Review for 10.1186/s12876-025-03839-6 (2025)

Title: Transient and Persistent Small-Bowel Intussusception in Children: A Diagnostic Tree
Analysis Model Based on Ultrasound and Clinical Findings
Version: 8 Date: 25 Feb 2025
Reviewer's report:
My recommendations are listed below.
In general:
1. It is more appropriate not to start the sentences with abbreviations or numbers. (Ex. CT – 2nd
paragraph of Introduction; PLP – Discussion 2nd paragraph)
2. Abbreviations that are used should be defined in parenthesis where the full word is first
mentioned. (Ex. SBI - Introduction)
3. The text should be edited by a native English speaker.
In the Introduction:
1. I recommend writing ‘differentiating TSBI from PSBI’ instead of ‘identifying TSBI and
PSBI’.
2. I could not understand what the authors mean by “The incidence is high in children with
TSBI6-8 but low in those with PSBI9-11.” Do the authors mean “The TSBI is more frequent
than PSBI.”? Also this sentence should be after the following sentence that defines the TSBI
and PSBI as terms. (“Intussusception that could be released spontaneously was defined as TSBI,
whereas intussusception that could not be released spontaneously was defined as PSBI12-14.
The TSBI is more frequent than PSBI.”
3. For the first 2 sentences of the 2nd paragraph of introduction, I recommend the following:
“Clinical presentation may be quite variable; thus, differentiating TSBI from PSBI according to
symptoms is difficult. Abdominal pain, nausea, vomiting, lethargy, “currant jelly” stools, and
even being asymptomatic can be seen both in patients with TSBI and those with PSBI18.
4. Could the authors rewrite the following sentences more understandable and fluent: “CT,
magnetic resonance imaging (MRI), and barium enema could provide clear images for patients
with SBI. However, these imaging techniques are not suitable for children because of their
low efficiency and the need for sedation, especially the ionizing radiation of CT and barium
enemas, for children who are unable to cooperate with the examination19.”  For example:
“Although CT, MRI and barium enema gives more detailed information, their use in children
is not recommended due to their adverse effects such as need for sedation, and exposure to
radiation.”
5. I recommend the following sentence for 2nd paragraph: “…. Since US is a simple, repeatable,
radiation-free and economical technique, it is suitable for the examination and diagnosis of SBI,
especially in children. It can help both in the differentiation of TSBI from PSBI and in the
detection of pathological lead points (PLP)20.”
6. Can the authors provide more details on USG features and correlates that are predictors of
surgical intervention according to previous studies?
In Materials and Methods:
1. Did the authors mean “Patients for whom complete data were unavailable due to missing
measurement data or unclear images because the children cried violently were excluded” by the
2nd sentence of Materials and Methods section?
2. Some sentences are unnecessary, and I recommend deleting these sentences: “The
sonographer subsequently measured and recorded the data in this study.” And “Not only the
subsequent pathological diagnosis and treatment of patients with PSBI but also the prognosis of
all patients who were followed up were recorded.”
3. Could the authors define better (in more details) the terms ‘head of the intussusception’ and
‘body of the intussusception’ at their first mention? I could not understand these terms although
defined later.
4. For the last sentence of the 2nd paragraph I recommend adding ‘diagnosis’ such as:
“Diagnosis, treatment and follow-up data of the patients were completely recorded.”
5. I could not understand from where and how the measurements taken by US. Could the authors
revise the following sentence: “The SBI diameter was measured on the largest transverse section
of the concentric circle, and the outer bowel wall thickness, the thickness of the head and body
of the intussusceptum (the fold and distal portion of the inserted small bowel), and the length of
the intussusceptum were measured on the longitudinal section.
6. What the authors mean by the term ‘the presence or absence of US’ in the following sentence:
“We investigated the PLP (secondary factors within SBI, such as a swollen intestinal wall or a
cystic or solid mass) and the presence or absence of US, especially in the head of the inserted
bowel.”
7. I think no need to write “The operator subsequently visualized the blue and red signals on the
US…”; I recommend the following sentence: “The blood flow of the intestinal wall evaluated
via Doppler US.”
8. I recommend the following sentence: “Patients were re-examined with US 45 minutes after
the initial US examination to confirm whether the SBI had released spontaneously2.” Instead
of “After completing the data collection, the US reexamined the patient after a 45-min delay to
confirm whether the SBI was released spontaneously2.”
9. I recommend the following changes: “If the SBI was partially released without signs of
ischemia, the US was repeated at an interval of 45 min until it was released completely. If SBI
resolved spontaneously, the diagnosis was defined as TSBI.”
