Triple Atresia, Triple Threat? An Unusual Constellation of Primary Surgical Abnormalities

Round 1

Reviewer 1 Report

Very nice case series of a rare congenital malfolmation. The manuscript is very clearly written and the results of the authors are excellent. The suggestion for staged repair is in line with the literature, however the table is a bit simplified. It would be good to see the gestation age, birth weight of the patients to see the mortality is really coming from the combined thoracotomy and laparotomy.

Otherwise I would suggest the acceptance of this manuscript for publication

 

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

The condition described in these cases sounds rare but interesting. It is unusual this type of association but described, as reported by authors.

In case 1 it is not described the prenatal history of the patient and this must be add in the description of the clinical case. Are not reported any details of type of anorectal malformation ( only "abscence of the anus" ) and in the text is reported that colostomy was performe after 7 days. Author must describe better the management of the patient ih the first week of life and type on ARM.

Case 2 is well described.

There are in both cases any description of anesthesiological management during the surgical procedures: which type of monitoring was used ( normal parameters, NIRS) ?

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Thank you for the opportunity to review this small case series and review of the literature, in a rare combination of surgical anomalies.  I have several questions/ clarifications I would like to pose to the authors.

1. Under 2. Case Reports.  Please define the abbreviation AVSD, and define a "small" aorta.
2. A representative radiograph of a newborn would be helpful for recognition.
3. Can the authors describe the abdominal incision used to address the DA and perform a colostomy?  One, or two separate.  Was consideration give to placing a gastrostomy?
4. In case 1, was the symptomatic PDA treated medically?  Was their consideration given to surgical ligation as the authors state the child was quite symptomatic.
5. Under 2. Case reports.  Define CTG and why this led to C section.
6. What do you mean by siting a replogle?
7. Please quantify your length of follow-up.  any other complications from the surgery ie esophageal strictures, et
8. Regarding the chylothorax, was the baby on breast mild feeds?  Any attempt to used a different formula to manage?  How long did the chyle leak take to resolve?
9. Under Results, please let the reader know why 23 studies were excluded.
10. As far as the outside cases, please clarify if possible why the dx was delayed up to 4 days.  Access to care issues?
11. It is very worrisome that some outside case reports fixed the DA before fixing the OA/TEF as could lead to the inability to ventilate, gastric distension with rupture as the air cannot go distally, pneumonitis.  I would ask the authors to use stronger language supporting the most prudent order of surgical repair, whether stage or not.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

The authors have addressed all of my prior questions thoroughly and completely and I believe have strengthened their submission for readership.