Reviewer ’s report  
 
Title: Gastropericardial fistula: getting to the heart of the matter  
 
Version: 0 Date: 17 Apr 2016  
 
Reviewer: Boris Sepesi  
 
Reviewer' s report:  
 
In this case report Vian Azzu describes a case of gastropericardial fistula and also reviews the 
literature on this topic. As demonstrated in this report, gastropericardial fistula is associated with 
very high mortality. It can occur most commonly after esophageal surgery either from the 
erosion of the staple line into the pericardium or from a gastric ulcer erosion into the 
pericardium. The contamination of the pericardial space results in inflammation and subsequent 
infection which l eads to sepsis. While the data on this topic are very limited, they suggest that 
patients who are able to withstand surgical correction of this problem fare better than patients 
who  are treated conservatively. Author, therefore recommends early surgical i ntervention as the 
key to survival and states that surgery should not be delayed.  
 
 
 
 
The manuscript is reasonably well written and there are no major issues preventing it from being 
published.   
 
 
 
However, I think we should be little be more careful about co nclusions, and perhaps some 
modification would make the conclusion more accurate.  I recommend that author states in the 
conclusion that the recommendations are based on Level 5 evidence (expert opinion). I do not 
believe that even review of 65 cases from the literature creates clear guidelines on how to 
manage these patients. While it makes intuitive sense that early surgical correction may be 
required, rushing to the operating room for a major surgical repair maybe potentially detrimental 
in some patients . As we have learned with the management of spontaneous esophageal 
perforation it is important to follow main principles of sepsis control, antibacterial therapy, and 
nutrition rather than submit all patients to immediate surgical repair. Patient selection  in these 
very difficult situations is of paramount importance for the achievement of optimal outcomes.   
 
 
 
At times adequate drainage of a contaminated cavity, resuscitation and correction of patient's 
hemodynamics may temporize an acute situation and allow  for more planned definitive 
procedure at a later time. With current endoscopic, interventional radiology, surgical techniques, 
and critical care, there are many options of how to temporize often dramatic situations. One 
could argue that it is the patient selection for intervention that ultimately results in improved 
outcomes of this otherwise dire circumstance.  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this m anuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publ ication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Cr eative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Gastropericardial fistula: getting to the heart of the matter  
 
Version: 0 Date: 17 Apr 2016  
 
Reviewer: Boris Sepesi  
 
Reviewer' s report:  
 
In this case report Vian Azzu describes a case of gastropericardial fistula and also reviews the 
literature on this topic. As demonstrated in this report, gastropericardial fistula is associated with 
very high mortality. It can occur most commonly after esophageal surgery either from the 
erosion of the staple line into the pericardium or from a gastric ulcer erosion into the 
pericardium. The contamination of the pericardial space results in inflammation and subsequent 
infection which l eads to sepsis. While the data on this topic are very limited, they suggest that 
patients who are able to withstand surgical correction of this problem fare better than patients 
who  are treated conservatively. Author, therefore recommends early surgical i ntervention as the 
key to survival and states that surgery should not be delayed.  
 
 
 
 
The manuscript is reasonably well written and there are no major issues preventing it from being 
published.   
 
 
 
However, I think we should be little be more careful about co nclusions, and perhaps some 
modification would make the conclusion more accurate.  I recommend that author states in the 
conclusion that the recommendations are based on Level 5 evidence (expert opinion). I do not 
believe that even review of 65 cases from the literature creates clear guidelines on how to 
manage these patients. While it makes intuitive sense that early surgical correction may be 
required, rushing to the operating room for a major surgical repair maybe potentially detrimental 
in some patients . As we have learned with the management of spontaneous esophageal 
perforation it is important to follow main principles of sepsis control, antibacterial therapy, and 
nutrition rather than submit all patients to immediate surgical repair. Patient selection  in these 
very difficult situations is of paramount importance for the achievement of optimal outcomes.   
 
 
 
At times adequate drainage of a contaminated cavity, resuscitation and correction of patient's 
hemodynamics may temporize an acute situation and allow  for more planned definitive 
procedure at a later time. With current endoscopic, interventional radiology, surgical techniques, 
and critical care, there are many options of how to temporize often dramatic situations. One 
could argue that it is the patient selection for intervention that ultimately results in improved 
outcomes of this otherwise dire circumstance.  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this m anuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publ ication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Cr eative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Gastropericardial fistula: getting to the heart of the matter  
 
Version: 0 Date: 17 Apr 2016  
 
Reviewer: Boris Sepesi  
 
Reviewer' s report:  
 
In this case report Vian Azzu describes a case of gastropericardial fistula and also reviews the 
literature on this topic. As demonstrated in this report, gastropericardial fistula is associated with 
very high mortality. It can occur most commonly after esophageal surgery either from the 
erosion of the staple line into the pericardium or from a gastric ulcer erosion into the 
pericardium. The contamination of the pericardial space results in inflammation and subsequent 
infection which l eads to sepsis. While the data on this topic are very limited, they suggest that 
patients who are able to withstand surgical correction of this problem fare better than patients 
who  are treated conservatively. Author, therefore recommends early surgical i ntervention as the 
key to survival and states that surgery should not be delayed.  
 
 
 
 
The manuscript is reasonably well written and there are no major issues preventing it from being 
published.   
 
 
 
However, I think we should be little be more careful about co nclusions, and perhaps some 
modification would make the conclusion more accurate.  I recommend that author states in the 
conclusion that the recommendations are based on Level 5 evidence (expert opinion). I do not 
believe that even review of 65 cases from the literature creates clear guidelines on how to 
manage these patients. While it makes intuitive sense that early surgical correction may be 
required, rushing to the operating room for a major surgical repair maybe potentially detrimental 
in some patients . As we have learned with the management of spontaneous esophageal 
perforation it is important to follow main principles of sepsis control, antibacterial therapy, and 
nutrition rather than submit all patients to immediate surgical repair. Patient selection  in these 
very difficult situations is of paramount importance for the achievement of optimal outcomes.   
 
 
 
At times adequate drainage of a contaminated cavity, resuscitation and correction of patient's 
hemodynamics may temporize an acute situation and allow  for more planned definitive 
procedure at a later time. With current endoscopic, interventional radiology, surgical techniques, 
and critical care, there are many options of how to temporize often dramatic situations. One 
could argue that it is the patient selection for intervention that ultimately results in improved 
outcomes of this otherwise dire circumstance.  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this m anuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publ ication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Cr eative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant