Reviewer ’s report  
 
Title:  Is Discard Better than Return Gastric Residual Aspirates: A Systematic Review and M eta-
analysis  
 
Version: 2 Date: 15 Apr 2019 
 
Reviewer:  Thangaraj  Abiramalatha  
 
Reviewer’s report:  
 
Comments -3 
 
I thank the authors for making the suggested changes. A few more changes need to be done. 
Some of the minor changes suggested were not done (minor comments 6 and 8); I will leave 
those to the editors' discretion.  
 
1. Title is vague: Should include the study population and the primary outcome. May I 
suggest:  
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Enteral Feeding in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"   (o r) 
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Gastric Emptying in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"  
 
 
2. GRADE level of evidence - is not moderate given the relatively poor quality of the 
studies included (methods of randomization and allocation concealment not clear) and 
imprecision of the results (wide confidence intervals).  
 
- Quality of evidence is low for serum potassium level, downgraded for serious limitations of the 
study design.  
 
- Quality o f evidence is very low for all other outcomes, downgraded for serious limitations of 
the study design and imprecision due to wide confidence intervals.  
 
- Should be modified as above.  
 
 
3. Conclusion:  
 
"This meta -analysis failed to determine effect and safet y differences between discarding or 
returning residual gastric aspirates……." may be written as  
 
"There is insufficient evidence to support either returning or discarding gastric residual aspirates 
in critically ill adult patients, since the quality of evid ence is low to very low for all the 
outcomes"  
 
 
Minor changes  
 
1. Confidence interval of 48th hour residual volume is wrong. minus symbol is missing.  
 
2. The GRADE level of evidence (low to very low) should be mentioned in the abstract.  
 
3. Methods: "Publicati on bias was evaluated with.." may be written as "we planned to do 
publication bias assessment if 10 or more studies were included"  
 
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 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:  Is Discard Better than Return Gastric Residual Aspirates: A Systematic Review and M eta-
analysis  
 
Version: 2 Date: 15 Apr 2019 
 
Reviewer:  Thangaraj  Abiramalatha  
 
Reviewer’s report:  
 
Comments -3 
 
I thank the authors for making the suggested changes. A few more changes need to be done. 
Some of the minor changes suggested were not done (minor comments 6 and 8); I will leave 
those to the editors' discretion.  
 
1. Title is vague: Should include the study population and the primary outcome. May I 
suggest:  
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Enteral Feeding in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"   (o r) 
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Gastric Emptying in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"  
 
 
2. GRADE level of evidence - is not moderate given the relatively poor quality of the 
studies included (methods of randomization and allocation concealment not clear) and 
imprecision of the results (wide confidence intervals).  
 
- Quality of evidence is low for serum potassium level, downgraded for serious limitations of the 
study design.  
 
- Quality o f evidence is very low for all other outcomes, downgraded for serious limitations of 
the study design and imprecision due to wide confidence intervals.  
 
- Should be modified as above.  
 
 
3. Conclusion:  
 
"This meta -analysis failed to determine effect and safet y differences between discarding or 
returning residual gastric aspirates……." may be written as  
 
"There is insufficient evidence to support either returning or discarding gastric residual aspirates 
in critically ill adult patients, since the quality of evid ence is low to very low for all the 
outcomes"  
 
 
Minor changes  
 
1. Confidence interval of 48th hour residual volume is wrong. minus symbol is missing.  
 
2. The GRADE level of evidence (low to very low) should be mentioned in the abstract.  
 
3. Methods: "Publicati on bias was evaluated with.." may be written as "we planned to do 
publication bias assessment if 10 or more studies were included"  
 
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 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:  Is Discard Better than Return Gastric Residual Aspirates: A Systematic Review and M eta-
analysis  
 
Version: 2 Date: 15 Apr 2019 
 
Reviewer:  Thangaraj  Abiramalatha  
 
Reviewer’s report:  
 
Comments -3 
 
I thank the authors for making the suggested changes. A few more changes need to be done. 
Some of the minor changes suggested were not done (minor comments 6 and 8); I will leave 
those to the editors' discretion.  
 
1. Title is vague: Should include the study population and the primary outcome. May I 
suggest:  
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Enteral Feeding in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"   (o r) 
 
"Returning Versus Discarding Gastric Residual Aspirates to Promote Gastric Emptying in 
Critically Ill Adult Patients: A Systematic Review and Meta -analysis"  
 
 
2. GRADE level of evidence - is not moderate given the relatively poor quality of the 
studies included (methods of randomization and allocation concealment not clear) and 
imprecision of the results (wide confidence intervals).  
 
- Quality of evidence is low for serum potassium level, downgraded for serious limitations of the 
study design.  
 
- Quality o f evidence is very low for all other outcomes, downgraded for serious limitations of 
the study design and imprecision due to wide confidence intervals.  
 
- Should be modified as above.  
 
 
3. Conclusion:  
 
"This meta -analysis failed to determine effect and safet y differences between discarding or 
returning residual gastric aspirates……." may be written as  
 
"There is insufficient evidence to support either returning or discarding gastric residual aspirates 
in critically ill adult patients, since the quality of evid ence is low to very low for all the 
outcomes"  
 
 
Minor changes  
 
1. Confidence interval of 48th hour residual volume is wrong. minus symbol is missing.  
 
2. The GRADE level of evidence (low to very low) should be mentioned in the abstract.  
 
3. Methods: "Publicati on bias was evaluated with.." may be written as "we planned to do 
publication bias assessment if 10 or more studies were included"  
 
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 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