Rare Postoperative Complication of Esophageal Atresia after Open Thoracotomy Repair in Newborn—Lung Torsion: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor, Thank you for the invitation to review the manuscript of Grybos et al.

Pediatric surgery is not my main field of activity and interest but I read the paper with pleasure.

I'm not a native English speaker so I can't give strong guidance on the language revision, but I think there is a need of some improvements. I noticed some typos, such as double spaces and sometimes lack of punctuation.

Regarding the content of the manuscript, I have some questions to ask the Authors:

- the works that anecdotally reported lung torsion as a complication of operated esophageal atresia have been correctly cited, but therefore the real incidence of this complication seems to be not known. If this were the case, the Authors should underline this aspect.

- from what is reported in the manuscript, it seems that lung torsion is a short-term complication. Being a physician in a pediatric emergency room, I was wondering if it could be a late complication of an outpatient.

- is "Fortu" the trade name of ceftazidime? I encourage the Authors to use the name of the molecules

- see above: I advise the Authors to use the name of the molecule and not the commercial name, also for catecholamines

- the Authors have rightly underlined that early diagnosis is mandatory for diagnosis, and that delay can prove death as in their case. I refer to this as expressed previously: the incidence of this complication should be reported, because knowledge of lung torsion in this case could have improved the patient's prognosis. This could be information that will sensitize other pediatric physicians and surgeons to think about this eventuality.

- I appreciate the brevity of the manuscript as well as its concreteness.

- the bibliography is essential but complete and the conclusions are complete, clear, and accessible to the reader.

Comments on the Quality of English Language

please refer to queries in the review process.

Author Response

Reviewer 1

Dear Editor, Thank you for the invitation to review the manuscript of Grybos et al.

Pediatric surgery is not my main field of activity and interest but I read the paper with pleasure.

I'm not a native English speaker so I can't give strong guidance on the language revision, but I think there is a need of some improvements. I noticed some typos, such as double spaces and sometimes lack of punctuation.

Regarding the content of the manuscript, I have some questions to ask the Authors:

1. the works that anecdotally reported lung torsion as a complication of operated esophageal atresia have been correctly cited, but therefore the real incidence of this complication seems to be not known. If this were the case, the Authors should underline this aspect.

Reply: Thank you so much for valuable comment. We added sentence about it (see Line 35-36).

2. from what is reported in the manuscript, it seems that lung torsion is a short-term complication. Being a physician in a pediatric emergency room, I was wondering if it could be a late complication of an outpatient.

Reply: Most of the complications described, such as torsion of the lung, were from a short-term point of view complications after trauma or surgery in the chest area. Spontaneous torsion is also mentioned in the literature (early unknown cause), so you have to be aware of a possible complication even when working in an emergency room.

3. is "Fortu" the trade name of ceftazidime? I encourage the Authors to use the name of the molecules

Reply: Yes „Fortum“ is a company name of Ceftazidime use in our hospital. We corrected in (Line 79).

4. see above: I advise the Authors to use the name of the molecule and not the commercial name, also for catecholamines

Reply: Thank you for comment, we corrected it according to instruction (Line 106).

5. the Authors have rightly underlined that early diagnosis is mandatory for diagnosis, and that delay can prove death as in their case. I refer to this as expressed previously: the incidence of this complication should be reported, because knowledge of lung torsion in this case could have improved the patient's prognosis. This could be information that will sensitize other pediatric physicians and surgeons to think about this eventuality.

Reply: Thank you for pointing this out. This complication is very rare, even in the adult population, which is several times higher than the child population. This work was written to increase the awareness of all involved specializations, which we believe will contribute to the improvement and increase of health care.
Our work points to the fatal end of the patient, despite the similar story of patients already described in other works. the conclusion of the knowledge is that after reading it, the surgeon who is at the operating table had time to make the right­ - better decision. the incidence cannot be measured in child population reports due to the promotion of research papers on the given issue. In adult population is Lung torsion (LT), a very rare with a reported incidence of 0.089% to 0.4% (Dai et al., 2016, https://pubmed.ncbi.nlm.nih.gov/27209019/)

6. I appreciate the brevity of the manuscript as well as its concreteness.

Reply: Thank you so much, we appreciate your opinion.

7. the bibliography is essential but complete and the conclusions are complete, clear, and accessible to the reader.

Reply: Thank you so much, we appreciate your opinion.

 

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

I thank the authors for giving me the opportunity to review their case report. This is a very interesting case with a rare complication. Despite the worse outcome there are two important learning points for the readers. Diagnostic/timing and what to do with the torsion parts of the lung. I think it will be of benefit for the readership of the Journal. 

Author Response

Reviewer 2

I thank the authors for giving me the opportunity to review their case report. This is a very interesting case with a rare complication. Despite the worse outcome there are two important learning points for the readers. Diagnostic/timing and what to do with the torsion parts of the lung. I think it will be of benefit for the readership of the Journal. 

 

Reply: Thank you for your valuable comments. Indeed, the timing of the reoperation is only possible if we think about the given problem, in our case there was a mistake and a bad assessment of the situation (presumed severe pneumonia). The procedure itself is up to the surgeon's decision, but our results in the presented case report will certainly help him in his decision-making.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors described a case of a newborn with congenital esophageal atresia and a postoperative complication of this defect as lung torsion. The case itself is interesting to present, however, the work in its current form cannot be published. The authors are requested to make additions, clarifications, and corrections.

1.       summary: It is not about the authors' condition but the child's, this sentence should be removed. The cause of death should be provided according to the data in the case description: bradycardia, sepsis. The conclusion should be phrased as "in any case" or "in every case."

2.       introduction: Table 1 should be removed, and the data from the studies should be presented in the introduction or discussion.

3.       In the clinical description, the authors repeat the same information – please revise. There is a lack of information regarding ECHO, EKG, ultrasound of the abdomen, and chest. Why was a CT scan not performed immediately? There is a lack of information about blood test results, CRP, PCT, blood cultures, and other biochemical tests.

4.       Please present the blood test results and blood cultures in a table. Additionally, please show the most recent CT scan taken after the surgery.

5.       The surgical description should be shortened or presented on a timeline.

6.       The conclusions and discussion are well-written.

7.       The entire paper should be rigorously checked for language accuracy.

Author Response

Reviewer 3

The authors described a case of a newborn with congenital esophageal atresia and a postoperative complication of this defect as lung torsion. The case itself is interesting to present, however, the work in its current form cannot be published. The authors are requested to make additions, clarifications, and corrections.

1. summary: It is not about the authors' condition but the child's, this sentence should be removed. The cause of death should be provided according to the data in the case description: bradycardia, sepsis. The conclusion should be phrased as "in any case" or "in every case."

Reply: Thank you for your valuable comments, we corrected these sentences in abstract (all changes are marked in yellow, in all manuscript).

2. introduction: Table 1 should be removed, and the data from the studies should be presented in the introduction or discussion.

Reply: Thank you for your opinion, but we do not agree, because the given table enables a quick and accessible overview of the given issue, and in addition, all the mentioned authors as well as their cited works are subsequently used in the discussion part.

3. In the clinical description, the authors repeat the same information – please revise. There is a lack of information regarding ECHO, EKG, ultrasound of the abdomen, and chest.

Reply: Thank you for valuable point. We added sentence about it in clinical history part.

 There is a lack of information about blood test results, CRP, PCT, blood cultures, and other biochemical tests.

Reply: Thank you for your important point. We added information about monitored parameters in surgical intervention part.

Why was a CT scan not performed immediately?

Reply: Due to the circumstances of this case (newborn), examinations were performed with a lower radiation load, taking into account the technical availability of the CT machine (which, unfortunately, is generally a very busy machine in our country).

4. Please present the blood test results and blood cultures in a table.

Reply: Thank you for your opinion. We are not sure if this is necessary, since we have a table with recorded data from each day, this means that we have too much data, and especially this case study is not aimed at tracking the connection of biochemical parameters with the described complication.

Additionally, please show the most recent CT scan taken after the surgery.

Reply: This will not be possible, as we do not routinely perform a CT scan immediately after surgery.

5. The surgical description should be shortened or presented on a timeline.

Reply: Thank you for your opinion, but we disagree, because the case report is primarily focused on describing the given complication from a surgical point of view.

6. The conclusions and discussion are well-written.

Reply: Thank you for your valuable comment.

7. The entire paper should be rigorously checked for language accuracy.

Reply: Thank you for your comment, we corrected all manuscript according to the certified english translator.

 

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Dear authors,

I would like to thank you for the opportunity to review this study, which presents a rare postoperative complication of esophageal atresia. Pulmonary torsion is rarely described as a complication after open thoracotomy repair of esophageal atresia in the newborn.

Here are my comments:

Abbreviations should not appear in the ABSTRACT chapter.

In the INTRODUCTION chapter, the purpose should be presented in more detail considering that the case study wants to draw our attention to a rare postoperative complication. This chapter should also describe in more detail the disease (esophageal atresia), classifications of esophageal atresia, treatment, normal course after surgery, and possible complications.

In MATERIAL AND METHOD the case is presented correctly, including the relevant information about the patient and a description of the symptoms, the diagnosis, the treatment and the expected outcome of the intervention.

