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Extracorporeal membrane oxygenation (ECMO), which has been shown to dramatically improve survival in selected neonatal patients, is now being used in some centers for pediatric patients with respiratory and cardiac failure. One of the major concerns with ECMO support is the permanent ligation of the right common carotid artery. We have used ECMO to support 10 pediatric patients with cardiac failure and 22 patients with respiratory failure. Thirty-one were cannulated via the common carotid artery and internal jugular vein on the right. Five of the last six patients with respiratory failure survived. One was on ECMO for 21 days, so the carotid artery was not amenable to repair. In the other four survivors the common carotid artery was reconstructed at the time of decannulation. In one patient, a segment of the artery was resected because of an intimal injury, and a primary anastomosis was performed. In all four, color Doppler studies of the artery prior to discharge were normal. None had clinical evidence of emboli, and a cranial computed tomography (CT) scan was normal in all four patients. These data suggest that in many pediatric patients supported with ECMO, reconstruction of the common carotid artery can be performed with low risk of embolic complications. Long-term follow-up is needed.

Extracorporeal membrane oxygenation (ECMO) can be lifesaving support for neonates with fulminant respiratory failure. In the 121 patients that we have placed on ECMO since 1983, bleeding, infection, and intracranial hemorrhage have constituted most of the major complications. We have also encountered two cases of biliary calculi in post-ECMO infants. The hemolysis, total parenteral nutrition, diuretics, and prolonged fasting associated with ECMO may predispose neonates to early calculous disease of the biliary tract and may require surgical intervention. Evaluation of abdominal pain or jaundice in infants and children who have been supported with ECMO should include examination of the biliary tree. Cholecystectomy should be seriously considered for infants with cholelithiasis.

Optimal surgical management of neonates with gastroschisis and omphalocele remains controversial. Suggested benefits of primary fascial closure include earlier return of gastrointestinal function, decreased hospital stay, less sepsis, less risk of postoperative intestinal obstruction and fistulae, and lower mortality. Between 1978 and 1989, 40 neonates with gastroschisis or omphalocele underwent repair. Primary fascial repair was performed in 30 children, 18 of whom had a gastroschisis and 12 of whom had an omphalocele. Ten children had staged repair with the use of a silastic silo; seven of these had a gastroschisis and three an omphalocele. Comparison between the groups was made regarding birth weight, days on the ventilator before and after surgery, days to first feeding, days in the hospital after surgery, postoperative complications, and survival. There was no significant difference in birth weight, days on the ventilator, days to first feeding, and postoperative days in the hospital. There were nine complications in nine patients (30%) with primary repair and four complications in two patients (20%) with staged repair. Two infants died after primary repair (6.7%), and one (10%) died after staged closure. It was concluded that silastic silo repair and primary fascial closure are both acceptable alternatives. Primary closure is attractive whenever possible to avoid additional operations.

The presence of an anterior mediastinal mass in an infant or child is a diagnostic and therapeutic challenge. Few papers in the literature specifically address subtypes of thymic tumors in the pediatric population and their treatment. Our purpose was to determine which children are at significant risk of having a malignant thymic tumor. Four children were younger than 18 months old. Of these, two (50%) had respiratory distress from tracheal compression although all four had benign tumors. Of the 14 older children, only two were symptomatic, both of these from myasthenia gravis rather than the size of the mass compressing surrounding structures. Four of the 14 masses (29%) were malignant although none of the four were symptomatic. Children with benign tumors lived significantly longer than those with malignant tumors. The significant incidence of malignancy in thymic tumors when the patient is 18 months or older necessitates surgical exploration with complete removal of the mass. Children younger than 18 months require close follow-up and a trial of corticosteroids. Surgery is necessary if the mass enlarges or becomes symptomatic.

An anterior approach to the spine via a thoracoabdominal incision offers the surgeon many advantages. The major vascular structures are visualized, stabilization of a long segment of the spine is strong, and recovery is speedy. Nevertheless, this is a major operation and one with potential morbidity and mortality. At Children's Hospital of New Orleans, the Pediatric Surgery and Pediatric Orthopedic Surgery Services work together to reduce these risks and in so doing maintain an acceptable morbidity. With this two-team approach; we operated on the spines of 39 patients between 1978 and 1988. The most common indications for operation included idiopathic scoliosis, neuromuscular disease, and congenital abnormalities. A thoracoabdominal approach was used in 32 patients, a thoracic approach in four patients, and an abdominal approach in three patients. Twenty-nine patients experienced 65 complications; 45 of these complications were respiratory in nature. There were no postoperative deaths. Factors unrelated to the incidence of postoperative complications included age, volume of crystalloid infused during operation, volume of blood replacement, and length of anesthesia.

Respiratory distress in newborns with CDH is the result of the interaction of pulmonary hypertension and pulmonary hypoplasia. Many patients will demonstrate adequate pulmonary parenchyma after repair as evidenced by adequate oxygenation and ventilation. Patients should be classified into groups of predicted mortality using Bohn's criteria. Patients in groups A, B, and D may be managed conventionally if blood gases can be kept in the normal range. These patients should be supported with ECMO if unresponsive to conventional management. In those patients with adequate gas exchange who fall into the C group, transfer to an ECMO center should be undertaken early, since mortality with continued conventional management is predictable. Some patients never demonstrate a "honeymoon" period, and mortality can be reliably predicted in this group as well by using Bohn's criteria. Because the relative significance of pulmonary hypoplasia compared with pulmonary hypertension in an individual patient cannot be reliably determined, any patient who has respiratory failure after repair of CDH should be supported with ECMO when conventional techniques fail as long as no contraindications exist. At least one institution will withhold ECMO therapy if lung parenchyma is judged inadequate as predicted by the inability to achieve a preductal PaO2 greater than 100 mm Hg and PaCO2 less than 50 mm Hg with maximal conventional therapy. In our experience, however, some patients can survive with ECMO support when all other indicators would suggest hypoplasia incompatible with life. Therefore, we do not believe any patient should be refused ECMO support when conventional measures fail.(ABSTRACT TRUNCATED AT 250 WORDS)

Wilms' tumors account for the vast majority of renal neoplasms in infants and children. Common areas for metastases include the lung, liver, and contralateral kidney. Less common sites include the bone, skin, brain, and orbit. We report a case of Wilms' tumor in a 13-month-old boy who, after radical left nephrectomy, developed a left testicular mass that turned out to be metastatic Wilms' tumor. The epidemiology, case history, review of the literature, and possible etiology of this rare site of metastatic Wilms' tumor are discussed.

Foreign bodies in the esophagus, such as coins, meat, marbles, buttons, and chicken bones, are quite commonly encountered. We present the case of a fishing lure that was retrieved from the esophagus of a child. Since Louisiana is the "Sportsman's Paradise," it seemed appropriate to report this case in the Journal of the Louisiana State Medical Society.

The leading cause of death in the neonatal period is respiratory failure, and extracorporeal membrane oxygenation (ECMO) is an effective means of improving survival in select patients. Only neonates with severe hypoxia and acidosis are treated with ECMO. To determine the developmental outcome of the neonates we supported with ECMO, we reviewed the records of all our patients who are at least 6 months of age. The results of follow-up assessment were available for 57 patients and growth parameters were available for 43 patients. Examinations were done at 6 to 48 months (mean, 22.1). Growth parameters showed that 14% of the patients were below the tenth percentile for height and weight while 16.3% were below the tenth percentile for head circumference. Twenty-four patients were evaluated using the Bayley Scales of Infant Development consisting of a Mental Developmental Index (MDI) and a Psychomotor Developmental index (PDI). Normal scores (>84) were obtained in 75% on the MDI and in 88% on the PDI. Only two patients (8%) scored less than 85 on both portions. Twelve patients were evaluated using the McCarthy Scales of Children's Abilities. The mean score was 95 and nine patients (75%) had scores greater than 85. The Gessell was used to evaluate six patients and five were normal. The Denver Developmental Screening Test was used to evaluate 23 patients and all passed. The results of neurologic examination were documented in 57 patients. One patient had severe spastic quadriplegia with cerebral palsy. The neurological examination was normal in the other patients. Only one of 57 patients is profoundly delayed (2%) and 45 (79%) are normal. These results suggest that ECMO can be used in severe neonatal respiratory failure with normal developmental outcome in most patients. Severe developmental delay is unusual in patients treated with ECMO and it may be related to hypoxia and acidosis before ECMO.

