Twisted Troubles: A Rare Case of Intestinal Obstruction Due to Endometriosis and a Review of the Literature

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

thank you for this case report on a tricky case of endometriosis involving bowel. The case is very well presented and complete. I highly appreciated the figures both intraoperative and hysthopatological. I would recommend a general overview of the spelling, some words are mispelled, please check. Moreover, I would appreciate a more deeply presentation of the patient, including basic anamnestics information such as the parity. Furthermore, although you state that a literature review has been performed, you do not present the methods used to perform it. In this latter case, you just provided a very extended and updated discussion. Please either present the methods used to include the articles in the revision or do not state that a literature review has been performed, but just present your interesting case with (as you did) an appropriate and updated discussion citing the living literature.

Thank you

best regards

Author Response

Dear Reviewer,

Thank you for your thoughtful and constructive feedback on our case report titled "Twisted Troubles: A Rare Case of Intestinal Obstruction due to Endometriosis and A Review of the Literature." We appreciate your positive comments regarding the presentation and the quality of the figures, both intraoperative and histopathological.

We have addressed the issues you raised as follows:

Spelling and Grammar: We have thoroughly reviewed the manuscript for spelling and grammatical errors and made the necessary corrections to improve the overall clarity and readability of the text.

Patient Information: In response to your suggestion, we have expanded the patient’s profile to include information, such as parity. We agree that this information is crucial for providing a complete clinical picture, and we appreciate your recommendation to include it.

Literature review methodology: We acknowledge your concern regarding the lack of detailed methodology for the literature review. Initially, our aim was to provide an extensive discussion that integrates relevant literature to support the case presented. However, to address your point, we have now explicitly outlined the methods used for our literature search and article selection. This includes the databases searched, the keywords used, and the inclusion and exclusion criteria applied. We believe this addition will clarify the scope and approach of our review for readers.

We hope these revisions meet your expectations and enhance the quality of our manuscript. We are grateful for your valuable feedback, which has undoubtedly contributed to the improvement of our work.

Thank you once again for your time and consideration.

Best regards,

Reviewer 2 Report

Comments and Suggestions for Authors

Dear colleagues,

Thank you very much for submitting your manuscript.

The article addresses a significant subject for medical practice, namely complications arising due to extragenital determinations of endometriosis.

The text is clear and easy to read. The manuscript has an excellent methodical description. The overall paper is organized and well-written. The authors present the case report and, in the discussion section, present other researchers' findings. The literature reviews are insightful and informative.

The table and the figures are well-presented and easy to read and understand. The presented aspects sufficiently support the conclusions.

I congratulate all the authors for their efforts.

I have only a few remarks to make:

-- The structure of the abstract should be similar to that of the article.

For keywords, I recommend introducing the word extragenital

In presenting the case, it would be interesting to specify when the patient had her last period.

In Figure 1, write that it is an ultrasound image. Please note the intraoperative findings in the figures photographed during the intervention.

In Figure 4, write that it is a CT image.

All abbreviations must be explicit when they appear in the text for the first time – for example, CT has no explanation.

Figures and tables must be referenced in the text before they appear in the text. Please check and correct this aspect.

 In the Discussions Section, a literature review is included when you discuss the Extragenital endometriosis. Please enter the keywords that were the basis of the search and the period in which the search was performed.

Author Response

Dear Reviewer,

Thank you very much for your thorough and positive review of our manuscript titled "Twisted Troubles: A Rare Case of Intestinal Obstruction due to Endometriosis and A Review of the Literature." We appreciate your kind words and the constructive feedback, which have been invaluable in improving our work.

We have carefully addressed each of your remarks as follows:

Abstract structure: We have revised the abstract to ensure that its structure mirrors that of the article, aligning the sections accordingly.

Keywords: As recommended, we have added the keyword "extragenital" to enhance the relevance and searchability of the manuscript.

Patient's last period: We have included information regarding the timing of the patient's last menstrual period in the presentation of the case to provide additional context to the clinical picture.

Figure descriptions:

In Figure 1, we have added that it is an ultrasound image.

We have also noted the intraoperative findings in the figures that were photographed during the intervention.

In Figure 4, we have specified that it is a CT image.

Abbreviations: We have ensured that all abbreviations, including "CT," are fully explained the first time they appear in the text.

References for figures and tables: We have reviewed the manuscript to ensure that all figures and tables are referenced in the text before they appear. Necessary corrections have been made.

Discussion section - literature review: We have included the keywords that formed the basis of our literature search and specified the period during which the search was conducted in the Discussions section, particularly when discussing extragenital endometriosis.