The DISCUSSION chapter is not well represented. An analysis is needed to provide a necessary explanation of specific treatment decisions, surgical approaches, etc. Even if the article talks about esophageal ateresis, the discussion can develop in the direction of solving postoperative problems that, even if they are not specific to this disease, are much better described in the specialized literature.

The CONCLUSIONS chapter will highlight more clearly whether the aim of the study has been achieved.

There should be more references.

I wish you luck!

Author Response

Reviewer 4

Dear authors,

I would like to thank you for the opportunity to review this study, which presents a rare postoperative complication of esophageal atresia. Pulmonary torsion is rarely described as a complication after open thoracotomy repair of esophageal atresia in the newborn.

Here are my comments:

Abbreviations should not appear in the ABSTRACT chapter.

Reply: Thank you for your comment, but according to our knowledge, abbreviations can be used if they are subsequently explained (only two abbreviations are involved in our abstract).

In the INTRODUCTION chapter, the purpose should be presented in more detail considering that the case study wants to draw our attention to a rare postoperative complication. This chapter should also describe in more detail the disease (esophageal atresia), classifications of esophageal atresia, treatment, normal course after surgery, and possible complications.

Reply: Thank you for your valuable comment, but we do not agree with the opinion of the reviewer, as all the necessary information is given mainly in the introduction section. In addition, the article is presented as a case report and not as a review, so we think that the information in the text is sufficient.

In MATERIAL AND METHOD the case is presented correctly, including the relevant information about the patient and a description of the symptoms, the diagnosis, the treatment and the expected outcome of the intervention.

Reply: Thank you so much for valuable comment.

The DISCUSSION chapter is not well represented. An analysis is needed to provide a necessary explanation of specific treatment decisions, surgical approaches, etc. Even if the article talks about esophageal ateresis, the discussion can develop in the direction of solving postoperative problems that, even if they are not specific to this disease, are much better described in the specialized literature.

Reply: Thank you so much for your opinion. First of all, we would like to point out the fact that the given case report is not primarily aimed at solving this rare complication, it aims to point out other possible consequences and especially to increase the awareness of pediatric surgeons about the possibility of embolism and death in this complication.

The CONCLUSIONS chapter will highlight more clearly whether the aim of the study has been achieved.

Reply: Thank you so much for your opinion. The conclusion is clearly formulated also on the basis of many years of experience in the field of pediatric surgery of the first author, Dr. Grybośa with a description of outputs for clinical practice.

There should be more references.

Reply: Thank you for your recommendation. However, In the given issue, the amount of available literary sources is considerably limiting.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

 

The authors did not respond to the previous comments from the reviewer. The manuscript is written in English that is difficult to understand. There is a lack of detailed data about the patient—since the cause of death was sepsis, the authors should present laboratory data in the table, indicating what happened with the child during the first 10 days of life. General statements such as routine tests, inflammatory parameters, etc., and the lack of bacteriological blood test results are questionable and do not reflect well on the quality of the work. In the manuscript, the authors repeatedly present similar data, and the overall case description is quite chaotic. In its current form, the manuscript cannot be accepted for publication.

Comments on the Quality of English Language

 

The authors did not respond to the previous comments from the reviewer. The manuscript is written in English that is difficult to understand. There is a lack of detailed data about the patient—since the cause of death was sepsis, the authors should present laboratory data in the table, indicating what happened with the child during the first 10 days of life. General statements such as routine tests, inflammatory parameters, etc., and the lack of bacteriological blood test results are questionable and do not reflect well on the quality of the work. In the manuscript, the authors repeatedly present similar data, and the overall case description is quite chaotic. In its current form, the manuscript cannot be accepted for publication.

Author Response

Reviewer 3 – round 2

The authors did not respond to the previous comments from the reviewer. The manuscript is written in English that is difficult to understand. There is a lack of detailed data about the patient—since the cause of death was sepsis, the authors should present laboratory data in the table, indicating what happened with the child during the first 10 days of life. General statements such as routine tests, inflammatory parameters, etc., and the lack of bacteriological blood test results are questionable and do not reflect well on the quality of the work. In the manuscript, the authors repeatedly present similar data, and the overall case description is quite chaotic. In its current form, the manuscript cannot be accepted for publication.

Reply:

The manuscript was carefully reviewed by another native speaker (canadian nationality) and all changes are listed in red font in all manuscript.

In my opinion, the patient died of septic fluid after the release of mediators after the torsion of the lung lobes. After a detailed study of sepsis criteria and current literature, careful study of the autopsy report, we corrected the cause of death according to the reviewer opinion.

All available data of this case have been included in the manuscript.

Author Response File: Author Response.docx