Russian Journal of Pediatric Surgery

BACKGROUND: Chronic pancreatitis in children, unlike in adults, is more often caused by genetic or anatomical factors and is commonly associated with persistent pain syndrome, which significantly reduces quality of life and limits functional activity. Surgical treatment, in particular longitudinal pancreatoenterostomy, is currently one of the most effective surgical approaches for patients with refractory disease. However, data on long-term outcomes of this intervention in pediatric patients remain limited, especially regarding differential outcomes in obstructive versus non-obstructive forms of chronic pancreatitis. This underlines the necessity of comprehensive analysis of clinical, instrumental, and laboratory data in the postoperative follow-up to assess the effectiveness and safety of the procedure.

AIM: To evaluate the long-term clinical and morphological outcomes of longitudinal pancreatoenterostomy in children with obstructive and non-obstructive forms of chronic pancreatitis.

METHODS: A retrospective-prospective study was conducted involving 82 children with verified chronic pancreatitis who underwent surgical treatment at a specialized pediatric center. The main cohort included 76 patients who underwent longitudinal pancreatoenterostomy. Among them, 59 had the obstructive form of the disease and 17 the non-obstructive form. Demographic, clinical, laboratory, and imaging data were assessed before surgery and during a follow-up period of up to 5 years. Comparative analysis was performed using non-parametric statistical tests and multiple regression analysis.

RESULTS: Over the five-year follow-up period, complete pain relief was achieved in 83.3% of patients. The frequency of acute pancreatitis exacerbations dropped to zero (p <0.001). Morphological improvements (reduced echogenicity, normalization of pancreatic size and structure) were observed in the majority of cases. Fecal elastase levels showed a positive trend, peaking in the third to fourth year of follow-up. Intergroup differences for most key indicators did not reach statistical significance, indicating comparable efficacy of the procedure in both disease forms.

CONCLUSION: Longitudinal pancreatoenterostomy in children with chronic pancreatitis demonstrates high clinical efficacy regardless of the disease form, contributing to functional recovery of the pancreas and a significant reduction in exacerbation frequency in the long term.

A team of the authors, based on their multi-year experience in the diagnostics and management of peritonitis in children, and after reviewing domestic and international literature sources, concluded that, to-date, none of the existing classifications considers peritonitis as a polyetiological disease, a point acknowledged by all researchers dealing with this issue. Therefore, the authors have decided to develop a classification of peritonitis in children which would take into account all types of the disease and their complications.

The proposed classification consists of 11 rubrics which categorize peritonitis by its course (acute and chronic), cause (primary, secondary, tertiary), etiology (aseptic, bacterial), route of infection penetration into the abdominal cavity, microbial factor, exudate nature and abdominal contents, as well as process extension, stage of purulent-septic process, type of purulent process development, complications, and outcomes.

In the rubric on peritonitis causes, the authors analyze in details the controversial topic on the tertiary peritonitis. Its division into progressive and low-grade is motivated by the fact that just these types are those factors which determine the development of complications in the postoperative period.

As to the extension of peritonitis, the authors support the opinion of the majority of authors who propose to divide peritonitis into the local and generalized one. Local peritonitis is classified by the authors as abscesses of types 1–3 and infiltrates, so called limited processes.

As to the types of purulent process formation, the authors also support the division of peritonitis into free, partially abscessing, totally abscessing, infiltrative (loose, dense), and mixed; outcomes of the disease are divided into “recovery” and “fatal” categories. In terms of “recovery”, it is divided into “complete” and “having late complications” (intestinal fistulas, adhesive disease, postoperative hernias), which reflect the effectiveness of the disease management.

The authors propose their classification of peritonitis in children for discussion among pediatric surgeons. They also welcome any opinions and suggestions from pediatric surgeons in Commonwealth of Independent States countries, so as to improve this classification.

Uterine appendage torsion in children is an urgent problem of pediatric gynecology and surgery. An increase in the ovarian volume is associated with the risk of uterine appendage torsion, while tumor stem torsion is one of the main complications of ovarian tumors. Any newly identified lesion should be evaluated for malignancy which defines the type of surgical intervention. If the malignancy of the formation is excluded, ovarian-sparing surgery can be successfully applied.

The paper presents a case of uterine appendage torsion in a teenage girl with a benign germinogenic ovarian tumor who had been initially hospitalized with a clinical picture of an acute abdomen and non-specific symptoms for torsion. During laparoscopic detorsion, it was decided to refrain from removing the cystic formation from the affected ovary. In 3 months at the repeated hospitalization, the child was examined with ultrasound, magnetic resonance imaging with contrast to determine the concentration of a number of markers (alpha-fetoprotein, lactate dehydrogenase, chorionic gonadotropin). The patients was also consulted by an oncologist: a teratoma was detected and removed laparoscopically. The patient’s management was staged: first, detorsion of the right uterine appendages, then removal of the bulky formation of the ovary using the technique of relaparoscopy. After morphological examination, diagnosis of mature teratoma was put; an immunohistochemical assay confirmed it.

The presented clinical observation underlines the importance of early diagnostics and an individual approach to choosing a curative modality in case of uterine appendage torsion in girls. Laparoscopic organ-preserving surgery is the preferred approach so as to minimize tissue injury and to preserve ovarian reserves.

Presenting this clinical case is an important step so as to raise doctors’ awareness of the complications of ovarian tumors in children and adolescents (in particular, torsion of uterine appendages) which will help to improve diagnostics and treatment of such conditions in adolescent girls.

An independent trichobezoar in the jejunum, which causes the acute obstruction, is an extremely rare case. A specific location, like that in the discussed case, influences the diagnostic process and surgical tactics, when one has to stay away from the traditionally used algorithms.

A 12-year-old patient was admitted to the pediatric surgical department with abdominal pain and repeated vomiting. In the clinical blood analysis, leukocytosis with neutrophil shift was registered. Ultrasound examination of the abdominal organs revealed dilated intestinal loops with sluggish peristalsis and liquid contents. Contrast X-rays of the abdominal cavity showed signs of intestinal obstruction. With preliminary diagnosis of acute intestinal obstruction, the patient was taken to the diagnostic laparoscopy. A foreign body was found at 100 cm distance from the ileocecal angle which obturated the intestinal lumen; proximal loops were dilated, hyperemic. To remove the foreign body with minilaparotomic approach, a loop of the small intestine was pulled into the wound, and a foreign body (trichobezoar) was removed by longitudinal enterotomy. At the postoperative period, fibrogastroduodenoscopy revealed no signs of gastric trichobezoar. On day 17, the patient was discharged in a satisfactory condition. She was given recommendations for further outpatient regime; psychiatrist’s consultation was also recommended to her.

Migration of a gastric trichobezoar into the jejunum complicated with acute small intestinal obstruction is a rare situation. Our clinical case is atypical one, given the patient’s age, lack of medical history, and trichobezoar location, which influenced diagnostic and therapeutic tactics. However, such a clinical picture of trichobezoar is also possible, and this case has to aware medical specialists in the diagnostic search of patients in urgent state.