Primary Omental Torsion in Children in the Laparoscopy Era: What Have we Learned so far?

BACKGROUND/AIM: Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment. MATERIALS AND METHODS: A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria. RESULTS: Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal. CONCLUSION: Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision.

Ileocolic Intussusception in Infancy is not Always Idiopathic - Adenomyoma as the Leading Point.

BACKGROUND Intussusception is a frequent abdominal emergency in infancy, requiring immediate diagnosis and therapeutic intervention. In approximately 90% of cases, intussusception seems to be idiopathic. There has been a reported association of intussusception with lymphoid hyperplasia of Peyer patches in the terminal ileum, possibly acting as the triggering factor. Clinical presentation varies substantially, while the etiology seems idiopathic in most reported cases. CASE REPORT This case describes a previously healthy 2-month-old girl who presented with an episode of non-bilious vomiting and deterioration during the 12 hours preceding the visit. Abdominal ultrasonography revealed the typical target sign in the right iliac fossa, without visible peristalsis, confirming the diagnosis of intussusception. Failure of non-surgical reduction led to emergency laparotomy with the working diagnosis of intussusception due to Meckel's diverticulum. However, laparotomy instead revealed an adenomyoma of the small intestine, a rare benign tumor-like lesion, as the pathological lead point. CONCLUSIONS This case is interesting for 2 distinct reasons. Not only does it underline the need to maintain a high index of suspicion for triggering factors, even in patients within atypically affected age groups, but it also adds to the remarkably limited selection of reported adenomyomas of the small intestine acting as the pathological lead point for intussusception. In this case report, we aspire to emphasize that especially in patients outside the most affected age group, pediatric surgeons should remain aware of the possibility of adenomyoma as a pathological lead point.

Post-Traumatic Stress as a Psychological Effect of Mild Head Injuries in Children.

BACKGROUND: Head trauma is one of the most common pediatric emergencies. While the psychological effects of severe head injuries are well studied, the psychological consequences of mild head injuries often go overlooked. Head injuries with a Glasgow Coma Scale score of 13-15, with symptoms such as headache, vomiting, brief loss of consciousness, transient amnesia, and absence of focal neurological signs, are defined as mild. The aim of this study is to evaluate the stress of children with mild head injuries and their parents' relevant perception during the early post-traumatic period. METHODS: This is a prospective cross-sectional study on a cohort of children with mild head injuries and their parents. Two questionnaires were implemented, the Child Trauma Screening Questionnaire (CTSQ) which was compiled by the children, and the Children's Revised Impact of Event Scale (CRIES-13), compiled by their parents. Both questionnaires are widely used and reliable. The first presents an excellent predictive ability in children with a risk of post-traumatic stress disorder, while the second is a weighted self-completed detecting instrument for the measurement of post-traumatic stress in children and adolescents, with a detailed evaluation of their reactions to the traumatic incident. The participants responded one week and one month after the traumatic event. RESULTS: A total of 175 children aged 6-14 years and 174 parents participated in the study. Stress was diagnosed in 33.7% of children after one week, and in 9.9% after one month. Parental responses suggesting stress presence in their children were 19.0% and 3.9%, respectively. These outcomes showed that mild head injuries are not so innocent. They are often underestimated by their parents and may generate a psychological burden to the children during the early post-traumatic period. CONCLUSIONS: Mild head injuries may affect the emotional welfare of children. Healthcare providers should understand the importance of the psychological effect of this overlooked type of injury. They should be trained in the psychological effect of trauma and be aware of this probability, promptly notify the parents accordingly, and provide psychological assistance beyond medical treatment. Follow-up and support are needed to avoid the possibility of future post-traumatic stress disorder. More extensive research is needed as the outcomes of this study regarded a limited population in numbers, age, and survey period. Furthermore, many children with mild head injuries do not ever visit the emergency department and stay at home unrecorded. Community-based research on the topic should therefore be considered.

Mesenteric Lymphadenitis Presenting as Acute Abdomen in a Child with Multisystem Inflammatory Syndrome.

