Postoperative Intestinal Intussusception in Polytraumatized Adult Patient: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The research is a case report that mentions postoperative intestinal intussusception in polytraumatized adult patient. This is an interesting case and will help clinicians think about this possibility following a surgery.

This is a simple case report, and it is unfair to mention gap in the field. The discussion mentions the research well.

This case report mentions the importance of thinking about the possibility of intussusception following surgery. This case report mentions one of the very important differential diagnosis of post operative abdominal pain.

The references are appropriate.

I think the images have been very helpful to understand the issue. I liked the inclusion of multiple images.

Comments:

In line 26: 'favorable evolution' needs to be changed to 'favorable resolution'.

As a reader, I would like to know what to do if the CT scan does not show intussusception and the clinical suspicion is high?

There are statements in the case report which were mentioned few times in the article needs rephrasing or change to keep the standard of the article high.

Author Response

We appreciate the feedback.
We have reviewed and revised the article according to your suggestions and comments.
We are sending the updated version, please see the attachment.

In line 26: 'favorable evolution' needs to be changed to 'favorable resolution'. - We agree, it has been modified. 

There are statements in the case report which were mentioned few times in the article needs rephrasing or change to keep the standard of the article high”. - We agree, we have modified the entire document and want to clarify that the initial management was done at an external institution due to the unavailability of vascular surgery. 

For diagnosis, computed tomography (CT) is considered the method of choice over other imaging modalities, with sensitivity ranging from 68% to 100% and specificity from 57% to 71%. Abdominal ultrasound and magnetic resonance imaging are also useful. However, there is little information beyond what was mentioned for the imaging diagnosis, considering it is a rare case, and surgical intervention is reserved for cases where there is failure of reduction with endoscopic treatment, perforation, pneumoperitoneum, signs of peritonitis, sepsis or shock, or the presence of a pathological lesion.  Treatment should be individualized according to the clinical presentation and comorbidities of each patient.

We remain attentive to any additional information or adjustments if necessary.

Reviewer 2 Report

Comments and Suggestions for Authors

The presentation of the case is very poor. It should be more detailed and precise.

For example “thoracotomy” for what? Why “drainage, and peritoneal lavage” since splenectomy was undertaken. What about the liver lacerations? Which “upper and lower limbs”? All four, right, left? Were there any bone fractures? What do you mean and how did you manage “vascular compromise”?

At which postoperative day the intestinal intussusception did happen? Was the patient on oral diet and solid food intake?

“a total abdominal CT” apparently refers to whole abdomen CT.

“with contrast” iv and/or per os?

“indicating signs of intestinal intussusception” which one?

“intussusception 20 centimeters from the ileocecal valve with” Do you mean ileo-ileal intussusception?

“was caused by adhesions” Please be more specific.

“and requiring suturing” Suturing of what?

“deserosation” What do you mean? Was it due to surgical manipulations during dissection or division of adhesions?

“An abdominal cavity lavage was performed” why did you perform lavage?

“bleeding was noted in  layers along with areas of hypoperfused intestine, so a Viaflex bag was left for a second surgical time” Please clarify.

“the patient showed adequate evolution, therefore a second surgical intervention was performed” Why was he reoperated since his condition was satisfactory and with no symptoms?

“and the sutures were found to be in good condition” what sutures, where they were paced and for what?

“infection control” where? What kind of infection?

Overall the condition of intestinal intussusception should be more accurately described. For example: Leading point of intussusception, length of intussuscepted jejunum, fibrous band as a cause etc.

Discussion

The statement “adult intestinal intussusception, which always requires surgical intervention” is not entirely true. Colonic intussusception can be deflated through colonoscopy.

Conclusions

“with CT scans being the most effective and precise diagnostic method, requiring surgical reintervention” Who requires surgery?

Figures

Figure 1. I do not see any contrast-in this CT image.

Figure 2 B and C. I do not see any band causing intestinal angulation. What I see is adhesion in a jejuna loop. Overall the pictures are not representative of the situation. Please use arrows to show points of interest.

