Title: Analysis of clinical diagnosis and treatment of intestinal volvulus
Version: 2 Date: 20 Dec 2022
Reviewer's report:
Thank you for the opportunity to review this manuscript.
Dr. Fo and colleagues published their center’s experience in gastro-intestinal volvulus over a
period of 7 years.
The manuscript describes an important problem that requires prompt treatment, however there
are some significant issues that need addressing. Most importantly, this is a small sample size
study that is further split into 3 subtypes of intestinal volvulus.
Major comments:
- The authors describe three subtypes of volvulus: jejunal, ileal and colonic. However, these are
all very different pathophysiological and epidemiological. Lumping these all together into one
retrospective study reduces the clarity of the message of the paper. Similarly, there is a difference
between primary and secondary volvulus (ie adhesional following surgery).
- In this retrospective cohort, all patients underwent surgery. However, there are cases where
conservative therapy can be attempted (as mentioned in the discussion). Are there any other
patients in this time period that underwent conservative therapy? Colonic volvulus, for instance,
can be managed endoscopically with an elective laparoscopic sigmoid resection at a later stage.
- Section 2.4 describes the surgical treatment; however the wording is a bit repetitive and
unclear (including the use of the ‘+’ sign). Instead, the authors should use a table to describe the
operations and provide a clearer overview. Also, did all patients undergo laparotomy, as early
onset cases can be managed laparoscopically?
- In the discussion the authors mention that ‘the occurrence of intestinal necrosis and the
cause of intestinal torsion were not significantly related to the presence or absence of signs of
peritonitis…’. I can only imagine that is due to very small sample size rather than intestinal
necrosis being insignificant for the clinical outcome.
- Regarding diagnostics: abdominal plain film are really obsolete by international guidelines
for acute abdominal pain investigations unless in exceptional circumstances. The gold standard
is CT with oral/rectal contrast if possible. There is no evidence why dual source CT is better
than standard CT in this setting (in contrast to other settings such as evaluating respectability
of borderline malignancies etc.).
Minor comments:
- Instead of ‘anal cessation of exhaust’ it is recommended to use ‘absence of flatus’.
- Some additional revision of language may be appropriate as it is difficult to follow some of the
wording: ’…17 patients with small bowel torsion who were not intestinal necrosis underwent
surgical reduction’.
- In section 2.5: the authors mention skin dehiscence with ‘skin grafts’ being placed under the
incision. It is unclear to me what they mean? Was the wound debrided and skin grafts placed?
How deep was the dehiscence, was it only the skin or did it include the fascia.
- The  methods describe the period from January 2015 unitl December 2022 but this is a typo,
this would mean the last patients had no significant follow-up.
Title: Analysis of clinical diagnosis and treatment of intestinal volvulus
Version: 2 Date: 20 Dec 2022
Reviewer's report:
Thank you for the opportunity to review this manuscript.
Dr. Fo and colleagues published their center’s experience in gastro-intestinal volvulus over a
period of 7 years.
The manuscript describes an important problem that requires prompt treatment, however there
are some significant issues that need addressing. Most importantly, this is a small sample size
study that is further split into 3 subtypes of intestinal volvulus.
Major comments:
- The authors describe three subtypes of volvulus: jejunal, ileal and colonic. However, these are
all very different pathophysiological and epidemiological. Lumping these all together into one
retrospective study reduces the clarity of the message of the paper. Similarly, there is a difference
between primary and secondary volvulus (ie adhesional following surgery).
- In this retrospective cohort, all patients underwent surgery. However, there are cases where
conservative therapy can be attempted (as mentioned in the discussion). Are there any other
patients in this time period that underwent conservative therapy? Colonic volvulus, for instance,
can be managed endoscopically with an elective laparoscopic sigmoid resection at a later stage.
- Section 2.4 describes the surgical treatment; however the wording is a bit repetitive and
unclear (including the use of the ‘+’ sign). Instead, the authors should use a table to describe the
operations and provide a clearer overview. Also, did all patients undergo laparotomy, as early
onset cases can be managed laparoscopically?
