Review for 10.1186/1471-230X-11-18 (2011)

Reviewer's report
Title:High APACHE 2 score and long length of bowel resection impair the
outcomes in patients with necrotic bowel induced hepatic portal venous gas
Version: 1Date:7 August 2010
Reviewer: ABDULZAHRA HUSSAIN
Reviewer's report:
Dear Authors;
I read with great interest your article.You have posed that APACHE scoreII and
the resected segment of the bowel are predicting factors for the outcome of the
HPVG.
I appreciate that great efforts have been put in the article,however the paper
need further revision to improve the quality and put more nsights and
knoweledge in the subject.
Please address these comments carefully;
INTRODUCTION:
1.You have mentioned the largest reported series up to date is 7 patient.that is
not true ,several papers in the literature are reporting more than this number.Im
attaching one reference,please check:Paran H, Epstein T, Gutman M, Shapiro
Feinberg M, Zissin R. Mesenteric and portal vein gas: computerized tomography
findings and clinical significance. Dig Surg. 2003;20(2):127-132.
2.The pathophysiology of HPVG can be explained by
a.mucosal damage and lumenal gas escape to the portal system via portal
microvenule.
b.Septic embolization or abscess that rupture through the small portal venules.
3.Gas forming portal pyemia.
Other less important factors are increased lumenal pressure such as during
colonoscopy or large bowel enema which are associated with HPVG.
PATIENTS AND METHODS:
1.Diagnosis is depending on the clinical presentation of septic shock and
peritoneal signs and also on the CT demonstaring poor enhancement :
Although this statement is generally true ,however sepsis and peritoneal signs
are not specific for bowel ischemia and other abdonimal catastrophes can
present similarly.Therefore taking this as a proof of diagnosis is not completley
trus.
Again CT scan specificity for bowel ischemia is not 100 % as we all know it is
radiologist dependent as in all other cross sectional studies.The final diagnosis is
made in theatre.Therefore the 6 patients who have been diagnosed on clinical
and perhaps radiological bases should be excluded from this study.
2.Why end stoma has been performed for every patients.
Double barrel stoma can be very helpful to assess the proximal and distal bowel
in borderline cases.
3.Second look laparoscopy rather than laparotomy may be indicated in some
cases.
THE RESULTS:
1.No data are mentioned on the type of procedure? small bowel resection,right
hemicolectomy,total colectomy,etc.
2.No thing mentioned about vascular involvement;some of the patients need
revascularization if the SMA critical narrowing is confirmed as the cause of
ischemia.The issue is very important for patients who need extensive resection
as revascularization my keep the patient with more than 110 cms of smll bowel
that safe him nutritional support.
3.Nothing mentioned about the extreme cases that surgeon do nothing but to
close the abdomen.How many of these have been encountered ?
4.How many patients have small bowel remanant less than 110 cms after
resection?and how may subjected to nutritional support asintestinal failure cases.
DISCUSSION:
1.The author should also consider benign causes of HPVG and should clarify
that it is not ominous sign in all patients as the course in benign cases is
complete recovery.
2.Other tests as arterial blood gas and lactate level shold be mentined as
supportive especially in unconscious patients [intubated ITU ]patients for
example.
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests