Innovative Treatment of Combat-Related Extraperitoneal Penetrating Rectal Injury with Intraluminal Vacuum Therapy: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This case report seeks to describe a patient treated for a high grade extraperitoneal rectal injury with intraluminal vacuum therapy.

Strengths: Interesting article describing a novel way to treat full thickness rectal injuries from combat.

Weaknesses: While sound, this may not be universally applicable in all combat scenarios as constraints from austere conditions may prove difficult to employ.

Overall: Good submission. This technique has been applied to blunt rectal trauma at other centres, but this is the first time it has been done for combat-related blast injury.

Comments:

1. P2L66 – Authors meant to put “NPWT” instead of “NWPT”
2. While not strictly required if it’s due to security, confidentiality, and restrictions, the location of the trauma centre and war zone was not specified. If the authors were to mention location, it may allow the reader to consider the feasibility of adapting these methods to their own situation.

Author Response

Comment 1: P2L66 – Authors meant to put “NPWT” instead of “NWPT”

Response 1: We appreciate your careful review and attention to detail. This was indeed a typographical error, and we have corrected "NWPT" to "NPWT" in the revised manuscript (Page 2, Line 74).

Comment 2: While not strictly required if it’s due to security, confidentiality, and restrictions, the location of the trauma centre and war zone was not specified. If the authors were to mention location, it may allow the reader to consider the feasibility of adapting these methods to their own situation.

Response 2: Thank you for this helpful suggestion. We agree that including the location provides important context and helps readers assess the feasibility of applying this technique in similar settings. We have updated the manuscript to include the location of both the trauma center and the operational environment where the injury occurred (Page 2, Lines 39-41). If published, affiliations of the authors would be mentioned anyway. Also, we believe that proposed technique may be applied at any modern Trauma Center and required resources are available at most facilities not restricted to specific region. 

Reviewer 2 Report

Comments and Suggestions for Authors

Congratulations on a very well described technique for the management of a complex injury. Minimal data exists on intra luminal vac therapy for management of complex rectal injury and this paper adds to the growing body of literature. 

The papers below describe a similar technique (one in trauma). As you have rightly suggested, more prospective studies will help validate this method. 

Ashley Althoff. Endoluminal vacuum-assisted closure for penetrating rectal injury in a pediatric patient, Journal of Pediatric Surgery Case Reports, 2021, https://doi.org/10.1016/j.epsc.2021.101885.

Sozutek A. Endoluminal Vacuum Therapy (EVT) for the Treatment of Rectal Perforation Following Cleansing Enema Application. Cureus. 2023 Mar 9;15(3):e35939. doi: 10.7759/cureus.35939. PMID: 36911591; PMCID: PMC9997685.

Soliman F. Intraluminal negative pressure wound therapy and rectal anastomotic leak management: regular vac sponge and a nasogastric tube. Ann R Coll Surg Engl. 2024 May;106(5):461-462. doi: 10.1308/rcsann.2024.0022. Epub 2024 Mar 13. PMID: 38478057; PMCID: PMC11060859.

 

Author Response

Comment 1: The papers below describe a similar technique (one in trauma). As you have rightly suggested, more prospective studies will help validate this method. 

Response 1: Thank you very much for your positive feedback and for highlighting relevant literature that supports the use of intraluminal vacuum therapy for complex rectal injuries. We appreciate your thoughtful comments and agree that our case contributes to the evolving evidence base.

As suggested, we have incorporated the references by Ashley et al., Sozutek et al., and Soliman et al. into the discussion section of the revised manuscript to further contextualize our findings. (Page 4, Line 128; Page 5, Lines 144-148).

Reviewer 3 Report

Comments and Suggestions for Authors

An interesting case report with commendable resourcefulness demonstrated in the application of the VAC system. However, I kindly request the following revisions in order to improve the quality of the manuscript and facilitate its potential publication:

1. Could you please specify the type of explosive device used? If the type is unknown, please state that it was an improvised explosive device (IED) in the text.