Seventeen cases of vascular ring have been encountered at Ochsner Clinic over the past 22 years. Anatomic configurations consisted of double aortic arch in 11 cases, right aortic arch with left ligamentum arteriosum in five cases, and aberrant right subclavian artery in one case. In four cases chest x-ray films revealed air block or hyperinflation and led to further diagnostic tests. The definitive diagnostic methods included esophagogram in 15 cases, aortography in 14 cases, two-dimensional echocardiography in one case, and esophagoscopy/bronchoscopy in eight cases. Presenting symptoms were respiratory in 13 cases and feeding difficulties in three; one asymptomatic case was found incidentally. Four cases of air block syndrome were observed as an early and unusual presentation of vascular ring in infants. Hyperinflation of the lung fields on chest x-ray film should spur suspicion of a possible vascular ring. Two case reports are included to demonstrate air block in relation to vascular rings in neonates.

Volvulus of the sigmoid colon is rare in children. The authors have reviewed a total of 29 cases, including five from our institution. The most common clinical picture is crampy abdominal pain and abdominal distention. In contrast to adults, in children plain abdominal films will often not yield a diagnosis. Barium enema examination can be done to locate the obstruction. Nonoperative reduction was successful in 27 per cent of all reported cases, while operative treatment was necessary in 69 per cent of pediatric patients reported. Recurrence following derotation by any means was rare. However, adequate long-time follow-up is lacking. From available data, it seems that in most cases resection is not necessary. Primary resection may be indicated for recurrence or if the bowel is compromised. Mortality was 14 per cent, occurring in poor risk patients, the very young, and patients with associated anomalies. A redundant sigmoid may undergo intermittent torsion over a period of years, making diagnosis difficult. At laparotomy, these patients have scarred striae on the sigmoid mesocolon.

Fifty-three neonates and seven pediatric patients were treated with extracorporeal membrane oxygenation from September 1983 until April 1986. Venoarterial bypass was achieved by cannulating the right atrium via the right internal jugular vein and the aortic arch via the right common carotid artery. In the neonatal group, 40 infants with acute respiratory failure were treated, and 36 (90%) survived. Five infants with congenital heart disease were treated and three (60%) survived. Among the eight patients with congenital diaphragmatic hernia, there were three (38%) survivors. In the pediatric group, four patients were treated for ventricular failure after cardiac operations. Two were weaned from bypass, with one long-term survivor. Three patients with acute respiratory failure were treated, with one survivor. salvaging high-risk neonates with minimal morbidity and mortality. It has also been useful in the support of infants with congenital heart disease and congenital diaphragmatic hernia. In pediatric patients one cannot expect to get results that are comparable to those found in neonates. Still, this modality can be useful in salvaging some moribund patients with pulmonary or cardiac failure, or both.

Meconium aspiration syndrome (MAS) is a common cause of morbidity and mortality in neonates. Chemical pneumonitis can lead to persistent pulmonary hypertension of the newborn (PPHN) with irreversible hypoxia and death. Extracorporeal membrane oxygenation (ECMO) for the treatment of severe PPHN became available at the Ochsner Foundation Hospital in September 1983. We reviewed the first 28 cases in which ECMO was used for the treatment of PPHN due to severe MAS; 26 of the 28 infants survived. During the three years preceding our development of ECMO capability, ten neonates had PPHN due to severe MAS and met the criteria for ECMO; only three survived. The difference in survival demonstrates the efficacy of ECMO for the treatment of severe MAS. We believe that when established criteria are met, ECMO should be instituted without delay.