Amylase Levels Are Useful for Diagnosing Omphalomesenteric Cysts: A Case Report
, Mitsuyuki Nakata, Tetsuya Mitsunaga, Shugo Komatsu, Takeshi Saito and Tomoro Hishiki
Round 1
Reviewer 1 Report
Manuscript No: pediatrrep-1539048
This manuscript was written about a case of omphalomesenteric cysts diagnosed by high local amylase levels. This manuscript is an important case report and states some important issues. However further discussion would be required. Therefore, authors would clarify matters that mentioned below.
- If you suspected omphalomesenteric remnant, did you perform a Meckel scan (Technetium-99m pertechnetate scintigraphy) preoperatively? If you perform the study, it is better to add the findings.
- Omphalomesenteric remnant is sometimes associated with umbilical abnormalities. Did the patient have any temporary umbilical abnormalities after birth?
Author Response
- If you suspected omphalomesenteric remnant, did you perform a Meckel scan (Technetium-99m pertechnetate scintigraphy) preoperatively? If you perform the study, it is better to add the findings.
→We thank you for your suggestion. If we performed the Meckel scan, we could have gotten more information in this case. However, we did not perform the Meckel scan, since we could already diagnose this case with our imaging studies and the amylase level of the cyst.
- Omphalomesenteric remnant is sometimes associated with umbilical abnormalities. Did the patient have any temporary umbilical abnormalities after birth?
→We thank you for bringing this up. To the best of our knowledge, the patient was never pointed out to have an abnormality in the umbilicus.
Reviewer 2 Report
Congrats to the authors on the management of this case.
They mention that the US did not show any obstruction. Did the US show the cyst? It is a big lesion with a large hematoma, so how diagnostic was the US or was it not helpful.
Was the centesis of the hematoma done for therapeutic or diagnostic purposes? I am not sure how safe that was that given at that stage the possibility of malignancy was not ruled out. Were you worried about spilling malignant cells and track metastasis?
It was a brilliant idea to send fluid for amylase. Is it routine to send such aspirate to be tested for amylase?
Line 85 and 86 need to be corrected. It implies that ventral hernias and urachal remnants are malignant.
Best wishes
Author Response
They mention that the US did not show any obstruction. Did the US show the cyst? It is a big lesion with a large hematoma, so how diagnostic was the US or was it not helpful.
→We thank you for pointing this out, and we apologize for the misunderstanding. We would like to clarify that “Abdominal radiography” meant “X-ray” in the text. Moreover, we first discovered a huge intraabdominal cyst on US, but on contrast-enhanced computed tomography (CT), the cyst was just below the navel in the abdominal wall. The content of the paper has been revised. We changed the description as follows: “Abdominal ultrasonography (US) revealed a large intraabdominal cyst, but contrast-enhanced computed tomography (CT) showed that the cystic lesion of 4 cm in diameter was located in the abdominal wall, beneath the umbilicus. "
Was the centesis of the hematoma done for therapeutic or diagnostic purposes? I am not sure how safe that was that given at that stage the possibility of malignancy was not ruled out. Were you worried about spilling malignant cells and track metastasis?
→We thank you for your comments. As you pointed out, there was a possibility of dissemination by puncture if the lesion was malignant. Since there was a big difference in the surgical method depending on whether it was malignant or not, we were aware of the risks. We examined the presence of malignant cells in the puncture fluid, but no malignant cells were observed.
It was a brilliant idea to send fluid for amylase. Is it routine to send such aspirate to be tested for amylase?
→We thank you for asking this question. Actually, it was not the routine to test the amylase level of the fluid. We sometimes experienced a case of omphalomesenteric duct remnants that involve ectopic pancreatic tissue. We speculated that if the cyst in this case originated from the remnant, ectopic pancreatic tissue may be involved. However, we also examined the biochemical contents and the presence of malignant cells in the puncture fluid, since we could not rule these out yet.
Line 85 and 86 need to be corrected. It implies that ventral hernias and urachal remnants are malignant.