2. Do you have photographs of the entry and exit wounds? Including these would clarify why a VAC was applied to the entry wound in the right groin. Currently, only endoscopic images and CT scans are provided—please include the requested wound photographs.

3. Paragraphs 52–55 are not clearly written. Figures should be referenced at the end of the sentence, for example: (Figure 1 A, B, C). Please revise the text accordingly.

4. In paragraph 65, Figure 2 is referenced correctly—just kindly move the figure citation to the end of the sentence as: (Figure 2 A, B).

5. Please use a consistent classification when reporting rectal tube sizes—either Charrière (Ch) or French (Fr)—since both are currently used in different sections (paragraphs 63 and 72).

6. Paragraphs 94–99 could be rewritten for improved clarity and detail. Also, figure referencing in this section needs to be corrected.

7. The paragraph in the Discussion states that the study resulted in increased expression of anti-inflammatory genes and cytokines. However, no PCR or other protein quantification techniques were performed. Please either delete this paragraph or revise it to align with the actual methods and findings of the study.

8. Figure 4 could be better arranged and provided in higher DPI/resolution.

Author Response

Comment 1: Could you please specify the type of explosive device used? If the type is unknown, please state that it was an improvised explosive device (IED) in the text.

Response 1: We have clarified in the manuscript that the injury resulted from an anti-tank guided missile, rather than an improvised explosive device (IED). (Page 2, Line 40)

Comment 2: Do you have photographs of the entry and exit wounds? Including these would clarify why a VAC was applied to the entry wound in the right groin. Currently, only endoscopic images and CT scans are provided—please include the requested wound photographs.

Response 2: Unfortunately, we do not have photographs of the external wounds. As noted, only endoscopic images and CT scans are available. VAC was applied on the second operation after repeat debridement was performed and wound was washed out and found to be suitable for NWPT. This is our common practice for all wounds resulted from blast injury with penetrating foreign bodies: hemostasis and packing at initial operation, second look after 24-48 hours with preferable VAC application.

Comment 3:  Paragraphs 52–55 are not clearly written. Figures should be referenced at the end of the sentence, for example: (Figure 1 A, B, C). Please revise the text accordingly.

Response 3: These paragraphs have been revised for clarity, and figure references have been moved to the end of the sentences as requested (e.g., Figure 1A, B, C). (Page 2, Lines 56-61)

Comment 4.: In paragraph 65, Figure 2 is referenced correctly—just kindly move the figure citation to the end of the sentence as: (Figure 2 A, B).

Response 4: The figure citation has been moved to the end of the sentence for consistency: (Figure 2A, B). (Page 3, Line 79).

Comment 5: Please use a consistent classification when reporting rectal tube sizes—either Charrière (Ch) or French (Fr)—since both are currently used in different sections (paragraphs 63 and 72).

Response 5: We have standardized the terminology and now consistently use the French (Fr) scale throughout the manuscript. (Page 3, Line 80).

Comment 6: Paragraphs 94–99 could be rewritten for improved clarity and detail. Also, figure referencing in this section needs to be corrected.

Response 6: This section has been rewritten for improved clarity and detail. Figure references have also been corrected as requested. (Page 4, Lines 98; 103-107; 110; 115-120).

Comment 7: The paragraph in the Discussion states that the study resulted in increased expression of anti-inflammatory genes and cytokines. However, no PCR or other protein quantification techniques were performed. Please either delete this paragraph or revise it to align with the actual methods and findings of the study.

Response 7: We appreciate your attention to this point. The last section about HBOT was shortened and statements not connected to the presented case were deleted (including references). (Page 5, Line 176).

Comment 8: Figure 4 could be better arranged and provided in higher DPI/resolution.

Response 8: Figure 4 has been rearranged and provided in higher resolution to improve visual clarity. (Page 4, Lines 113-120)

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

all comments addressed

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have revised the manuscript in line with the majority of the comments. I support its publication.