Ingrowing Liver as Atypical Recurrent Diaphragmatic Hernia Presentation—Diagnostic and Treatment Difficulties: A Case Report

Round 1

Reviewer 1 Report

Firstly, I would like to congratulate the authors for managing this case. The authors propose the concept of ingrowing liver. My comments are as follows:

Abstract and Introduction sections: well-written. No changes are needed.

Case presentation: can be another section instead of a part of the Introduction section (Number it as 2 instead of 1.1).

The case has been managed very well with thoracoscopy. It is difficult to perform a thoracoscopic repair in recurrent CDH. 

Discussion: The concept of liver ingrowth is very speculative. Although the authors have discussed other possibilities including liver heterotopia, I would advise them to outline the concept of "ingrowing liver" in detail in the discussions section. 

There are grammatical errors. Please take the help of a writing assistant.

Author Response

1. Case presentation: I have corrected the section number
2. Discussion: I have outlined the details of 'ingrowing liver' by adding a sentence 'The liver with its proliferative potential could grow up in pleural cavity through a small defect in diaphragm leading to recurrence. The primary sutures were intact and the herniation liver had a limited size and a shape with narrow neck similar to extent of the defect.'
3. I have corrected some grammatical errors.Thank You for the review.

Reviewer 2 Report

The authors reported a rare case of recurrent CDH with intrathoracic ingrowing liver.

1. Table 1

Date should be changed into age.

2. Diagnostics and therapeutic intervention

The following information should be involved:

Diameter of hernia (operative finding)

The size of intrathoracic ingrowing liver

Prognoses of respiratory symptoms and postoperative follow-up period

Author Response

1. I have corrected dates into age in the Table 1
2. I have added informations about diameter of hernia, intrathoracic ingrowing liver, postoperative period and prognoses of respiratory symptoms. Thank You for the review.

Reviewer 3 Report

The authors presented a case of recurrent congenital diaphragmatic hernia in 4.5- year old patient

Introduction is poor. The authors should present problem of recurrent congenital diaphragmatic hernia in more details, provide mechanisms why does it occur, treatment options… They presented just few lines.

Next, clinical presentation, diagnostic and therapeutic modalities of this case is quite standard. I do not see any, as the authors stated, atypical presentation. The main question is how this single case adds to the scientific literature?! All presented regarding this condition is well known and several very similar reports has been published previously in medical literature. I do not see any novelty from this report

Discussion is very poorly designed and wordy, mostly repeating well known facts from literature. The authors should discuss this case in short lines and compare it to published cases from literature and should emphasize why this case is important and what is a difference from published data.

Conclusions made by the authors are general and do not follow from the present case.

The quality of English needs to be improved. Manuscript should be edited for the language from a native English speaker or professional language editing service to improve the grammar and readability.

Unfortunately, I do not see any benefits for the readers from this case report.

Author Response

1. I have presented problem of recurrent congenital diaphragmatic hernia, atypical recurrence, other problems such as lung hypoplasia and diaphragmatic impairment, possible mechanisms of herniation and other surgical treatment options in discussion.
2. The conventional clinical picture and symptoms of diaphragmatic hernia recurrence is usually different from our case. In this case the symptoms have not been results of solely recurrence. In CT scan there were no pleural effusion, diaphragmatic discontinuity or other lesions that could be signs of recurrent diaphragmatic hernia. Thoracoscopy revealed primary sutures intact. Our department is a part of The European Reference Network for Rare Inherited Congenital Anomalies and we haven't seen such case previously. 
3. In the literature I haven't seen such case so it has scientific value. I have compared our case to some published cases describing intrathoracic presentation of liver in diaphragmatic hernia recurrence. Thank You for the review. 

Round 2

Reviewer 1 Report

All my comments have been adequately addressed in the revised manuscript. Congratulations to the authors for the successful management of this case.

Reviewer 3 Report

Unfortunately I do not see any improvement in this report. The authors performed just technical corrections.

As I mentioned in my previous review introduction is poor. The authors should present problem of recurrent congenital diaphragmatic hernia in more details, provide mechanisms why does it occur, treatment options… They presented just few lines. Next, clinical presentation, diagnostic and therapeutic modalities of this case is quite standard. I do not see any, as the authors stated, atypical presentation. The main question is how this single case adds to the scientific literature?!

All presented regarding this condition is well known and several very similar reports has been published previously in medical literature. I do not see any novelty from this report. An explanation from authors regards to novelty of this is premature.

Discussion is very poorly designed and wordy, mostly repeating well known facts from literature.