Multisystem inflammatory syndrome in children (MIS-C) may develop as a rare complication following COVID-19. MIS-C presentation varies substantially, but fever and gastrointestinal symptoms are the most prominent. Indeed, gastrointestinal involvement may be severe enough to present as acute abdomen, posing challenges to clinicians. We present herein the case of a healthy five-year-old male who presented with fever, vomiting, and abdominal pain, resembling acute abdomen. The patient had no history of SARS-CoV-2 infection or exposure, and MIS-C diagnosis was initially surpassed unnoticed. The patient underwent exploratory laparotomy that only revealed mesenteric lymphadenitis. Postoperatively, the patient met the clinical and laboratory diagnostic criteria of MIS-C. SARS-CoV-2 exposure was serologically confirmed and MIS-C treatment was commenced, resulting in defervescence and a satisfactory outcome. In young patients presenting with acute abdomen, surgeons should be aware of MIS-C, so that earlier diagnosis and appropriate treatment are made prior to surgical interventions.

Abdominal Cocoon Syndrome: An Extremely Rare Cause of Small Bowel Obstruction.

Abdominal cocoon syndrome or encapsulating peritoneal sclerosis is a rare condition causing small bowel obstruction. It is called cocoon syndrome because of the existence of an abnormal membrane that contains part or the entire small intestine. We present a case of a 49-year-old male, presenting to our department with recurrent episodes of obstructive ileus that did not respond to conservative treatment. He underwent exploratory laparotomy and a thick membrane covering the small bowel loops was found. The membrane was excised and sent for pathological examination. Abdominal cocoon syndrome is an acquired condition caused by an inflammatory process that is not yet completely understood. There are many theories for the pathophysiology of the disease. In most cases, the diagnosis is established during surgery. Complete removal of the membrane is the indicated surgical treatment. In mild cases, when the diagnosis is made preoperatively, conservative treatment should be the first choice.

Multiple magnet ingestion causing instestinal obstruction and entero-enteric fistula: Which imaging modality besides radiographs? A case report.

Ingested foreign bodies occur in children younger than 3 years and pass uneventfully through the gastrointestinal tract. However, multiple magnet ingestion are associated with serious complications. A 9-year old male with abdominal pain and vomiting 3 days prior to admission, underwent abdominal radiographs showing radiopaque foreign bodies. Ultrasonography (US) independently discovered one magnet floating in the jejunum. Preoperative Computed Tomography (CT) confirmed the presence of two neighbouring magnets causing obstruction and beaking of an adjacent jejunal loop. Laparotomy led to uneventful recovery of transmesenteric fistula formation following pressure necrosis in two jejunal loops. We present the first case of multiple magnet ingestion managed in our institution, where the prevalence of magnet ingestions is low due to unpopularity of magnet toys. CONCLUSION: Awareness of the potentially devastating effects of multiple magnets passing the pylorus and the contribution of different imaging modalities for the diagnosis are emphasized and discussed.

Primary bacterial peritonitis in a previously healthy adolescent female: A case report.

INTRODUCTION: Acute pneumococcal peritonitis represents an unusual entity characterized by infection in the abdominal cavity despite the absence of an obvious causative source. Patients with portal hypertension such as cirrhotics and those with nefrotic syndrome are more frequently encountered in the every day practice. PRESENTATION OF CASE: A 14 years old female was referred to our department by his general practitioner with a 24h history of right lower abdominal pain and fever. Clinical examination was suggestive for peritonitis and the girl was transferred to the operation room. A diagnosis of primary pneumococcal peritonitis was made on the basis of the findings during surgery and the microbiological tests. Institution of appropriate antibiotics resulted to complete recovery. DISCUSSION: A mini literature review was performed. CONCLUSION: Primary bacterial peritonitis in adolescents is extremely rare. Surgeons are required to be aware of this entity.

Acute coagulopathy in children with multiple trauma: a retrospective study.

BACKGROUND: Acute coagulopathy associated with trauma has been recognized for decades and is a constituent of the "triad of death" together with hypothermia and acidosis. STUDY OBJECTIVE: The aim of this study was to determine to what extent coagulopathy is already established upon emergency department (ED) admission and the association with the severity of injury, impaired outcome, and mortality. METHODS: Ninety-one injured children were admitted to the ED in our hospital. Pediatric Trauma Score (PTS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) score were used to estimate injury severity, and organ function was assessed by the Sequential Organ Failure Assessment (SOFA) score. RESULTS: Coagulopathy upon pediatric intensive care unit admission was present in 33 children (39.3%): 21 males and 12 females. PTS ranged from 1 to 12 (mean 8.2) in 51 children without coagulopathy and from -1 to +11 (mean 6.8) in 33 children with coagulopathy (p = 0.087). ISS and GCS ranged from 4 to 57 (mean 28) and from 3 to 11 (mean 7.3), respectively, in the coagulopathy group, whereas in the group without coagulopathy, ISS score ranged from 4 to 41 (mean 20.5; p = 0.08) and GCS from 8 to 15 (mean 12.8; p = 0.01). SOFA ranged from 0 to 10 (mean 3.4) in children without coagulopathy and from 0 to 15 (mean 5.4) in the coagulopathy group (p = 0.002). Among 33 children with coagulopathy, 7 did not survive (21%), all with parenchymal brain damage, whereas all trauma patients without coagulopathy survived (p < 0.001). CONCLUSION: Acute coagulopathy is present on admission to the ED and is associated with injury severity and significantly higher mortality.

A fatal case of seronegative, late-onset systemic lupus erythematosus presenting with motor sensory axonal polyneuropathy.

Systemic lupus erythematosus is a multisystemic, autoimmune, inflammatory disorder predominantly affecting young females. Its onset may be abrupt or insidious, presenting with a broad range of clinical and immunological features. We report an unusual case of elderly-onset systemic lupus erythematosus in a woman initially diagnosed with discoid lupus, and subsequently admitted to hospital due to a progressive psycho-motor deficit. Electrophysiological measurements suggested a diagnosis of acute motor sensory axonal neuropathy. Unusual clinical features and negative serology led to diagnostic uncertainty. This case report offers information on the course of the disease through the entire chain of the health care delivery (from primary to tertiary). Despite the efforts of the hospital staff, it was not possible to save the life of the woman.

Fournier's Gangrene Associated with Local Cutaneous HPV Lesions in a Previously Healthy Girl.

A case of an 11-year-old prepubertal girl with Fournier's gangrene is presented. The diagnosis was posed after the disease had progressed to the typical clinical picture of frank gangrene. A benign viral infection, common warts, possibly represents the initiating event of the development of this necrotizing soft tissue infection. The development of childhood Fournier's gangrene in association with viral infections has been reported in the past. An optimal outcome was achieved by aggressive antibiotic and surgical treatment despite the late diagnosis. In children, Fournier's gangrene develops in previously healthy individuals with benign diseases often representing the initiating events; thus, high index of suspicion is necessary for an early diagnosis that will lead to the optimal outcome.

Meckel's diverticulum in paediatric practice on Crete (Greece): a 10-year review.

BACKGROUND: Although Meckel's diverticulum (MD) is the most prevalent congenital abnormality of the gastrointestinal tract, it has varied presentations and often becomes a diagnostic challenge. The purpose of this study was to review the diverse presentations of MD, record the epidemiologic features for Crete and review the detection techniques and the treatment options. PATIENTS AND METHODS: This was a review of the records of all children who underwent surgery for MD in the department of Paediatric Surgery of the University Hospital of Crete (Greece) between January 1999 and January 2009. RESULT: A total of 45 patients (32 male and 13 female) aged 1 to 13 years (median 10 years) with a diagnosis of MD were retrospectively reviewed. The collected data were analysed, looking at age, gender, clinical features, investigations, histopathological findings and surgical interventions. In 25 patients, MD was an incidental finding at laparotomy because of appendicitis. The remaining 20 patients were symptomatic and presented with various clinical features. Nine patients (19.9%) had clinical features of peritonitis; of these, three had perforated MD and six had Meckel's diverticulitis at laparotomy. Four patients were diagnosed with intestinal obstruction. Seven patients (15.5%) presented with lower gastrointestinal bleeding. Ultrasound scans revealed intussusception in three patients, requiring open reduction. The remaining four patients with bleeding per rectum underwent a Meckel's Tc99 scan that showed a positive tracer. CONCLUSION: All patients with MD underwent Meckel's diverticulectomy with appendicectomy. MD has an incidence of approximately 1 to 2% in our population. It is necessary to maintain a high index of suspicion in the diagnosis of MD paediatric age group because it can be easily misdiagnosed.

Small bowel intussusception with pelvic plastron secondary to acute appendicitis in child.

We report an unusual case of a 3-year-old child with appendicitis complicated by ileoileal intussusception. Although acute complicated appendicitis and concurrent ileoileal intussusception represent a possible cause of an acute abdomen, very few cases have been reported in the literature.