We hope these revisions meet your expectations and further enhance the quality of our manuscript. Once again, we thank you for your thoughtful review and valuable suggestions.

Best regards,

Reviewer 3 Report

Comments and Suggestions for Authors

This is a good study. But need some corrections.

1- Even this is a case and review, I suggest them to add a figure of  PRISMA study selection. This will give a good readability.

2- Write your objective  (aim) as the last paragraph of the introduction section.

3- Change line 77-79. Should be written as recommended by CARE guidelines.

4- Authors should follow CARE guidelines for writing skills of their case report.

5- Why you begin to operation with median laparotomy firstly ? Why you don't take a look with laparoscopy ? Any cases ?

6- The case was volvulus or internal hernia ?

7- I suggest you to cite: Azizoglu M, Arslan S, Kamci TO, Basuguy E, Aydogdu B, Karabel MA, Okur MH. Can direct bilirubin-to-lymphocyte ratio predict surgery for pediatric adhesive small bowel obstruction? Cir Cir. 2024;92(3):307-313. English. doi: 10.24875/CIRU.23000524. PMID: 38862103.   AND.  Senejoa N, González-Ausique PS, Enamorado-Enciso N. Sigmoid volvulus and descending colon adenocarcinoma, a double cause of intestinal obstruction: a case report. Cir Cir. 2023;91(6):839-843. English. doi: 10.24875/CIRU.22000179. PMID: 38096878.  AND  Kose Kusluk B, Ozcakir E, Okay ST, Kaya M. A case of intestinal perforation due to multiple magnet ingestion: Minimally invasive approach is possible. Coc Cer Derg/Turkish J Ped Surg 2022;36(1): 62-65. doi: 10.29228/JTAPS. 53681

Comments on the Quality of English Language

minor polishing

Author Response

Dear Reviewer,

Thank you for your valuable feedback and suggestions regarding our manuscript titled "Twisted Troubles: A Rare Case of Intestinal Obstruction due to Endometriosis and A Review of the Literature." We appreciate your positive comments and the time you took to provide detailed recommendations for improving our work.

We have carefully considered your suggestions and made the following revisions:

 

PRISMA study selection figure:

We have added a PRISMA flow diagram to illustrate the study selection process for the literature review. This addition enhances the transparency and readability of our review.

 

Objective statement in introduction:

We have moved the objective of the study to the last paragraph of the Introduction section, as you recommended. This clearly sets the stage for the study and aligns with standard practices.

 

Revision of lines 77-79:

The content on lines 77-79 has been revised to comply with the CARE guidelines. We ensured that the description is precise and follows the recommended format for case reports.

 

Adherence to CARE guidelines:

We reviewed the entire manuscript and made necessary adjustments to ensure that it fully adheres to the CARE guidelines for case report writing. This includes refining the structure and presentation to meet these standards.

 

Surgical approach explanation:

The patient presented with an intestinal obstruction, characterized by a significantly distended and tense abdomen, which are clear contraindications for laparoscopic surgery. The severity of the abdominal distension and the risk of increased intra-abdominal pressure in such cases can compromise the safety and efficacy of a laparoscopic approach. As a result, we opted for a median laparotomy to ensure immediate and comprehensive access to the abdominal cavity, which was necessary given the urgency and complexity of the case.

 

Clarification on volvulus vs. internal hernia:

The manuscript has been revised to clarify that the case involved a volvulus, not an internal hernia. We have included additional details to differentiate between the two conditions and explain the diagnostic findings that led to this conclusion.

 

Additional Citations:

We have cited the suggested references in the appropriate sections of the manuscript. These references provide valuable context and support for our discussion, particularly in relation to surgical decision-making and similar case reports:

We believe these changes have significantly strengthened our manuscript. We are grateful for your insightful feedback and suggestions, which have helped us enhance the quality of our work.

Thank you once again for your time and consideration.

Best regards,

Reviewer 4 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for your great topic on women’s health. The paper is very well written. I have only some comments:

Q1. The grade of endometriosis should be added in introduction.

Q2. In line 77-84, the most important point in endometriosis is the lower abdominal pain following the menstrual period. Please provide the menstrual characteristics. The patient was diagnosed with pre-,peri-, or post-menopausal stage?

Q3. Did the patient follow-up the gynecologic visit before gastrointestinal symptoms? The presence of endometriosis must be exist in a long-time before complication.

Q4. Pregnancy test (serum/urine beta-HCG) should be entercounted to exclude the abdominal pain in pregnancy although the patient age was 50.

Q5. Gravida, parity should be provided. Since endometriosis may relate to female infertility.

Q6. Body mass index (BMI) should be added.

