COVID-19 associated multisystem inflammatory syndrome in children mimicking acute appendicitis - how to differentiate and conduct pediatric patients during the pandemic? - Proposal of a management flowchart.

INTRODUCTION: the new coronavirus pandemic has been a reality throughout 2020, and it has brought great challenges. The virus predominantly manifests in the pediatric population with mild symptoms. However, an increase in the incidence of Multisystemic Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 has been described in the literature. MIS-C manifests mainly with fever and gastrointestinal symptoms and may mimic acute abdomen due to acute appendicitis. The objective of this study is to propose a care flowchart for suspected cases of acute appendicitis in the initial phase in pandemic times, considering the possibility of MIS-C. This situation was brought up by a patient treated in a pediatric hospital in Brazil. DISCUSSION: It was possible to identify common signs and symptoms in the reported patient and those published cases that may serve as alerts for early identification of MIS-C cases. Based on the literature review and on the similarities between the syndrome and the inflammatory acute abdomen in children, we elaborated an initial approach for these cases to facilitate the identification, early diagnosis, and management. The flowchart considers details of the clinical history, physical examination, and complementary exams prior to the indication of appendectomy in patients with initial phase symptoms. CONCLUSION: MIS-C, although rare and of poorly known pathophysiology, is most often severe and has a high mortality risk. The use of the proposed flowchart can help in the diagnosis and early treatment of MIS-C.

COVID-19 associated multisystem inflammatory syndrome in children mimicking acute appendicitis - how to differentiate and conduct pediatric patients during the pandemic? - Proposal of a management flowchart / Síndrome inflamatória multissistêmica em crianças associada ao COVID-19 mimetizando apendicite aguda - como diferenciar e conduzir pacientes pediátricos durante a pandemia? - Proposta de fluxograma de atendimento

ABSTRACT Introduction: the new coronavirus pandemic has been a reality throughout 2020, and it has brought great challenges. The virus predominantly manifests in the pediatric population with mild symptoms. However, an increase in the incidence of Multisystemic Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 has been described in the literature. MIS-C manifests mainly with fever and gastrointestinal symptoms and may mimic acute abdomen due to acute appendicitis. The objective of this study is to propose a care flowchart for suspected cases of acute appendicitis in the initial phase in pandemic times, considering the possibility of MIS-C. This situation was brought up by a patient treated in a pediatric hospital in Brazil. Discussion: It was possible to identify common signs and symptoms in the reported patient and those published cases that may serve as alerts for early identification of MIS-C cases. Based on the literature review and on the similarities between the syndrome and the inflammatory acute abdomen in children, we elaborated an initial approach for these cases to facilitate the identification, early diagnosis, and management. The flowchart considers details of the clinical history, physical examination, and complementary exams prior to the indication of appendectomy in patients with initial phase symptoms. Conclusion: MIS-C, although rare and of poorly known pathophysiology, is most often severe and has a high mortality risk. The use of the proposed flowchart can help in the diagnosis and early treatment of MIS-C.

RESUMO Introdução: a pandemia do novo coronavírus arrastou-se ao longo de 2020 e trouxe grandes desafios. Acredita-se que o vírus manifesta-se na população pediátrica predominantemente com quadros leves, entretanto, aumento da incidência da Síndrome Inflamatória Multissistêmica em Crianças (SIM-C) associada à COVID-19 tem sido descrito na literatura. A SIM-C manifesta-se principalmente com febre e sintomas gastrointestinais, podendo mimetizar abdome agudo inflamatório por apendicite aguda. O objetivo deste trabalho é propor fluxograma de atendimento dos casos suspeitos de apendicite aguda em fase inicial, em tempos de pandemia, considerando-se a possibilidade de SIM-C, motivado pelo caso de paciente atendido em hospital pediátrico no Brasil. Discussão: Foi possível identificar sinais e sintomas em comum entre o paciente aqui relatado e casos publicados que podem servir de alerta para identificação precoce dos casos de SIM-C. Com base na revisão da literatura e nas semelhanças entre a síndrome e quadros de abdome agudo inflamatório na criança, foi elaborado fluxograma de abordagem inicial destes doentes para facilitar a identificação, diagnóstico precoce e condução dos pacientes. O fluxograma leva em consideração detalhes da história clínica, exame físico e exames complementares antes da indicação de apendicectomia em pacientes com sintomas na fase inicial. Conclusão: A SIM-C, apesar de rara e da fisiopatologia pouco conhecida, apresenta-se na maioria das vezes de forma grave e possui alto risco de mortalidade. O uso do fluxograma proposto pode auxiliar no diagnóstico e tratamento precoce da SIM-C.

Simulation in Pediatric Video Surgery: Training with Simple and Reproducible Exercises Elaborated by Residents.

Background: Most residents do not have a defined program for simulation training in video surgery in Brazil. The training takes place for the most part in vivo or in short courses. The goal of this article is to describe and evaluate a set of exercises using low-cost materials, created by the residents themselves, to enable basic skills training in video surgery. Materials and Methods: Seven exercises were elaborated aiming to simulate main maneuvers performed in video surgery. The residents were guided by a written and video description showing the execution of the exercises, performed the exercises, and answered a questionnaire. After 3 weeks of free training, the residents performed the exercises and answered the questionnaire again. Results: Seven residents started the study; however, 6 completed the two steps. Among the participants, 83% received in vivo video surgery training, and only 2 (33%) received some supervised simulation training in minimally invasive surgery before this time. All participants considered the set of seven exercises representative of the actual skills in video surgery. There was no difficulty in acquiring the materials or in assembling them to carry out the training. All the participants had a shorter training time than initially proposed, on average 1 day/week for 20 minutes. Conclusions: A simple set of exercises can be elaborated by the residents themselves and make feasible the simulated training in video surgery even without the availability of sophisticated and expensive materials. The presence of a tutor and the scheduling of exclusive training seem necessary for more satisfactory results.

Choledochal cyst in the pediatric population: experience of 13 laparoscopic procedures in two years at a single institution.

OBJECTIVE: to describe the first 13 cases of laparoscopic correction of common bile duct cyst in the Pequeno Príncipe Hospital, Curitiba, Paraná, Brazil. METHODS: we performed a retrospective analysis of medical records of cases of choledochal cyst operated by laparoscopy between March 2014 and September 2016. RESULTS: of the 13 patients, eight were female and the mean age at surgery was 7.8 years. The most common symptom was abdominal pain. The hepaticoduodenal anastomosis was the most used reconstruction technique, in 84.6% of the cases. There was no conversion to laparotomy or intraoperative complications. Only one patient presented anastomotic fistula and was reoperated by laparotomy. All patients were followed up in an outpatient clinic, were asymptomatic and had no episode of cholangitis after surgery, with a mean follow-up of 16 months. CONCLUSION: laparoscopy is a safe method to correct choledochal cysts, even in younger children, with low rates of complications and low rates of conversion to open surgery when performed by well trained surgeons.

Choledochal cyst in the pediatric population: experience of 13 laparoscopic procedures in two years at a single institution / Cisto de colédoco na população pediátrica: experiência de 13 procedimentos laparoscópicos em dois anos de uma única instituição

ABSTRACT Objective: to describe the first 13 cases of laparoscopic correction of common bile duct cyst in the Pequeno Príncipe Hospital, Curitiba, Paraná, Brazil. Methods: we performed a retrospective analysis of medical records of cases of choledochal cyst operated by laparoscopy between March 2014 and September 2016. Results: of the 13 patients, eight were female and the mean age at surgery was 7.8 years. The most common symptom was abdominal pain. The hepaticoduodenal anastomosis was the most used reconstruction technique, in 84.6% of the cases. There was no conversion to laparotomy or intraoperative complications. Only one patient presented anastomotic fistula and was reoperated by laparotomy. All patients were followed up in an outpatient clinic, were asymptomatic and had no episode of cholangitis after surgery, with a mean follow-up of 16 months. Conclusion: laparoscopy is a safe method to correct choledochal cysts, even in younger children, with low rates of complications and low rates of conversion to open surgery when performed by well trained surgeons.

RESUMO Objetivo: descrever os primeiros 13 casos de correção laparoscópica de cisto do ducto biliar comum no Hospital Pequeno Príncipe, Curitiba, Paraná, Brasil. Métodos: análise retrospectiva dos registros médicos em prontuário dos casos de cisto de colédoco operados por via laparoscópica entre março de 2014 e setembro de 2016. Resultados: dos 13 pacientes, oito eram do sexo feminino e a média de idade na ocasião da cirurgia foi de 7,8 anos. O sintoma mais comum foi dor abdominal. A anastomose hepático-duodenal foi a técnica de reconstrução mais utilizada, em 84,6% dos casos. Não houve conversão para laparotomia ou complicações intraoperatórias. Apenas um paciente apresentou fístula da anastomose e foi reoperado por laparotomia. Todos permanecem em acompanhamento ambulatorial, com tempo de seguimento médio de 16 meses, assintomáticos e não apresentaram episódio de colangite após a cirurgia. Conclusão: a laparoscopia é um método seguro para correção dos cistos de colédoco, mesmo em crianças mais jovens, com baixas taxas de complicações e baixas taxas de conversão para cirurgia aberta quando realizada por cirurgiões com bom treinamento.