Case Report of a Neonate with Complex Gastroschisis: A Multidisciplinary Approach
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe paper describes a case of vanishing gastroschisis that is, although rare, a well known complication of the malformation. Literatire review is provided on this particular aspect.
Introduction: The authors should remove the sentence as "complicated by segmental ileal and colonic atresia" (see explanation below).
The Authors claim they present a "comprehensive review" but no PRISMA (or similar) methodology is shown. How was the review carried on?
Case presentation
This paper is too lenghty and should be shortened.
The Authors consider as "complication" the "segmental ileal and colonic atresias". However, this is the "natural" consequence of the amputation of the intestine at the umilical level. Such sentence ("complicated by segmental ileal and colonic atresia") should be removed from abstract, introduction and case description. In the Discussion, the Authors report the classification of vanishing gastroschisis and themselves classified their case as type B that, indeed, includes the "atresias"
An important detail is missing, that is the initial lenght of the remaining intestine. Such datum defines and affects the subsequent follow up.
Why did the authors wait 10 days before operating the child at the second episode of NEC (in which portal venous gas is clearly visible)?
Fig.5: it looks like a complete deishence of the wound with herniation of abdominal content occurred. But no mention of such complication is described in the text
Why, in spite of a demonstrated obstruction at the proximal jejunum, the patient was put on an increasing sham feeding?
Discussion
The authors write "resection of duodenal atresia", without mentioning anything before. Where does this come from?
Overall, this part includes some well known concepts (see the second, third, and last paragraph) that do not add anything new and illude the readers.
Author Response
Comment 1: The paper describes a case of vanishing gastroschisis that is, although rare, a well-known complication of malformation. The literature review is provided on this particular aspect.
Thank you for your detailed review and constructive feedback on our manuscript. Below, we address each of your points in detail:
Introduction:
Comment 2: The authors should remove the sentence "complicated by segmental ileal and colonic atresia" (see explanation below).
Response: We agree with your suggestion and will remove the sentence from the Introduction.
Comment 3: The Authors claim they present a "comprehensive review," but no PRISMA (or similar) methodology is shown. How was the review carried on?
Response: We have modified the sentence mentioning it’s a case report.
Case presentation
Comment 4: This paper is too lengthy and should be shortened.
Response: We have shortened the manuscript to enhance clarity and conciseness without compromising essential details.
Comment 5: The Authors consider as "complication" the "segmental ileal and colonic atresias". However, this is the "natural" consequence of the amputation of the intestine at the umilical level. Such sentence ("complicated by segmental ileal and colonic atresia") should be removed from abstract, introduction and case description. In the Discussion, the Authors report the classification of vanishing gastroschisis and themselves classified their case as type B that, indeed, includes the "atresias"
Response: We have removed the sentence “complicated by segmental ileal and colonic atresia” from the abstract, and introduction.
Comment 6: An important detail is missing, that is the initial length of the remaining intestine. Such datum defines and affects the subsequent follow up.
Response: Thank you for your observation. We performed a 10 cm segmental ileal resection, and the small intestine's initial remaining length was 30 inches. This detail has been added to the revised manuscript to provide a clearer understanding of the subsequent follow-up.
Comment 7: Why did the authors wait 10 days before operating the child at the second episode of NEC (in which portal venous gas is clearly visible)?
Response: Thank you for your question. The decision to wait 10 days before operating on the child during the second episode of NEC, despite the presence of portal venous gas, was due to the neonate's critical clinical status. The patient required vasopressors and was experiencing significant third spacing. Given these conditions, the surgeon preferred to stabilize the neonate before proceeding with exploratory surgery.
Comment 8: Fig.5 - it looks like a complete dehiscence of the wound with herniation of abdominal content occurred. But no mention of such complication is described in the text.
Response: We appreciate the reviewer's feedback. However, we would like to clarify that Figure 5 does not depict herniation of abdominal contents. After attempting temporary closure of the perforated intestinal loops, the abdomen was intentionally left open for healing and covered with a sterile dressing under a transparent adhesive film, with the repaired loops positioned beneath. We have included this description in the revised manuscript.
Comment 9: Why, in spite of a demonstrated obstruction at the proximal jejunum, the patient was put on an increasing sham feeding?
Response: Thank you for your question. Despite the demonstrated obstruction at the proximal jejunum, the patient was placed on increasing sham feeding, which involves oral feeding followed by removal via a nasogastric tube to low intermittent suction before digestion occurs. This approach is not intended for nutritive purposes but rather to stimulate the gastrointestinal tract and assess its function safely. In this patient, it was deemed safe to increase sham feeding as it helps in evaluating the recovery of bowel function without exacerbating the obstruction.
Discussion
Comment 10: The authors write "resection of duodenal atresia", without mentioning anything before. Where does this come from?
Response: Thank you for your feedback. We have revised the text for clarity: "Following recurrent NEC, the patient underwent extensive lysis of adhesions, resection of the proximal stenotic bowel, and a jejunum-to-duodenum anastomosis.”
Comment 11: Overall, this part includes some well-known concepts (see the second, third, and last paragraph) that do not add anything new and illude the readers.
Response: We have revised the discussion to focus on novel insights and relevant implications of our findings.
Thank you once again for your valuable feedback. We believe these revisions will significantly improve the quality and clarity of our manuscript.
Reviewer 2 Report
Comments and Suggestions for AuthorsDear Authors,
Gastroschisis is a congenital abdominal wall defect that presents an increasing occurrence in the past decades and great costs for the health system. Although it is a relatively benign malformation, is associated with substantial perinatal morbidity and there is still no consensus about the best mode and time of delivery, about the algorithm for its treatment and about the main risk factors for morbidities. Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. Also, the presence of complex gastroschisis, preterm delivery and very low birth weight are associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and hospital length of stay.
Complex gastroschisis is a subject that deserves all the attention of researchers, and that is why I congratulate you for the chosen subject. Instead, your manuscript requires some corrections before it can be published.
Title: please specify in the title that this is a case report.
Introduction: Since your manuscript is a case report, please revise the statements about a comprehensive review (line 39), especially since you only have 16 citations for references.
Case presentation: -line 64: since this is very important, I would like to know how many hours of life the surgical intervention took place. It has already been demonstrated that the delay of the surgical intervention is a risk factor for the occurrence of infections and sepsis.
-line 64-66: since the newborn had ileal atresia and colic atresia, did you measure the length of the remaining intestine at the first surgery? Later in the manuscript you talk about vanishing gastroschisis and short bowel syndrome, therefore the length of the remaining bowel is mandatory to know.
On line 67 you mentioned that the anterior abdominal wall defect was closed, but on line 101 you mentioned the anterior abdominal wall defect remaining after laparoschisis. This does not make sense, please explain.
Line 135-136: it is important to know the evolution of the patient even after discharge from the hospital; do you have data on this?
Discussion: line 164-165: wrapping the intestinal loops with sterile gauze is no longer recommended due to the risk of causing additional injuries; the intestinal loops will be immediately after birth washed with saline serum and mild disinfectants and inserted directly into a silo bag or other sterile plastic container.
-line 185: I think that you were referring to duodenal stenosis and not "duodenal atresia".
Conclusion: the case presented by you is a typical one for a complex gastroschisis that can associate short bowel syndrome, with prolonged hospitalization and complications such as enterocolitis, sepsis, occlusions through peritoneal adhesions.
Author Response
Comment 1: Gastroschisis is a congenital abdominal wall defect that presents an increasing occurrence in the past decades and great costs for the health system. Although it is a relatively benign malformation, is associated with substantial perinatal morbidity and there is still no consensus about the best mode and time of delivery, about the algorithm for its treatment and about the main risk factors for morbidities. Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. Also, the presence of complex gastroschisis, preterm delivery and very low birth weight are associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and hospital length of stay. Complex gastroschisis is a subject that deserves all the attention of researchers, and that is why I congratulate you for the chosen subject. Instead, your manuscript requires some corrections before it can be published.
