Managing Gallstone Ileus and Surgical Considerations in Resource-Limited Settings: A Case Series from the Amazon Jungle

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This case series study discusses the role of additional biliary surgery, particularly subtotal cholecystectomy, in managing gallstone ileus in a rural medical setting. The study presents four cases, all undergoing enterolithotomy to relieve intestinal obstruction. Subsequently, two of the four patients underwent subtotal cholecystectomy. No perioperative mortality was observed. The rural setting where these cases occurred, with limited access to advanced imaging and specialized biliary surgery, may have influenced clinical decision-making. This study on decision-making regarding cholecystectomy or its technique (total vs. subtotal) after gallstone ileus surgery in a resource-limited rural setting is fascinating. However, several concerns can be raised:

1. In Table 1, "obesity" is mentioned in the medical history; however, it is not a specific disease name. Please provide a more specific diagnosis. What were the CRP and other values? As this is a case report, please briefly describe the patients' physical findings, including vital signs.
2. Please use a diagram to explain the difference between subtotal cholecystectomy and total cholecystectomy techniques.
3. How experienced were the surgeons who performed these operations? Were they specialists? Are they among the co-authors?
4. It seems necessary to discuss the differences between specific guidelines (e.g., Tokyo Guidelines: TG18 or your country's guidelines) and the author's approach in the rural setting.
5. The references appear to be old and few.
6. Adding terms such as "rural setting" and "Colombia" to the title or keywords may be beneficial.

 

Comments on the Quality of English Language

Minor English editing is required. 

Author Response

Comment: In Table 1, "obesity" is mentioned in the medical history; however, it is not a specific disease name. Please provide a more specific diagnosis. What were the CRP and other values? As this is a case report, please briefly describe the patients' physical findings, including vital signs.

Response: Consults in Colombia use "CIE 10" to classify diagnoses. due to BMI over 30 the patient can be classified as E669 OBESIDAD, NO ESPECIFICADA within the corresponding diagnosis code. CPR was not available and the other lab values were bilirubin, electrolytes and haemoglobin. Some values were missing, others were incomplete and the rest were within range. Therefore, to present a table with complete findings we decided to only present mainly abnormal values. This also concatenates with the reason we did not presented vital signs. All vital signs were within range except for two high blood pressures from the two patients that had a prior medical history of hypertension and tachycardia for the patient that had acute abdomen which we reported on description of table 1. Also, another reviewer considers the table can be shortened and therefore conflicts with the suggestion of adding more data to the table. 

Comment: Please use a diagram to explain the difference between subtotal cholecystectomy and total cholecystectomy techniques.

Response: The diagram was added accordingly

Comment: How experienced were the surgeons who performed these operations? Were they specialists? Are they among the co-authors?

Response: The main surgeon is a general surgeon with more than 20 years of experience and adapted to decision making in rural environments with low resources and challenging infrastructure. He's among the co-authors. The other co-author is a hepatobiliary surgeon which helped constructing the article. 

Comment: It seems necessary to discuss the differences between specific guidelines (e.g., Tokyo Guidelines: TG18 or your country's guidelines) and the author's approach in the rural setting. The references appear to be old and few.

Response: We widened the discussion and added more references

Comment: Adding terms such as "rural setting" and "Colombia" to the title or keywords may be beneficial.

Response: We added "Rural surgery" to the keyword, thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

The abstract provides a basic summary but lacks numerical detail and clarity. The phrase "Ever patient had a successful recovery" contains a grammatical error ("Every" instead of "Ever"). Include sample size, key patient demographics, and main outcomes numerically. Clarify the surgical techniques and decision-making rationale.

The introduction adequately defines gallstone ileus but could better emphasize the study's rationale and how it addresses a gap in the literature. Some references are outdated. It is recommended to include more recent studies to highlight advancements in management techniques. 

Material and Methods section lacks clarity on patient selection criteria and data analysis methods. Ethical considerations are mentioned, but more detail on informed consent and patient confidentiality would strengthen this section.

The data presentation in Table 1 is comprehensive but cluttered. Simplifying the table layout would improve readability. The narrative in the Results section is sometimes redundant with the table data. Grammatical issues are present ("Average hospice stay" should be "Average hospital stay").

The discussion provides useful insights but is somewhat repetitive and lacks critical analysis. The limitations of the study are acknowledged but could be expanded to include selection bias and lack of long-term follow-up. The discussion about subtotal cholecystectomy could benefit from citing more comparative data from larger studies.  Avoid repeating points already made in the Results section. Expand on how findings compare with similar studies in both rural and urban settings. Provide a clearer rationale for future research directions, including prospective studies and multicenter collaborations.

The conclusion accurately reflects the study findings but could be strengthened by emphasizing specific clinical implications and potential guidelines for practice in resource-limited environments.

Comments on the Quality of English Language

• The manuscript addresses an important topic—managing gallstone ileus in rural settings—but it would benefit from clearer articulation of its novelty and contribution to existing literature.
• Grammatical and typographical errors are present throughout the manuscript and should be corrected for clarity and professionalism.
• Consistency in terminology (e.g., "Gallstone Ileus" vs. "biliary ileus") is recommended for better readability.

Author Response

Comment: The introduction adequately defines gallstone ileus but could better emphasize the study's rationale and how it addresses a gap in the literature. Some references are outdated. It is recommended to include more recent studies to highlight advancements in management techniques. 

