Abstract
BACKGROUND: Asparaginase (ASP) has significantly improved the complete remission rate and long-term event-free survival in children with acute lymphoblastic leukemia (ALL). Asparaginase-associated pancreatitis (AAP) is a potentially toxic side effect of ASP, which may even lead to fatal abdominal compartment syndrome (ACS) in extreme cases. Currently, there is no consensus on the indications for decompressive laparotomy (DL), including when to initiate it, what criteria to use for decision-making, or how to perform the procedure. Moreover, available research data remain limited. CASE DESCRIPTION: We present a case of a 2-year-old boy with ALL who developed ACS, a fatal complication of severe acute pancreatitis (SAP) following treatment with pegaspargase (PEG-ASP). Massive transfusion stabilized his hemodynamics and intraluminal contents were evacuated, yet his symptoms progressed. Consequently, the patient underwent DL and continuous venovenous hemodiafiltration (CVVHDF) with ultrafiltration. Postoperative complications including enteroatmospheric fistulas and abdominal abscesses were gradually corrected by negative-pressure wound therapy (NPWT). The boy was discharged from the intensive care unit (ICU) on the 93rd day after hospital admission. During follow-up, the child's abdominal symptoms gradually improved, and bridging therapy with blinatumomab was administered. CONCLUSIONS: In this case, a pediatric ALL patient developed life-threatening complications following PEG-ASP administration, which were ultimately successfully managed through multidisciplinary intervention. When pediatric hematology-oncology patients develop ACS, clinicians should carefully evaluate the oncological context and thoroughly assess the risks of surgical versus conservative management for this potentially fatal condition. Optimal timing of surgical intervention combined with advanced perioperative care is critical for achieving favorable outcomes. We strongly recommend conducting high-quality clinical research to establish evidence-based treatment guidelines.