Beržanskis, Mindaugas

AIM OF THE STUDY To present a pediatric case in which unrecognized trauma and suspected abuse contributed to the development of sepsis, emphasizing the significance of comprehensive clinical evaluation, early identification of non-accidental injuries, and the essential role of a multidisciplinary approach in protecting vulnerable children. CASE DESCRIPTION A 3-year-old boy was admitted to a primary care hospital with a history of fever and cough following attendance at a family New Year’s Eve gathering. Despite initial treatment with broad-spectrum antibiotics, his clinical condition deteriorated, with progression to sepsis, prompting transfer to our tertiary hospital for advanced management. Upon transfer, a comprehensive evaluation identified multiple previously unrecognized injuries of uncertain etiology. These included oval-shaped lesions on the hand, suggestive of cigarette burns, as well as deep tissue injuries in the forearm and calf. Additionally, an anal fissure extending into the anal canal was identified and confirmed during rectoscopy. The anal fissure was managed conservatively. The lesion in the calf progressed to necrosis, requiring surgical intervention, including debridement, vacuumassisted closure (VAC) therapy, and subsequent autodermoplasty. The parents provided inconsistent explanations regarding the origin of the injuries and failed to attend scheduled follow-up visits, raising concerns of potential abuse. As a result, social services and child protection authorities were notified, prompting a formal safeguarding investigation. CONCLUSIONS This case underscores the critical consequences of missed non-accidental trauma, which progressed to severe infection and sepsis. Early recognition of suspicious injuries, comprehensive physical examinations, and close collaboration between medical and child protection teams are essential to prevent harm. Healthcare professionals must remain vigilant, as delayed diagnosis of abuse can lead to life-threatening complications.

Aim of Study: To highlight the severity of air gun injuries in children, focusing on diagnostic challenges and the diverse therapeutic approaches required for varying injury types. Methods:This case series reviews five pediatric patients who sustained severe air gun injuries to different anatomical regions, including the chest, abdomen, and retroperitoneum. Diagnostic imaging and treatment strategies, ranging from conservative management to surgical interventions, were tailored to each case based on injury severity. Results:The injuries affected multiple anatomical areas and presented varying levels of complexity: • Chest injuries: Three children sustained thoracic injuries. One developed pneumothorax and subcutaneous emphysema, managed conservatively due to a retained bullet near the vertebral column. Another suffered a cardiac injury causing asystole, successfully managed with emergency sternotomy. The third child’s lung injury, causing minor pneumothorax, was treated with thoracoscopy and conservative care. • Abdominal injuries: One child required laparotomy for injuries to the liver, stomach, and pancreas. Months later, a migrating kidney bullet caused ureteral obstruction, resolved with stenting and cystoscopic removal. • Retroperitoneal injuries: A lumbar wound caused a retroperitoneal hematoma and ureteral damage, managed with drainage and stenting, leading to full recovery. Conclusions: Air guns can cause diverse and severe injuries across multiple anatomical regions, necessitating a range of diagnostic and therapeutic strategies. Prompt and tailored management is critical for positive outcomes. Public awareness and stricter regulations are essential to prevent such incidents.

Ūmi kirkšnies srities patologija- nereta pediatrinio amžiaus pacientų problema Dažniausiai susiduriama su patologija, būdinga tam tikrai amžiaus grupei, tačiau pasitaiko ir retesnių ar netipiškų atvejų. Norint pagerinti gydymo kokybę bei rezultatus, diskutuojama apie laparoskopinės chirurgijos galimybes ir pritaikomumą pediatrinio amžiaus pacientams. Toks gydymo metodas mažiau invazyvus, mažesnis nuskausminamųjų vaistų poreikis, trumpesnė stacionarizavimo trukmė, tačiau reikalauja specifinės gydytojo patirties ir negali būti taikomas visiems pacientams.
1 atvejis 7 metų berniukas stacionarizuotas į LSMU KK Vaikų chirurgijos sk. sergantis apie 1 parą laiko dėl dešinės sėklidės skausmo, įtariamo sėklidės ataugėlės apsisukimo. Apžiūrint dešinė kapšelio pusė bei kirkšnies kanalo sritis nežymiai patinusi, abi sėklidės kapšelyje, paraudimo nematyti, palpuojant skausminga dešinio kirkšnies kanalo projekcijoje, virželis laisvas, abi sėklidės neskausmingos. Aiškių išvaržų nečiuopiama. Echoskopiškai matomas galimai infiltruotas virželis. Negalint atmesti išvaržos strigimo operuotas, atlikta laparoskopija, rasta dešinės kirkšnies kanale įstrigusi nedidelė taukinės dalis, ji ištraukta, atlikta herniorafija. Sklandi pooperacinė eiga.
2 atvejis: 2m berniukas atvežtas į VSPS dėl skausmingo darinio kirkšnies srityje, stacionarizuotas į Vaikų chirirgijos sk. Apžiūrint k. kirkšnies srityje matomas patinimas, palpuojant skausmingas, vaikas priešinasi apžiūrai. Abi sėklidės kapšelyje, neskausmingos. Echoskopinis tyrimas neatliktas. Nuskausmintas, bet pacientas apžiūrai priešinasi, manualinis atstatymas nesėkmingas, nuspręsta atlikti laparoskopiją dėl įtariamos įstrigusios kirkšnies srities išvaržos. Operacijos metu išvaržos nerasta. Atviru būdu revizuotas kirkšnies kanalas, rasta ū. funikulocelė, atlikta herniorafija, sklandi pooperacinė eiga.
Detalus anamnezės surinkimas bei pacieto apžiūra, tikslingas tyrimų paskyrimas, jų atlikimo kokybė, pacientų indvidualizavimas bei gydytojo patirtis lemia gerus gydymo rezultatus naudojant laparoskopinės chirurgijos metodą pediatrinio amžiaus pacientams esant ū. kirkšnies srities patologijai.

Aim of the Study. The aim of this study was to evaluate the efficacy and advantages of endoscopic pilonidal sinus treatment (EPSiT) according to our clinic’s experience and to review existing literature on the endoscopic technique of pilonidal sinus treatment. Methods. A literature review was performed by searching the Medline (PubMed) database for literature sources using the following search terms: pilonidal or sacrococcygeal and endoscopic or minimally invasive or video-assisted. We interviewed 12 patients treated at the Department of Pediatric Surgery at the Lithuanian University of Health Sciences Kaunas Clinics who underwent either EPSiT or conventional treatment for pilonidal sinus between 2021 and 2023. Data on hospital length of stay, operative time, postoperative complications, healing time, recurrence rate, and time until return to work were collected. Main results. 22 studies were included in the literature review. The mean age was 23.5 years. The mean operative time was 36.2 minutes. The mean length of stay in the hospital was 15.4 hours. The mean healing time was 27 days, and the mean time to return to work was 2.8 days. The mean recurrence rate was 10.4 %, and the overall healing rate was 89.6 %. In our clinic, the mean age of EPSiT group was 16.7 years compared to 16 years of conventional surgery group. The mean length of stay in the hospital was 1.2 vs. 2.7 days, the average healing time was 12.7 vs 17.3 days, and the recurrence rate was 50 vs. 83.3%. Conclusions. Endoscopic pilonidal sinus treatment is effective method with shorter healing time and lower recurrence rate compared to classic treatment. It allows for an early return to normal life without restrictions.

Aim of the Study: we wanted to analyze immune markers (Interleukin‐10 (IL‐10), Interleukin‐17A (IL‐17A) and Interleukin‐22 (IL‐22)) in children with different types of acute appendicitis.Methods: During a 4‐month period blood samples from children with acute appendicitis (with regional Bioethics Committee approval No. BE‐2‐40) were taken before the incision and analyzed with ELISA for levels of IL‐10, IL‐17A and IL‐22. The patients’ groups were formed according to type of appendicitis and duration of disease ‐ the early (symptoms ≤24 hours) and the late ‐ (>24 hours). According to the pathology report phlegmonous appendicitis was categorized as uncomplicated appendicitis and gangrenous or perforated appendicitis ‐ as complicated. The early uncomplicated appendicitis (A1) group was compared to the late uncomplicated (resolving) appendicitis (A2) group. Also, the early complicated (rapidly progressive) appendicitis (B1) group was compared to the late complicated appendicitis (B2) group. Main Results: 39 patients were analyzed: 9 with A1, 8 with A2, 6 with B1 and 16 with B2. B1 group had higher IL‐10 rates than B2 (26,5 pg/ml [7,98;44,2] vs. 10,88 pg/ml [4,85;17,82], p=0,027), however they did not differ between A1 and A2 (8,76 pg/ml [4,6;21,3] vs. 10,86 pg/ml [6,6;15,3] p=0,321). IL‐17A had lower than traceable values in most patients <1,6 pg/ml and no significant difference was found in IL‐22 levels: A1 vs. A2 145,69 pg/ml [75,66;242,08] vs. 161,35 pg/ml [84,67;280,8] p=0,662 or B1 vs. B2 136,77 pg/ml [95,3;210,71] vs. 166,62 pg/ml [92,44; 263] p=0,383. Conclusions: Increased cytokine IL‐10 could have importance in rapidly progressive acute appendicitis.

Background. Over recent years acute appendicitis has been shown not to always progress towards perforation as in cases of complicated disease, but sometimes have the possibility to resolve in uncomplicated acute appendicitis, thus prompting that an operation may not always be needed. However, we have noticed that some cases exist, where the gangrene and perforation seem to happen very rapidly, which in turn requires prompt surgical treatment and this has not yet been addressed in literature. Aim. We aimed to see if we can predict if patients with rapidly progressive complicated acute appendicitis can be anticipated in children, as well as cases where the disease is uncomplicated and could have the possibility to resolve only using routinely performed and readily available tests. Methods. We retrospectively analyzed patients’ records from the Pediatric Surgery departments in two hospitals with surgically treated acute appendicitis over a 15-year period. The patients’ groups were formed according to type of appendicitis (uncomplicated or complicated) and duration of disease: the early (duration of symptoms <24 hours) and the late (>24 hours duration). Phlegmonous appendicitis was categorized as uncomplicated appendicitis. Gangrenous or perforated appendicitis was categorized as complicated. Patient anamnestic data and routinely performed tests were analyzed. The early uncomplicated appendicitis (A1) group was compared to the late uncomplicated (resolving) appendicitis (A2) group. Also, the early complicated, or as we called it, rapidly progressive acute appendicitis (B1) group was compared to the late complicated appendicitis (B2) group. Results. Overall, 456 patient records were analyzed. We found that the resolving A2 group in comparison to A1 showed a lower median white blood cell count 12.3 [3.9; 34.3] vs. 16.5 [4.1; 29.5], p<0.0001, neutrophil percentage 74.6 [38.7; 91] vs. 83.8 [42.7; 94.6], p<0.0001 and neutrophil to lymphocyte ratio (NLR) 4.3 [0.8; 24.7] vs. 9.6 [0.9; 33.7], p<0.0001 but a higher CRP 20 [0.9; 177] vs. 5 [0.7; 227], p<0.0001. In the complicated groups’ comparison, we found that rapidly progressive B1 showed a higher median basophil count 0.068 [0; 0.629] vs. 0.017 [0; 0.151], p<0.0001, but a lower CRP 17 [0.9; 155] vs. 35.5 [4.2; 431.3], p=0.003. There were no other differences in anamnestic and demographic data in the groups. Conclusions. Resolving acute appendicitis appears to show signs of deteriorating inflammation by a lower white blood cell count, neutrophil percentage, and neutrophil to lymphocyte ratio, while CRP stays elevated. Rapidly progressive acute appendicitis on the other hand could be suspected with an early higher basophil count.

Background. Multisystem inflammatory disorder (MIS-C) currently presents a diagnostic challenge to suspect it early, especially in patients who present like acute appendicitis. Aim. We aimed to compare patients with MIS-C and patients with regular acute appendicitis and those with a positive COVID-19 test at the time, and find factors which can help suspect MIS-C. Methods. We analyzed patient data from over a six-month period in 2021 of patients admitted to the PICU, Pediatric Department of Pediatric Surgery Department, and selected patients operated for acute appendicitis as well as unoperated MIS-C cases. Patients were categorized into 4 groups: Group A- patients with acute appendicitis; Group B – patients operated for acute appendicitis with a later confirmed MIS-C, Group C – either solitary MIS-C cases or patients operated for acute appendicitis found to have minimal or no inflammatory changes on pathology with later confirmed MIS-C and into group D- patients operated for acute appendicitis with a positive COVID-19 PCR antigen test on admission or during the stay at the hospital. We compared demographic values, symptoms, other organ system involvement and laboratory test values to find the most prominent differences between these groups. The most prominent differences were added into a makeshift score to see how it could help differentiate MIS-C cases from appendicitis cases. Results. Overall, 76 patients were analyzed: 36 in Group A, 6 in Group B, 29 in Group C, and 5 in Group D. The most significant differences were found in duration of disease (1.4, 4.5, 4, and 4 days in Groups A, B, C and D, respectively, p<0.0001), CRP values (19.3, 112.5, 143.8 and 141 mg/l, respectively, p<0.0001), presence of febrile fever (13.9%, 66.7%, 96.6% and 40%, respectively, p<0.0001) and other system involvement (0%, 100%, 100% and 20%, respectively). Other differences were found in symptoms, WBC, platelet count, hemoglobin and pediatric appendicitis score. A makeshift score was made using the most significant differences and found to predict MIS-C in a ROC curve with an AUC=0.983 (p<0.0001) and a sensitivity of 94.3%, a specificity of 92.7% when at least 3 criteria were met. Conclusions. Our current data suggests that MIS-C could be suspected if patients with acute appendicitis symptoms have at least 3 out of 4 symptoms: a CRP count higher than 55.8 mg/l on admission, a fever of at least 38 degrees Celsius, show other organ system involvement and have symptoms lasting at least 3 days.