Q7. Please describe the appearance of pelvic cavity as well as the uterus and bilateral ovaries.

Q8. The time duration from volvulus detection to surgical intervention should be given.

Q9. The intraoperatively estimated blood loss should be added.

Q10. The antibiotic therapy should be given postoperatively.

Q11. The number of figures is excessive. Fig 5,6,7,8,9 should be presented in the same frame. Similarly, the fig 10 and 11.

Q12. The anatomic note should be added in fig 5,6,7,8,9.

Q13. Please reorder the published year in Table 1 following chronological order. (2020,2021,2022,2023,2024).

Q14. Please add full-word as foot-note under the table 1. CT, MRI, IVA, DIE.

Q15. Please add the full-word for DIE in line 475: Deep infiltrating endometriosis (DIE) as well as gastrointestinal tract (GI) in line 481: the most common sites of GI endometriosis. Similar to line 414: Gastrointestinal anastomosis (GIA) stapler.

Q16. The differentiated diagnosis should be established. Malignant tumors in associated with GI should be excluded firstly.

Q17. The underlying mechanism relating to twisted bowel obstruction due to endometriosis should be expanded. It may relate to the size of endometriosis tumor.

Q18. Evaluation of bowel necrosis and risk of artificial anus should be mentioned.

Q19. The strategy prevents the recurrence should be added.

Q20. Monitoring with a gynecologist should be advised. The pelvic pain should be considered as early sign for timely management among women with endometriosis.

Best regards,

Author Response

Dear Reviewer,

 

Thank you for your thoughtful and constructive feedback on our case report titled "Twisted Troubles: A Rare Case of Intestinal Obstruction due to Endometriosis and A Review of the Literature." We appreciate your positive comments regarding the presentation and the quality of the figures, both intraoperative and histopathological.

 

We have addressed the issues you raised as follows:

Reviewer Comment Q1: The grade of endometriosis should be added in the introduction.

Response: Thank you for the question. The diagnose of endometriosis was a surprise for the surgical team as well as this was an emergency surgery of a volvulus. Only after the biopsy result came, roughly 4 weeks later, we found out that it was endometriosis. During the procedure itself we did not detect any lesion that would suggest is an endometrial tissue.

 

Reviewer Comment Q2: In line 77-84, the most important point in endometriosis is the lower abdominal pain following the menstrual period. Please provide the menstrual characteristics. The patient was diagnosed with pre-, peri-, or post-menopausal stage?

Response: We appreciate your insight. We have now provided additional details on the patient's menstrual characteristics, noting that she was in the peri-menopausal stage. The clinical presentation included lower abdominal pain that correlated with her menstrual cycle, particularly during the 18th day, consistent with the typical endometriosis symptomatology.

 

Reviewer Comment Q3: Did the patient follow-up the gynecologic visit before gastrointestinal symptoms? The presence of endometriosis must be exist in a long-time before complication.

Response: We have clarified the patient's medical history to indicate that she did not had a previous gynecological evaluation.

 

Reviewer Comment Q4: Pregnancy test (serum/urine beta-HCG) should be encountered to exclude the abdominal pain in pregnancy although the patient age was 50.

Response: The patient did not have any clinical symptoms of endometriosis, thus we did not perform any pregnancy test. We treated the case as a normal intestinal occlusion.

 

Reviewer Comment Q6: Body mass index (BMI) should be added.

Response: The patient's BMI has been added to the case report under the patient information section.

 

Reviewer Comment Q7: Please describe the appearance of the pelvic cavity as well as the uterus and bilateral ovaries.

Response: The intraoperative findings have been expanded to include a detailed description of the pelvic cavity, including the appearance of the uterus and bilateral ovaries. These structures were evaluated during surgery and showed no significant abnormalities that would suggest endometriotic lesions.

 

Reviewer Comment Q8: The time duration from volvulus detection to surgical intervention should be given.

Response: The manuscript now includes the time interval between the detection of the volvulus and the surgical intervention, which was approximately 14 days. After admission

 

Reviewer Comment Q9: The intraoperatively estimated blood loss should be added.

Response: We have added the estimated blood loss during surgery, which was less than 100 mL

 

Reviewer Comment Q10: The antibiotic therapy should be given postoperatively.

Response: The postoperative management section now includes a description of the antibiotic regimen administered to the patient, which consisted of broad-spectrum antibiotics to prevent infection.

 

Reviewer Comment Q11: The number of figures is excessive. Fig 5,6,7,8,9 should be presented in the same frame. Similarly, the fig 10 and 11.