- In the discussion the authors mention that ‘the occurrence of intestinal necrosis and the
cause of intestinal torsion were not significantly related to the presence or absence of signs of
peritonitis…’. I can only imagine that is due to very small sample size rather than intestinal
necrosis being insignificant for the clinical outcome.
- Regarding diagnostics: abdominal plain film are really obsolete by international guidelines
for acute abdominal pain investigations unless in exceptional circumstances. The gold standard
is CT with oral/rectal contrast if possible. There is no evidence why dual source CT is better
than standard CT in this setting (in contrast to other settings such as evaluating respectability
of borderline malignancies etc.).
Minor comments:
- Instead of ‘anal cessation of exhaust’ it is recommended to use ‘absence of flatus’.
- Some additional revision of language may be appropriate as it is difficult to follow some of the
wording: ’…17 patients with small bowel torsion who were not intestinal necrosis underwent
surgical reduction’.
- In section 2.5: the authors mention skin dehiscence with ‘skin grafts’ being placed under the
incision. It is unclear to me what they mean? Was the wound debrided and skin grafts placed?
How deep was the dehiscence, was it only the skin or did it include the fascia.
- The  methods describe the period from January 2015 unitl December 2022 but this is a typo,
this would mean the last patients had no significant follow-up.
Please review this paper.
user
Title: Analysis of clinical diagnosis and treatment of intestinal volvulus
Version: 2 Date: 20 Dec 2022
Reviewer's report:
Thank you for the opportunity to review this manuscript.
Dr. Fo and colleagues published their center’s experience in gastro-intestinal volvulus over a
period of 7 years.
The manuscript describes an important problem that requires prompt treatment, however there
are some significant issues that need addressing. Most importantly, this is a small sample size
study that is further split into 3 subtypes of intestinal volvulus.
Major comments:
- The authors describe three subtypes of volvulus: jejunal, ileal and colonic. However, these are
all very different pathophysiological and epidemiological. Lumping these all together into one
retrospective study reduces the clarity of the message of the paper. Similarly, there is a difference
between primary and secondary volvulus (ie adhesional following surgery).
- In this retrospective cohort, all patients underwent surgery. However, there are cases where
conservative therapy can be attempted (as mentioned in the discussion). Are there any other
patients in this time period that underwent conservative therapy? Colonic volvulus, for instance,
can be managed endoscopically with an elective laparoscopic sigmoid resection at a later stage.
- Section 2.4 describes the surgical treatment; however the wording is a bit repetitive and
unclear (including the use of the ‘+’ sign). Instead, the authors should use a table to describe the
operations and provide a clearer overview. Also, did all patients undergo laparotomy, as early
onset cases can be managed laparoscopically?
- In the discussion the authors mention that ‘the occurrence of intestinal necrosis and the
cause of intestinal torsion were not significantly related to the presence or absence of signs of
peritonitis…’. I can only imagine that is due to very small sample size rather than intestinal
necrosis being insignificant for the clinical outcome.
- Regarding diagnostics: abdominal plain film are really obsolete by international guidelines
for acute abdominal pain investigations unless in exceptional circumstances. The gold standard
is CT with oral/rectal contrast if possible. There is no evidence why dual source CT is better
than standard CT in this setting (in contrast to other settings such as evaluating respectability
of borderline malignancies etc.).
Minor comments:
- Instead of ‘anal cessation of exhaust’ it is recommended to use ‘absence of flatus’.
- Some additional revision of language may be appropriate as it is difficult to follow some of the
wording: ’…17 patients with small bowel torsion who were not intestinal necrosis underwent
surgical reduction’.
- In section 2.5: the authors mention skin dehiscence with ‘skin grafts’ being placed under the
incision. It is unclear to me what they mean? Was the wound debrided and skin grafts placed?
How deep was the dehiscence, was it only the skin or did it include the fascia.
- The  methods describe the period from January 2015 unitl December 2022 but this is a typo,
this would mean the last patients had no significant follow-up.
assistant