Tikslas. rutiniškai atliekamais tyrimais atpažinti ūminį greitai progresuojantį apendicitą. Tyrimo metodai. 19 metų laikotarpiu išanalizavome pacientų, kurie buvo gydyti Vaikų chirurgijos skyriuose dviejose ligoninėse dėl ūminio apendicito, duomenis. Palyginome ankstyvųjų nekomplikuotų apendicitų (Al) grupę su vėlyvųjų nekomplikuotų arba regresuojančio apendicito (A2) grupe, o anksti komplikuotus, kuriuos praminėme greitai progresuojančiu apendicitu (B1) su vėlyvai komplikuotais (B2). Rezultatai. A2, lyginant su Al, turėjo žemesnį leukocitų kiekį 12,3x109/1, neutrofilų kiekį - 76 proc. ir neutrofilų limfocitų santykį (NLR) 4,3, p < 0,0001, bet pasižymėjo aukštesniu CRB - 20 mg/l, p < 0,0001. B1 grupė parodė aukštesnę bazofilų medianą, lyginant su B2 - 0,068x 109/1, p < 0,0001, tačiau turėjo žemesnį CRB - 17 mg/l, p = 0,003. Išvada. Didesnis bazofilų kiekis kraujyje bei pakilęs CRB gali leisti spėti apie galimą greitai progresuojantį ūminį apendicitą, o žemesnis leukocitų kiekis, neutrofilų procentas ar neutrofilų-limfocitų santykis - apie regresuojantį ūminį apendicitą.

Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A—1.4 days, B—4.5 days, C—4 days, D—4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.

Įvadas: anksčiau manyta, kad COVID-19 virusas vaikams pasireiškia lengva arba besimptome forma, tačiau pastebėta, kad jis gali sukelti daugiasisteminį uždegiminio atsako sindromą vaikams (MIS-C). MIS-C gali pažeisti širdies ir kraujagyslių, krešumo, nervų, šlapimo sistemas, odą ir gleivines, tačiau dažnai pirmiausia pažeidžiamas virškinamasis traktas, pasireiškiantis ūmaus pilvo simptomais ir aukštais uždegiminiais rodikliais (ūminio apendicito klinikiniu vaizdu).Tikslas: palyginti pacientus, gydytus dėl ūminio apendicito su pacientais, kuriems nustatytas MIS-C (operuotais su pakitusia kirmėlinė atauga bei neoperuotais ar nesant pakitimų operacijos metu kirmėlinėje ataugoje), taip pat su operuotais vaikais dėl ūminio apendicito, kuriems nustatytas COVID-19 virusas ir rasti kriterijus, kada tikslinga įtarti MIS-C, bei pateikti gydymo rekomendacijas.Rezultatai: išanalizuoti 76 pacientų duomenys: 36 su ūminiu apendicitu (ŪA grupė), 6 vaikai operuoti dėl ūminio apendicito, kuriems nustatytas MIS-C (ŪA-MIS-C grupė), 29 vaikai su MIS-C be ūminio apendicito (27 neoperuoti, 2 operuoti su nepakitusia kirmėline atauga- MIS-C grupė) ir 6 vaikai su ūminiu apendicitu, kuriems patvirtintas COVID-19 PGR antigeno tyrimu stacionarizavimo/gydymo ligoninėje metu (ŪA-COVID-19). Nustatyta, kad ŪA grupėje stebėta reikšmingai trumpesnė sirgimo trukmė 1,4 dienos (lyginant su 4 dienomis kitose grupėse), mažiausias CRB – 19,3[3;139,6] mg/l (ŪA-MIS-C 112mg/l; MIS-C 143,8 mg/l; ŪA-COVID-19 141 mg/l), mažiausiai febriliai karščiuojančių pacientų 13,9% (ŪA-MIS-C 66,7%; MIS-C 96,6%; ŪA-COVID-19 40%). Visiems MIS-C ir ŪA-MIS-C stebėti kitos organų sistemos simptomai (kliniškai arba tyrimuose). Išvados: MIS-C turėtų būti įtartas vaikams net ir su ūminio apendicito klinikiniais, laboratoriniais ir ultragarsiniais požymiais, ypač kai stebimas CRB >55,8 mg/l, simptomai trunka daugiau kaip dvi dienas, yra febrilus karščiavimas >38 °C ir stebimi kitų organų sistemos simptomai. Taip pat jį reikėtų įtarti, jei ūminio apendicito gydymo metu būklė negerėja ir stebimas uždegiminių rodiklių augimas.