.)  
 
In summary, the manuscript needs revision but may be suitable for publication in the BM C 
Gastroenterology.  
 
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 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 am able to assess the statistics  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
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: 23 Apr 2019 
 
Reviewer:  C Gutschow  
 
Reviewer’s report:  
 
Namikawa T et al.: Bowel obstruction associated with a feeding jejunostomy and its association 
to weight loss after thoracoscopic esophagectomy  
 
This retr ospective monocentric study analyzes bowel obstruction due to jejunal feeding catheters 
after thoracoscopic esophagectomy. One hundred consecutive patients that underwent surgery 
between 2009 and 2017 were included. The study shows a high rate of revisiona l surgery (17%) 
due to acute (n=9) or chronic (n=8) symptoms of bowel obstruction. Further analysis of the 
dataset revealed a higher preoperative weight and BMI and a greater postoperative weight loss in 
patients needing surgical revision for bowel obstruc tion.  
 
This trial looks at a relevant topic in esophageal surgery, as feeding jejunostomies are frequently 
used in this group of patients. The study design - although retrospective - is clear and the 
statistics seem sound, and all in all I think that this work is a valuable contribution to an ongoing 
scientific debate. However, I have a few remarks:  
 
* The main message of the paper is that in the univariate analysis, bowel obstruction after 
feeding jejunostomy is more frequent in patients with higher preop body weight and BMI 
and greater postop weight loss. Also, although not significant, patients undergoing a 
laparoscopic procedure were also at risk. Why didn´t the authors perform a multivariate 
analysis of all potential factors? This would certainly improv e the message of this paper.  
 
* The authors describe a technique for jejunal catheter insertion that includes a Witzel 
maneuver, which is unusual for laparoscopic procedures but commonly performed in 
open feeding tube placement. Also, the manufacturer of th e tube and the surgical thread is 
not mentioned. Moreover, no anti -rotation stitches are described, which are generally 
used by most surgeons performing this procedure. Given the extremely high reoperation 
rate - did the authors consider modifying their te chnique at some point of their 
experience? Fixation of the jejunal loop to the abdominal wall over a longer distance 
could possibly avoid rotation and twisting of the jejunum as shown in Figure 2. 
Consequently, it needs to be discussed that the main reason  for the exceptionally high 
rate of BOFJ in this study may be the technique used by the authors and not the preop 
BMI.  
 
* How many patients had other complications of feeding jejunostomy than bowel 
obstruction (leakage, infection, accidental removal needing  reinsertion, luminal 
obstruction of the catheter, kinking)? A thorough analysis of all potential complications 
attributable to feeding catheters would be interesting here.  
 
* Please include detailed information on other previous abdominal surgeries. This i s an 
important issue, as postoperative bowel obstruction could also be caused by adhesions 
other than from the jejunostomy site. Also, please state whether there were other reasons 
for bowel obstruction, i.e. other regions of the small bowel that actually needed 
adhesiolysis.  
 
* Please describe the surgical procedure for esophagectomy correctly. Did all patients 
undergo a McKeown esophagectomy with a thoracoscopic esophagectomy first, followed 
by a cervico -abdominal reconstruction phase?  
 
* Epigastric pain i s a frequent symptom after esophagectomy. How many patients 
presented with this symptom, how many patients underwent a diagnostic work -up 
including CT scan, and how many of them were finally diagnosed with bowel 
obstruction? Was the whirl sign a specific d iagnostic parameter in all patients and could 
this be verified during revisional surgery? Did all patients with unclear upper abdominal 
crampy pain undergo surgery or were some of the patients treated conservatively?  
 
* Higher weight loss may be due to (chr onic) bowel obstruction and therefore, rather a 
consequence of BOFJ than its cause.  
 
* Please explain the units used in the tables (n,% or mean/median range /IQR etc.)  
 
In summary, the manuscript needs revision but may be suitable for publication in the BM C 
Gastroenterology.  
 
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 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 am able to assess the statistics  
 
Quality of written English  
Please in dicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
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