Title: Management of esophageal perforations in infants by endoscopic vacuum therapy – a
single center case series
Version: 1 Date: 13 Apr 2022
Reviewer:  Benedikt Duckworth-mothes
Reviewer's report:
To the authors of the article "Management of esophageal perforations in infants by endoscopic
vacuum-assisted closure therapy".
This paper deals with a highly relevant and up-to-date subject but has a few weaknesses. The
current status of the manuscript does not meet the requirements for the journal or for a journal
with a corresponding impact. Should the editor consider that the manuscript should be revised,
a major revision of the article is recommended due to relevant points that need to be worked on.
Major comments:
1. the title suggests a study or a treatment guide for EVT in infants, but the submitted article
has to be considered as a retrospective case series (as stated on page 6), therefore a clearer title
would be desirable.
2. 50% of the abstract consists of method, which means that the results and the conclusion
are too short. Furthermore, there is no clear indication that this publication has to be seen as a
retrospective case series.
3) The anaesthesia of the children over the entire period of the EVT is to be regarded as critical,
since according to the discussion it primarily only served to prevent manipulation of the orally
placed tubes; in this case, especially with the older/heavier children, discharge via the nose and
fastening, e.g. with a nose bridle, would also have been a possibly viable alternative. Or are there
other relevant points here, why anaesthesia of the children was carried out over the complete
period of EVT (up to 27 days in infant 1).
Minor comments:
1. page 5 line 7: please change study to retrospective case series
2. page 7 lines 16/17: Why were the infants kept under constant anaesthesia (see also major
comment 3)?
3. page 8 line 23: why were two different PEG sizes used in children of somewhat equal weight?
4. page 8: infant 1 and 2 were EVT after previous surgery (infant 1 lateral suture insufficiency,
infant 2 circular insufficiency after anastomosis), but infants 3 and 4 were treated directly
following perforation, so these cases are not directly comparable. Clarification that this is a
retrospective analysis and that 4 more or less independent case reports are combined here would
be desirable.
Page 9 Line 8: All treatments were started with the film, why was the first two patients switched
to the sponge in the course of treatment, but the later infants 3 and 4 continued the therapy with
the sponge? An explanation is necessary here.
Page 9 Line 18: Why was a pressure of 75 mmHg chosen? If the work of Riez [18] served as
a reference, this choice would be very questionable due to the data published there (and also
discuss later on in this article). Please provide an explanation here of how the applied pressures
were chosen.
Page 9 Line 21: Why 150 mmHg for infant 1 and 125 mm Hg for infant 2?
8. page 9 line 23: Why was 100 mmHg used initially for infants 3 and 4? Experience from infant
1 and 2?
Page 10 Line 12-14: Can also be interpreted as a discussion, therefore take up this aspect again
in the discussion.
Page 11 Line 23/24: Please clarify here that the 5 patients are data from Ritz et al.
Comments of a general nature:
a) Please write et al. (missing dot).
b) Please include a space for SI units (e.g. 1500 g, 150 mmHg) [https://en.wikipedia.org/wiki/
International_System_of_Units#Common_notions_of_the_metric_units].
c) Please be consistent about the type of publication (e.g. page 5 study, page 6 retrospective
analysis, page 11 case series).
Title: Management of esophageal perforations in infants by endoscopic vacuum therapy – a
single center case series
Version: 1 Date: 13 Apr 2022
Reviewer:  Benedikt Duckworth-mothes
Reviewer's report:
To the authors of the article "Management of esophageal perforations in infants by endoscopic
vacuum-assisted closure therapy".
This paper deals with a highly relevant and up-to-date subject but has a few weaknesses. The
current status of the manuscript does not meet the requirements for the journal or for a journal
with a corresponding impact. Should the editor consider that the manuscript should be revised,
a major revision of the article is recommended due to relevant points that need to be worked on.
Major comments:
1. the title suggests a study or a treatment guide for EVT in infants, but the submitted article
has to be considered as a retrospective case series (as stated on page 6), therefore a clearer title
would be desirable.
2. 50% of the abstract consists of method, which means that the results and the conclusion
are too short. Furthermore, there is no clear indication that this publication has to be seen as a
retrospective case series.
3) The anaesthesia of the children over the entire period of the EVT is to be regarded as critical,
since according to the discussion it primarily only served to prevent manipulation of the orally
placed tubes; in this case, especially with the older/heavier children, discharge via the nose and
fastening, e.g. with a nose bridle, would also have been a possibly viable alternative. Or are there
other relevant points here, why anaesthesia of the children was carried out over the complete
period of EVT (up to 27 days in infant 1).
Minor comments:
1. page 5 line 7: please change study to retrospective case series
2. page 7 lines 16/17: Why were the infants kept under constant anaesthesia (see also major
comment 3)?
3. page 8 line 23: why were two different PEG sizes used in children of somewhat equal weight?
4. page 8: infant 1 and 2 were EVT after previous surgery (infant 1 lateral suture insufficiency,
infant 2 circular insufficiency after anastomosis), but infants 3 and 4 were treated directly
following perforation, so these cases are not directly comparable. Clarification that this is a
retrospective analysis and that 4 more or less independent case reports are combined here would
be desirable.
Page 9 Line 8: All treatments were started with the film, why was the first two patients switched
to the sponge in the course of treatment, but the later infants 3 and 4 continued the therapy with
the sponge? An explanation is necessary here.
Page 9 Line 18: Why was a pressure of 75 mmHg chosen? If the work of Riez [18] served as
a reference, this choice would be very questionable due to the data published there (and also
discuss later on in this article). Please provide an explanation here of how the applied pressures
were chosen.
Page 9 Line 21: Why 150 mmHg for infant 1 and 125 mm Hg for infant 2?
8. page 9 line 23: Why was 100 mmHg used initially for infants 3 and 4? Experience from infant
1 and 2?
Page 10 Line 12-14: Can also be interpreted as a discussion, therefore take up this aspect again
in the discussion.
Page 11 Line 23/24: Please clarify here that the 5 patients are data from Ritz et al.
Comments of a general nature:
a) Please write et al. (missing dot).
b) Please include a space for SI units (e.g. 1500 g, 150 mmHg) [https://en.wikipedia.org/wiki/
International_System_of_Units#Common_notions_of_the_metric_units].
c) Please be consistent about the type of publication (e.g. page 5 study, page 6 retrospective
analysis, page 11 case series).
Please review this paper.
user
Title: Management of esophageal perforations in infants by endoscopic vacuum therapy – a
single center case series
Version: 1 Date: 13 Apr 2022
Reviewer:  Benedikt Duckworth-mothes
Reviewer's report:
To the authors of the article "Management of esophageal perforations in infants by endoscopic
vacuum-assisted closure therapy".
This paper deals with a highly relevant and up-to-date subject but has a few weaknesses. The
current status of the manuscript does not meet the requirements for the journal or for a journal
with a corresponding impact. Should the editor consider that the manuscript should be revised,
a major revision of the article is recommended due to relevant points that need to be worked on.
Major comments:
1. the title suggests a study or a treatment guide for EVT in infants, but the submitted article
has to be considered as a retrospective case series (as stated on page 6), therefore a clearer title
would be desirable.
2. 50% of the abstract consists of method, which means that the results and the conclusion
are too short. Furthermore, there is no clear indication that this publication has to be seen as a
retrospective case series.
3) The anaesthesia of the children over the entire period of the EVT is to be regarded as critical,
since according to the discussion it primarily only served to prevent manipulation of the orally
placed tubes; in this case, especially with the older/heavier children, discharge via the nose and
fastening, e.g. with a nose bridle, would also have been a possibly viable alternative. Or are there
other relevant points here, why anaesthesia of the children was carried out over the complete
period of EVT (up to 27 days in infant 1).
Minor comments:
1. page 5 line 7: please change study to retrospective case series
2. page 7 lines 16/17: Why were the infants kept under constant anaesthesia (see also major
comment 3)?
3. page 8 line 23: why were two different PEG sizes used in children of somewhat equal weight?
4. page 8: infant 1 and 2 were EVT after previous surgery (infant 1 lateral suture insufficiency,
infant 2 circular insufficiency after anastomosis), but infants 3 and 4 were treated directly
following perforation, so these cases are not directly comparable. Clarification that this is a
retrospective analysis and that 4 more or less independent case reports are combined here would
be desirable.
Page 9 Line 8: All treatments were started with the film, why was the first two patients switched
to the sponge in the course of treatment, but the later infants 3 and 4 continued the therapy with
the sponge? An explanation is necessary here.
Page 9 Line 18: Why was a pressure of 75 mmHg chosen? If the work of Riez [18] served as
a reference, this choice would be very questionable due to the data published there (and also
discuss later on in this article). Please provide an explanation here of how the applied pressures
were chosen.
Page 9 Line 21: Why 150 mmHg for infant 1 and 125 mm Hg for infant 2?
8. page 9 line 23: Why was 100 mmHg used initially for infants 3 and 4? Experience from infant
1 and 2?
Page 10 Line 12-14: Can also be interpreted as a discussion, therefore take up this aspect again
in the discussion.
Page 11 Line 23/24: Please clarify here that the 5 patients are data from Ritz et al.
Comments of a general nature:
a) Please write et al. (missing dot).
b) Please include a space for SI units (e.g. 1500 g, 150 mmHg) [https://en.wikipedia.org/wiki/
International_System_of_Units#Common_notions_of_the_metric_units].
c) Please be consistent about the type of publication (e.g. page 5 study, page 6 retrospective
analysis, page 11 case series).
assistant