→We thank you for your comments. The content of the paper has been revised accordingly. We changed the description as follows: “Differential diagnosis of pediatric body wall masses includes rectus abdominis hernia, urachus remnants, rectus abdominis hematoma, abdominal wall abscess, hematoma, lymphatic/vascular malformations, and malignant tumors, such as rhabdomyosarcoma and other rare sarcomas.”
Reviewer 3 Report
The authors presented a case of a 15-month-old pediatric female patient with a omphalomesenteric cysts in which the local level of amylase was useful for diagnosis.
I read an article with great interest. Unfortunately it is poorly designed and written. The case is not suitable for publication due to the following reasons:
- An introduction is very poor and should be updated, focusing more on the main objection of this report (uncommon presentation and laboratory values of increased enzyme levels due to heterotopic tissue).
- Normal values of presented laboratory markers should be presented in brackets.
- Intraoperative findings are poorly presented. The surgical findings should be described with more details. Also, why was the procedure not terminated by laparoscopy, why the authors converted this into an open procedure?
- Discussion is poorly designed and totally missed, mostly repeating well known facts from literature. The authors should discuss this case in short lines and compare it to published cases from literature and should emphasise why this case is important and what is a difference from published data.
- Conclusions drawn by the authors are mostly general and do not follow from their case. They should provide only conclusions that directly arise from the presented case.
- The main question is how this single case adds to the scientific literature?! All presented regarding this condition is well known and has been published several times previously. I do not see any novelty from this report. A slightly different clinical presentation (hematoma with increased amylase level) does not represent any significant novelty
Author Response
1. An introduction is very poor and should be updated, focusing more on the main objection of this report (uncommon presentation and laboratory values of increased enzyme levels due to heterotopic tissue).
→We thank you for your advice. As you pointed out, it seems that the introduction should be specific to this case. However, as far as I investigated, there were only a few similar cases. Moreover, the introduction focused on explaining the general contents, whereas the discussion focused on similar reports to the present case. Although the introduction was short, we would like to ask for your kind understanding given these circumstances and the recommended limit on the number of characters.
2. Normal values of presented laboratory markers should be presented in brackets.
→We thank you for your suggestion. We have added the normal value of amylase in our hospital. Accordingly, we have changed the description as follows: “Blood examination indicated a white blood cell count of 14,500/μL, a C-reactive protein level of 2.4 mg/dL, a hemoglobin level of 9.6 g/dL, and an amylase level of 98 U/L (44−132 U/L).”
3. Intraoperative findings are poorly presented. The surgical findings should be described with more details. Also, why was the procedure not terminated by laparoscopy, why the authors converted this into an open procedure?
→We thank you for your comments. Cyst and hematoma removal was performed directly from the wound to avoid peritoneal damage. The content of the paper has been revised, and we have changed the description as follows: “Moreover, the omphalomesenteric cyst was connected to the hematoma, which extended to the right abdominal wall (Figure 1c). During surgery, the mesodiverticular band was detached laparoscopically, the omphalomesenteric cyst was completely removed via circumumbilical and small median incisions, and the hematoma was excised to the greatest extent possible.”
4. Discussion is poorly designed and totally missed, mostly repeating well known facts from literature. The authors should discuss this case in short lines and compare it to published cases from literature and should emphasize why this case is important and what is a difference from published data.
→We thank you for your suggestions. The content of the paper has been revised with the suggestions of the previous comments. We would like to ask for your kind understanding with our brief discussion given the circumstances of previous studies and the recommended limit on the number of characters.
5. Conclusions drawn by the authors are mostly general and do not follow from their case. They should provide only conclusions that directly arise from the presented case.
→We thank you for your comments. The content of the paper has been revised, and we have changed the description as follows: “Apart from imaging findings, a high local level of amylase may indicate the existence of ectopic pancreatic tissue, which is helpful for the diagnosis of omphalomesenteric cysts.”
6. The main question is how this single case adds to the scientific literature?! All presented regarding this condition is well known and has been published several times previously. I do not see any novelty from this report. A slightly different clinical presentation (hematoma with increased amylase level) does not represent any significant novelty
→We thank you for your comments. To the best of our knowledge, the present case was the first case of omphalomesenteric cyst that was diagnosed with a high level of amylase in the aspirated fluid of the hematoma. Apart from imaging findings, a high local level of amylase indicates the existence of ectopic pancreatic tissue, which is helpful for the diagnosis of omphalomesenteric cysts. Since such a diagnostic method has not been reported so far, this case report was made.
Reviewer 4 Report
The present case report is presenting an observation in a 15 mo old female with a cystic lesion beneath the umbilicus and a huge hematoma within the abdominal wall. In hematoma increased amylase levels suggested the diagnosis of an omphalomesenteric duct containing aberrant pancratic tissue.
The case is well structured and clearly written, and presented with good images.
Abstract: Shows in a short and clear way the story
Introduction: Alright
Case report:
1: L37: The indication of CT Examination should be discussed. There seems to be no more information out of the CT compared to a sensitive ultrasound examination. Radiation could have been minimized.
2.: L 41: Centesis seems not to be the correct term (aspirate?)
3.: L 48: Was there any connection detectable between the omphalomesenteric cyst and the hematoma intraoperatively? Please comment
Discussion:
The discussion is well written and good structured:
1.: L85: may include malignancies, such as ventral hernia … these are no malignancies. Please avoid the term malignancies if you talk about non malignant diseases or aberrations.
References: are complete and due to rareness of the disease spread over a very long time period
Author Response
1: L37: The indication of CT Examination should be discussed. There seems to be no more information out of the CT compared to a sensitive ultrasound examination. Radiation could have been minimized.
→We thank you for your suggestion. We first discovered a large intraabdominal cyst by ultrasonography, but on contrast-enhanced computed tomography (CT), the cyst was found to be just below the navel in the abdominal wall. The content of the paper has been revised, and we have changed the description as follows: “Abdominal ultrasonography (US) revealed a large intraabdominal cyst, but contrast-enhanced computed tomography (CT) showed that the cystic lesion was only 4 cm in diameter and was located intraabdominally beneath the umbilicus.”
2.: L 41: Centesis seems not to be the correct term (aspirate?)
→We thank you for pointing this out. The content of the paper has been revised, and we have changed the description as follows: “Aspiration revealed bloody fluid with an amylase level of 38,250 U/L, …”
3.: L 48: Was there any connection detectable between the omphalomesenteric cyst and the hematoma intraoperatively? Please comment
→We thank you for your suggestion. As you stated, the content of the paper has been added, and we have changed the description as follows: “Moreover, the omphalomesenteric cyst was connected to the hematoma, which extended to the right abdominal wall (Figure 1c). During surgery, the mesodiverticular band was detached laparoscopically, the omphalomesenteric cyst was completely removed via circumumbilical and small median incisions, and the hematoma was excised to the greatest extent possible.”
Discussion:
The discussion is well written and good structured:
1.: L85: may include malignancies, such as ventral hernia … these are no malignancies. Please avoid the term malignancies if you talk about non malignant diseases or aberrations.
→We thank you for your pointing this out. The content of the paper has been revised, and we have changed the description as follows: “Differential diagnosis of pediatric body wall masses includes rectus abdominis hernia, urachus remnants, rectus abdominis hematoma, abdominal wall abscess, hematoma, lymphatic/vascular malformations, and malignant tumors, such as rhabdomyosarcoma and other rare sarcomas.”
Round 2
Reviewer 3 Report
The authors performed some minor, mostly technical corrections, although they did not respond to all (eg. they added normal values for amylase level, only, but not for the other parameters). Description of surgery as well as discussion are still poor. Introduction is very poor, below the standard.
As I pointed out previously, all presented regarding this condition is well known and has been published several times in literature. I do not see any novelty from this report. A slightly different clinical presentation (hematoma with increased amylase level) does not represent any significant novelty that deserves publication in international journal. Unfortunately, I do not see any benefits for the readers from this case report and this is not enough for publication in international journal.
Author Response
Thank you for your comments.
