An unrecognised right aortic arch (RAA) found at thoracotomy may complicate the repair of oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF). This paper analyses the patient characteristics, peri-operative management, and outcome of 16 infants with a RAA, and proposes management guidelines. Between 1948 and 1996, 709 patients with OA/TOF were admitted to the Royal Children's Hospital, of whom 13 had a RAA. Three additional cases from two other paediatric surgical units were included. All 16 case records were reviewed retrospectively. The overall incidence of RAA in OA was 1.8%. Neither a chest radiograph in 16, nor antenatal ultrasonography in 7 detected a RAA. Post-natal echocardiography (ECHG) detected a RAA in only 1 of 7 infants examined; that patient underwent repair of the OA through a left (L) thoracotomy. The other 15 infants underwent initial right (R) thoracotomy. Six of these had a complete repair from the R side and 5 had division of the fistula only; 2 of these 5 had initial division of the fistula, and the OA was repaired through a repeat R thoracotomy 4 and 7 weeks later. In the remaining 4 infants where the fistula could not be located at the initial R thoracotomy, complete repair proved possible through the L chest. Three of these infants underwent an immediate L thoracotomy; the 4th had a delayed L thoracotomy 1 week later. There were 6 deaths: these occurred early in the study and were related to severe prematurity, congenital heart disease (CHD), and post-operative respiratory complications. CHD was identified in 11 of 16 infants (71%). Routine pre-operative ECHG is unreliable in determining the laterality of the aortic arch. Should a RAA be encountered during a R thoracotomy for OA, it is often possible to divide the fistula and repair the OA from that side, but where repair looks potentially difficult it is wise to proceed to an immediate L thoracotomy.

No abstract

ABSTRACT. We describe a newborn infant (<24 hours of age) who presented with mild swelling on the back and buttocks attributable to a neuroenteric fistula complicated by an epidural parasacral abscess infected with mixed coliforms. Epidural abscesses in infancy are extremely rare, and one has not been observed previously in the newborn period. The infant was surprisingly mildly affected. Prompt intervention led to an excellent outcome. Coliforms may colonize the infant gut in <24 hours, even in the developed world. Unexplained swellings on the backs of infants should lead to a search for underlying malformations and an early surgical review, which is best conducted with a combined pediatric surgical and neurosurgical approach. N euroenteric cysts (fistulas) are rare, with Ͻ30 cases being described in the pediatric literature. Epidural abscesses presenting in infancy are even rarer, with the youngest patient reported being 20 days of age. 1 An epidural abscess complicating a congenital neuroenteric cyst appears not to have been reported previously. CASE REPORTA Ͻ1-day-old boy was admitted to the neonatal unit at a peripheral hospital with irritability, lethargy, and poor feeding. He had been delivered at 42 weeks of gestation through normal vaginal delivery and weighed 3250 g. His mother had an older healthy child and had remained in good health during this pregnancy. She admitted to smoking cigarettes and occasionally drinking alcoholic drinks. Results of ultrasound scanning performed in the first trimester had been reported as normal and consistent with dates. The infant's condition at birth was excellent, and he was allowed home, breastfeeding successfully, at 12 hours of age. In the examination, the infant was mildly jaundiced and lethargic. He had cool extremities, with a capillary return of 4 seconds, a heart rate of 150 beats per minute, a respiratory rate of 68 breaths per minute, and a skin temperature of 36.6°C. There was no sign of respiratory difficulty. The patient's anterior fontanelle was not distended, and his posture was normal. His abdomen was soft, without organomegaly. Movements were normal in all limbs, with normal tone and reflexes. The patient's anus was in a normal position, and he passed stools without difficulty. His back was normal, with no sign of sinuses or fistulas. Blood and urine cultures were obtained. Blood tests showed a C-reactive protein level of 25 g/mL (normal: Ͻ10 g/mL) and a white blood cell count of 10 300 cells per mm 3 (neutrophils: 8000 cells per mm 3 ). Results of a chest radiograph were normal. Lumbar punctures were performed as part of the septic screening and on 2 occasions revealed frank yellow-green pus, which showed large numbers of pus cells and mixed flora with Gram-staining and subsequently showed heavy growth of Escherichia coli and enterococci. A provisional diagnosis of mixed-organism meningitis was made, and the infant began broad-spectrum antibiotic treatment and was transferred to the neonatal intensive care unit of Wellington Hospital for additional in...

Complete ectopia cordis in the newborn represents a significant management challenge. There are minimal data available to inform optimal clinical care for those infants with coexisting complex congenital heart disease who are therefore not candidates for surgical intervention. The exteriorisation of the heart and absence of the pericardial sac requires meticulous wound care to prevent desiccation of the myocardium and to minimise infection risk. Additionally, the technique selected must address the risk of occlusion of the cardiac vascular pedicle and abrasion between the mobile myocardium and dressing surface. We report a novel approach to wound management and integrated palliative care that enabled community-based care. Our patient, a full-term male infant with complete ectopia cordis was born in good condition by assisted vaginal delivery. He was discharged from hospital on day 8 and was cared for in the community until his demise from cardiac failure on day 15.

We have demonstrated a high degree of elasticity in the abdominal wall vessels of young children. This may help to explain why children do not bruise when hit in the abdomen. Our findings have potential implications for both clinical practitioners and paediatric surgeons involved in child abuse cases.