Response: The discussion was widened and more references were added

Comment: Material and Methods section lacks clarity on patient selection criteria and data analysis methods. Ethical considerations are mentioned, but more detail on informed consent and patient confidentiality would strengthen this section.

Response: We selected all available patients with this diagnosis, the only criteria was a patient who had a diagnosis of gallstone ileus and we collected descriptive data of all patients. there was no inferential or comparative analysis. Data was extracted, summarized and logically synthesised by all co-authors to find counts and patterns which are reported on the description on table one. As the main objective is to create awareness and more information about cases in rural scenarios we collected everything we could find. Regarding informed consent and data confidentiality we added the corresponding clarifications on materials and methods. 

Comment: The data presentation in Table 1 is comprehensive but cluttered. Simplifying the table layout would improve readability. The narrative in the Results section is sometimes redundant with the table data. Grammatical issues are present ("Average hospice stay" should be "Average hospital stay")

Response: Pertinent corrections were made and grammatical issues. This comment enters in conflict with the comment of another reviewer who states the table should be expanded with more data. 

Comment: The discussion provides useful insights but is somewhat repetitive and lacks critical analysis. The limitations of the study are acknowledged but could be expanded to include selection bias and lack of long-term follow-up. The discussion about subtotal cholecystectomy could benefit from citing more comparative data from larger studies.  Avoid repeating points already made in the Results section. Expand on how findings compare with similar studies in both rural and urban settings. Provide a clearer rationale for future research directions, including prospective studies and multicenter collaborations.

Response: The discussion was expanded following your comments

Comment: The conclusion accurately reflects the study findings but could be strengthened by emphasizing specific clinical implications and potential guidelines for practice in resource-limited environments.

Response: The conclusion was modified following your comments.

Comment: The manuscript addresses an important topic—managing gallstone ileus in rural settings—but it would benefit from clearer articulation of its novelty and contribution to existing literature. Grammatical and typographical errors are present throughout the manuscript and should be corrected for clarity and professionalism. Consistency in terminology (e.g., "Gallstone Ileus" vs. "biliary ileus") is recommended for better readability.

Response: Grammatical and typographical modifications were made

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, congratulations on your article.

Here are some suggestions to improve your article's quality:

I recommend this title of the article regarding interesting place of living.
Managing Gallstone Ileus and Surgical Considerations in Resource-Limited Settings: A Case Series from the Amazon jungle

In the section Materials and Methods, please state the level of education and experience of surgeons. Please indicate whether the surgeries were performed in a general or university hospital.
In Table 1, please clearly state the reference value of all laboratory parameters.
Please correct arteria hypertension- arterial hypertension. You have written diabetes in the table, put type 1 or type 2 diabetes mellitus.
Please write about the dietary habits of the patients.
Please put the size of the largest gallstone for all four cases in Table 1. 
In the discussion section please explain more precisely why you chose subtotal cholecystectomy and not total cholecystectomy?
Line 119.please correct this Xray…x-ray.
It would be interesting to explain what additional risk factors your patients may have for gallstones, depending on where they live. What kind of food they eat, since they have diabetes. It would be interesting for readers to see if their lifestyle differs from Western fast-food habits.

 

Best Regards

Comments on the Quality of English Language

 

I suggest minor language corrections. 

Author Response

Comment: Managing Gallstone Ileus and Surgical Considerations in Resource-Limited Settings: A Case Series from the Amazon jungle

Response: The title was modified accordingly 

Comment: In the section Materials and Methods, please state the level of education and experience of surgeons. Please indicate whether the surgeries were performed in a general or university hospital.

Response: The section was modified accordingly

Comment: In Table 1, please clearly state the reference value of all laboratory parameters.

Response: The table was modified accordingly

Comment: Please correct arteria hypertension- arterial hypertension. You have written diabetes in the table, put type 1 or type 2 diabetes mellitus.

Response: The table was modified accordingly

Comment: Please put the size of the largest gallstone for all four cases in Table 1. 

Response: Unfortunately we have reports of only 2/4 gallstone sizes and we considered, to keep the table simple, to only add the data that is complete for all four patients. The reports we have are the following : Ileo biliar, Calculo de 5X3,2X2,5 cms de diametro, localizado en ileon terminal. Asas dilatadas y con signos de sufrimiento , ILEO BILIAR. FISTULA COLECISTOENTERICA. CALCULOS DE 5X4 CMS UNO EN VESICULA Y OTRO OBSTRUYE ILEON 

Comment: In the discussion section please explain more precisely why you chose subtotal cholecystectomy and not total cholecystectomy?

Response: The discussion was modified accordingly

Comment: Line 119.please correct this Xray…x-ray.

Response: The section was modified accordingly

Comment: It would be interesting to explain what additional risk factors your patients may have for gallstones, depending on where they live. What kind of food they eat, since they have diabetes. It would be interesting for readers to see if their lifestyle differs from Western fast-food habits.

Response: The section was modified accordingly

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have revised their manuscript appropriately, and it has improved.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have satisfactorily addressed the requirements raised by the reviewers, improving the methodological, structural, and semantic quality of the manuscript. From my perspective, in its current version, the article is suitable to proceed to the next stage of the editorial publication process.