Abstarct

“ Abdominal ultrasound and magnetic resonance imaging are also useful” This sentence is not supported by this case report. You did not perform US or MRI in this patient.

Comments on the Quality of English Language

Moderate editing of English language is required for better syntax.

Author Response

We appreciate the feedback.
We have reviewed the article according to your suggestions and comments.
We are sending the updated version, please see the attachment.

"For example “thoracotomy” for what? Why “drainage, and peritoneal lavage” since splenectomy was undertaken. What about the liver lacerations? Which “upper and lower limbs”? All four, right, left? Were there any bone fractures? What do you mean and how did you manage “vascular compromise”?"
- We agree, we clarify that the patient was referred to this institution postoperatively after multiple extra institutional surgical interventions; therefore, we are unaware of the reasons for that management, and we explain in more detail in the case report (from line 58) the multiple fractures the patient had and the extra- and intra-institutional management.

"At which postoperative day the intestinal intussusception did happen? Was the patient on oral diet and solid food intake?" -  On the tenth day postoperatively (laparotomy - splenectomy, lavage, and drainage of hemoperitoneum) (line 83).

"“a total abdominal CT” apparently refers to whole abdomen CT" - We agree. We have modified it in the text.

“with contrast” iv and/or per os?” - oral and iv. We have modified it in the text.

“indicating signs of intestinal intussusception” which one? - abdominal pain associated with multiple emetic episodes, abdominal distension, and intolerance to oral intake. (from line 81).

“intussusception 20 centimeters from the ileocecal valve with” Do you mean ileo-ileal intussusception?, “was caused by adhesions” -  yes, revealed adhesions at the level of the jejunum and ascending colon, an ileo-ileal intussusception 20 centimeters from the ileocecal valve with a length of 20 centimeters, caused by adhesions to the retroperitoneum and right pelvis.(from line 81).

“and requiring suturing” Suturing of what?, “deserosation” What do you mean? Was it due to surgical manipulations during dissection or division of adhesions?” - There was also overdistension in three segments of the small intestine 20, 90, and 120 centimeters from the ileocecal valve, compromising the serosa, which required enterorrhaphy due to the high risk of perforation. (from line 92)

“An abdominal cavity lavage was performed” why did you perform lavage?, “bleeding was noted in  layers along with areas of hypoperfused intestine, so a Viaflex bag was left for a second surgical time”, “the patient showed adequate evolution, therefore a second surgical intervention was performed” Why was he reoperated since his condition was satisfactory and with no symptoms?,  - Peritoneal lavage was performed due to turbid fluid, and areas of hypoperfused intestine were found, leading to the placement of a Viaflex bag for a second surgical procedure to evaluate the evolution of the enterorrhaphy and areas of hypoperfusion (from line 94).

“and the sutures were found to be in good condition” what sutures, where they were paced and for what?” - During the second surgical procedure, a systematic review of the intestine was conducted, revealing that the enterorrhaphy were in good condition with improved perfusion of the intestinal wall, with no evidence of other lesions. Therefore, the abdominal wall was closed. (from line 98).

“infection control” where? What kind of infection?” - Continued orthopedic management, infection control of the open fractures (from line 102).

The statement “adult intestinal intussusception, which always requires surgical intervention” is not entirely true. Colonic intussusception can be deflated through colonoscopy. - We agree, we have modified (from line 139).

We have modified conclusions from line 147. 

Figure 1. We have adjusted the image.

Figure 2. We have adjusted the image with arrows.

Abstract “ Abdominal ultrasound and magnetic resonance imaging are also useful” This sentence is not supported by this case report. You did not perform US or MRI in this patient.”. We agree, we have modified.

We remain attentive to any additional information or adjustments if necessary.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors responded sufficiently to the comments.

The manuscript has largely improved.

I have no more comments.

Regards

Comments on the Quality of English Language

Moderate editing of English language is required for better syntax.