10. No need to the term “…compared with those of the normal intestine” at the end of the
‘Treatment and Follow-up Results’ section.
11. What do authors mean by medical treatment?
12. What was the results of surgical exploration? Were there any ileocolic intussusception
misdiagnosed as SBI by US?
In the Results:
1. Could the authors give the mean or median of the patients’ age and SD or min-max (range)?
2. No need to write “In total, 87% (288/331) of patients with SBI were not detected with the
PLP via US” as previous sentence means the same.
3. For the PLP could not be detected via US, how they were detected? During operation? What
the authors mean by “…which was not consistent with the pathological results”?
4. For the last sentence of ‘US Findings’ section, did authors mean “Furthermore, 5.4% of
patients with TSBI had an intussusceptum length of #3.8 cm, whereas 81.6% of patients with
PSBI had an intussusceptum length of < 3.8 cm (P < 0.001)”?
5. Could the authors shorten and summarize the following section: “A patient with SBI and MD
was misdiagnosed with intestinal duplication by US. The abdominal purpura type was detected
in two patients, whereas US misdiagnosis was considered intestinal wall inflammatory edema.
A patient with a heterotopic pancreas was misdiagnosed with a small intestinal polyp by US. A
patient with intestinal duplication was misdiagnosed with a mesenteric cyst by US. All patients
in this study had favourable prognoses”?
6. Was surgery decided directly in patients with PLP detected by US? Please mention.
7. Could the authors give p values for the following sentence: “The Mann–Whitney U test
revealed that the US-measured data (diameter of the SBI, outer bowel wall thickness, head
and body of the intussusceptum, and length of the intussusceptum) were significantly different
between the TSBI and PSBI groups.” Also, no need to mention the statistical method as it was
mentioned at materials and methods section.
8. Did the authors mean “No PLP was detected and 81.6% of patients had intussusception shorter
than 3.8 cm (P < 0.001) at TSBI patients” by the sentence “All TSBI patients without PLP had
an intussusception length shorter than 3.8 cm (P < 0.001)”?
In the Discussion:
1. Have other factors been investigated in the literature? In the discussion, can you elaborate
further on the factors used in the literature to distinguish between temporary and permanent
intussusception (even for ileocolic intussusceptions)?
2. The following two sentences were contradicts: “A patient with a malignant lymphoma was
treated with chemotherapy before surgery. Because of ischemia of the inserted intestine, the
patient underwent surgical treatment for SBI before chemotherapy.” Was the operation before
or after the chemotherapy?
3. Could the authors summarize and rewrite the following sentences: “Approximately 88.9%
(8/9) of the MDs were detected via US, and 77.8% (7/9) of the MDs were consistent with the
pathological results. In 77.8% (7/9) of the MDs, abnormally shaped intestines were detected in
the SBI. In 71.4% (6/9) of the MDs, a swollen diverticulum wall was detected via US. In 11.1%
(1/9) of the MDs, the diverticulum was secondary perforated, and adhesions formed around it”?
4. According to the following sentence: “The US detection rate of MD in children has increased
because of the characteristics of thin abdominal walls”, is the increase of MD detection was
between children and adults or whether by time? Could the author re-write the sentences?
5. According to the following sentence: “Because of the small size of the lesions and limitations
of US (susceptible to intestinal gas interference), eight patients were misdiagnosed with PLP by
US.” Whether the diagnosis of PLP wrong ( Ex.US reported MD and during operation polyp
was found) or US reported PLP but during operation no PLP found or US reported no PLP and
during operation PLP was found?
6. What did the authors mean by ‘an experimental result’ in the following sentence: “A single
factor was often used as an experimental result in previous studies”?
7. I recommend the term ‘cut-off value’ instead of ‘boundary value’.
8. Could the authors report the data that mentioned at the following sentence, in results section
in detail: “Single-factor statistical analysis revealed that the head-of-intussusceptum thickness
(AUC = 0.984) had the highest diagnostic efficiency, followed by the intussusception length
(AUC = 0.959)”?
9. What are the p values and results of comparison of clinical information between TSBI and
PSBI? Could authors give the distribution of each clinical findings and their comparison p values
between TSBI and PSBI at results section? These data could be given as table also.
In Conclusion:
1. I recommend the following sentences as conclusion, by deleting unnecessary parts: “In
conclusion, an effective DTA model was established to differantiate TSBI and PSBI. Identifying
the PLP could help clinicians manage these patients. The application of the DTA model for the
diagnosis of SBI could decrease the surgical rate of TSBI, allowing patients with PSBI to obtain
an accurate and early diagnosis and treatment.”