Response: Thank you for your thorough review and constructive feedback on our manuscript. We appreciate your recognition of the importance of researching complex gastroschisis and your helpful suggestions for improvement. Below, we address each of your points in detail:
Comment 2: Title: please specify in the title that this is a case report.
Response: We have revised the title to specify that this is a case report clearly.
Comment 3: Introduction: Since your manuscript is a case report, please revise the statements about a comprehensive review (line 39), especially since you only have 16 citations for references.
Response: We have modified the introduction to clarify that our manuscript is a case report.
Comment 4: Case presentation: line 64: since this is very important, I would like to know how many hours of life the surgical intervention took place. It has already been demonstrated that the delay of the surgical intervention is a risk factor for the occurrence of infections and sepsis.
Response: We have included the exact number of hours of life (6 hours of life) at which the surgical intervention took place.
Comment 5: lines 64-66: since the newborn had ileal atresia and colic atresia, did you measure the length of the remaining intestine at the first surgery? Later in the manuscript you talk about vanishing gastroschisis and short bowel syndrome, therefore the length of the remaining bowel is mandatory to know.
Response: Thank you for your comment. The surgical intervention included a 10 cm segmental ileal resection, colo-colonic anastomosis, ileal-ileal anastomosis, and closure of the gastroschisis defect, with a tunneled left 4.2 Fr external jugular central intravenous catheter for access. The small intestine's initial remaining length was 30 inches. We have included these details in the revised manuscript.
Comment 6: On line 67 you mentioned that the anterior abdominal wall defect was closed, but on line 101 you mentioned the anterior abdominal wall defect remaining after laparoschisis. This does not make sense, please explain.
Response: Thank you for your observation. The anterior abdominal wall defect was initially closed, but during the second NEC episode, the abdomen was left open for healing after the temporary closure of the perforated loops was attempted. We have included this detail in the revised manuscript.
Comment 7: Line 135-136: it is important to know the evolution of the patient even after discharge from the hospital; do you have data on this?
Response: Thank you for your comment. We have included data on the patient's evolution after discharge. The infant is now nine months old, with a gastrostomy tube in place and the central line removed. The patient continues on enalapril and is under close cardiology follow-up. This information has been added to the revised manuscript.
Comment 8: Discussion: line 164-165: wrapping the intestinal loops with sterile gauze is no longer recommended due to the risk of causing additional injuries; the intestinal loops will be immediately after birth washed with saline serum and mild disinfectants and inserted directly into a silo bag or other sterile plastic container.
Response: Thank you for your feedback. We have revised the description according to your suggestion.
Comment 9: line 185: I think that you were referring to duodenal stenosis and not "duodenal atresia."
Respone: Thank you for your observation. You are correct; we were referring to the proximal stenotic bowel, not duodenal atresia. We will make the necessary corrections in the manuscript.
Comment 10: Conclusion: the case presented by you is a typical one for a complex gastroschisis that can associate short bowel syndrome with prolonged hospitalization and complications such as enterocolitis, sepsis, occlusions through peritoneal adhesions.
Thank you once again for your valuable feedback. We believe these revisions will significantly improve the clarity and quality of our manuscript.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe authors have responded satisfactorily to the reviewers' requests.
They present an interesting clinical case, where a rare entity such as evanescent gastroschisis is discussed, as well as the associated surgical complications. The presentation of the case, as well as the discussion of postoperative management is well structured and well written. The quality of the images provided is adequate, as well as the bibliographic references, which are current.
From my point of view, the manuscript is ready for publication in its current version.
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsDear authors,
Thank you for your responses. Your manuscript is improved and can be published.
Regards,
Author Response
Comments: Dear authors, Thank you for your responses. Your manuscript is improved and can be published.
Response: Thank you for your positive feedback and for approving our manuscript for publication. We appreciate your valuable comments and suggestions, which have significantly improved our work.