Response: We appreciate your suggestion regarding the consolidation of figures. However, we believe that presenting Figures 5, 6, 7, 8, and 9 separately allows for a more detailed and clear depiction of the complex surgical findings and step-by-step process involved in managing this rare case. Each figure highlights specific aspects of the surgical intervention, which we feel is critical for the reader’s understanding of the procedure and its outcomes. Similarly, Figures 10 and 11 each provide unique histopathological insights that are best appreciated when viewed independently.

 

Reviewer Comment Q14: Please add full-word as foot-note under the table 1. CT, MRI, IVA, DIE.

Response: Full terms for CT (Computed tomography), MRI (Magnetic resonance imaging), IVA (Intravenous anesthesia), and DIE (Deeply infiltrating endometriosis) have been added as footnotes under Table 1.

 

Reviewer Comment Q15: Please add the full-word for DIE in line 475: Deep infiltrating endometriosis (DIE) as well as gastrointestinal tract (GI) in line 481: the most common sites of GI endometriosis. Similar to line 414: Gastrointestinal anastomosis (GIA) stapler.

Response: Full terms have been added where appropriate, including Deep Infiltrating Endometriosis (DIE), Gastrointestinal Tract (GI), and Gastrointestinal Anastomosis (GIA) stapler.

 

Reviewer Comment Q16: The differentiated diagnosis should be established. Malignant tumors in associated with GI should be excluded firstly.

Response: We have expanded the differential diagnosis section to discuss the exclusion of malignant tumors as part of the initial diagnostic workup. This is particularly important given the patient's age and presentation.

 

Reviewer Comment Q17: The underlying mechanism relating to twisted bowel obstruction due to endometriosis should be expanded. It may relate to the size of endometriosis tumor.

Response: The study has been revised to include a more detailed explanation of the possible mechanisms leading to bowel obstruction, including the role of the size and location of endometriotic lesions.

 

Reviewer Comment Q18: Evaluation of bowel necrosis and risk of artificial anus should be mentioned.

Response: We have included a section on the evaluation of bowel necrosis during surgery and discussed the consideration of creating an artificial anus, which was ultimately not required due to the viability of the bowel. We added that the tumor was located precisely at the level of the ileocecal valve, where it caused a progressive stenosis, leading to the distension of the small intestine in an attempt to overcome the obstruction. However, the intestine was excessively distended, which contraindicated the creation of an anastomosis. Therefore, a minor enterectomy of approximately 8 cm starting from the ileocecal valve was performed, followed by a terminal ileostomy.

 

Reviewer Comment Q19: The strategy prevents the recurrence should be added.

Response: A discussion on strategies to prevent recurrence has been added, including the potential use of hormonal therapy and regular follow-up with a gynecologist.

 

Reviewer Comment Q20: Monitoring with a gynecologist should be advised. The pelvic pain should be considered as early sign for timely management among women with endometriosis.

Response: We have emphasized the importance of continued gynecological monitoring for patients with a history of endometriosis, advising that pelvic pain should be promptly investigated to enable timely management.

 

We appreciate your detailed feedback and believe these revisions have significantly improved the manuscript.

 

Thank you once again for your time and consideration.

 

Best regards,

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

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Author Response

Dear Reviwer

 

I would like to sincerely thank you for your thoughtful and positive feedback on our manuscript. Your assessment is highly appreciated, and your recognition of the work put into this research is truly encouraging.

Thank you again for your time and effort in reviewing this paper. We are grateful for your support in bringing this work closer to publication.

Dr. Iordache Eduard

Reviewer 4 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for your revision. The paper is well-improved. However, In previous comment, I recommended that the authors should describe 4 grades of endometriosis following AAGL 2021 classification and mention the present case according to which grade in the presentation case. But the authors misunderstood and replied on histopathological examination and diagnosis. Please provide the classification since the severe grade may relate to the current entity. The authors could find the classification in these paper:

Pašalić E, Tambuwala MM, Hromić-Jahjefendić A. Endometriosis: Classification, pathophysiology, and treatment options. Pathol Res Pract. 2023;251:154847. doi:10.1016/j.prp.2023.154847

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score Abrao, Mauricio S. et al. Journal of Minimally Invasive Gynecology, Volume 28, Issue 11, 1941 - 1950.e1

 

Author Response

Thank you for your valuable feedback. We have made the requested changes and included a detailed description of the 4 grades of endometriosis according to the AAGL 2021 classification. Additionally, we have specified that the present case corresponds to Grade II endometriosis. These revisions can be found in lines 408-421 of the revised manuscript. We appreciate your guidance in enhancing the clarity and accuracy of our work.

 

Kind regards,

Dr. Iordache Eduard