Management Of Late Complications Research Articles

Long-Term Survival Rate of ATOMS Implant for Male Stress Urinary Incontinence and Management of Late Complications

stress urinary incontinence (SUI) still represents a major drawback of prostate surgery. The aim of this study is to evaluate long term efficacy, safety and survival of ATOMS system implant in a single center. we retrospectively included al consecutive patients treated with ATOMS implant for SUI from October 2014 to July 2019. Patients received anamnesis, urodynamic evaluation, pre- and postoperative 24 h pad test and count. Patients were considered "continent" when dry or when wearing a security pad (social continence). we treated99 patientswith median age 77.98 years (IQR 72.7-82.52). Most of the patients had undergone radical prostatectomy. Median follow-up was 62.9 months (IQR 47.5-75.9). At last follow-up 74 (74.7%) patients reported continence. We had 21 early (<30 days) postoperative complications, all Clavien-Dindo (CD) grade 1 [11 temporary perineal pain, 4 urinary retention, 3 scrotal edema, 2 superficial wound dehiscence, 1 dysuria]. We had late postoperative complications in 28 patients [7 port dislocations requiring surgical repositioning (CD 3a), 6 device removals (CD 3a) due to port erosion (2), inefficacy (2), cushion leakage (1), mesh detachment (1), perineal pain (5), 2 cases of port extrusion solved with port removal leaving the device in place (CD 3a), 2 superficial wound dehiscence (CD 1), 2 UTI (CD 1), 1 scrotal edema (CD 1), 1 cushion deflate (CD 1), 1 dysuria (CD 1), 1 perineal pain (CD 1)]. The survival of the device was 97% at 12 months, 93% at 24 months, 91% at 36 months, 90% at 48 months and 87.9% at 60 months. This study demonstrates the good safety and efficacy of ATOMS implant for the treatment of SUI.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review.

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Conditional Long-Term Survival Among Diffuse Large B-Cell Lymphoma (DLBCL) Patients Treated with Autologous Hematopoietic Cell Transplantation (AHCT)

Introduction: AHCT is standard therapy for chemosensitive relapsed DLBCL and survival from the time of AHCT has been well described in large patient cohorts. Outcomes have not been well described for patients who survive a certain time period after transplantation, when the risks of relapse have diminished. We performed a retrospective cohort study to delineate conditional survival in patients with DLBCL who survived 1, 2, and 5 yrs after AHCT. We also compare survival for these cohorts to their general population controls.Methods: We included 371 consecutive adult (≥18 yrs) patients with DLBCL who received AHCT at our institution from 2000-2014. 10-year overall survival (OS), progression-free survival (PFS), relapse mortality (RM) and non-relapse mortality (NRM) from AHCT were determined for three cohorts: 1-yr survivors (N=272), 2-yr survivors (N=232), and 5-yr survivors (N=157). Outcomes were estimated with Kaplan-Meier (OS, PFS) or cumulative incidence (RM, NRM). Cox regression analyses were performed to evaluate prognostic factors for OS and PFS. In addition, standardized mortality ratio (SMR) compared to the age-, gender- and race-matched healthy population was estimated for each survivor cohort.Results: Median age for 1-yr cohort was 56 yrs (19-78 yrs). 61% were male, 78% were stage III/IV and 45% had B-symptoms at diagnosis, 28% had received prior radiation and 81% had received prior rituximab. 77% patients received chemotherapy mobilization and Bu/Cy/VP was conditioning regimen for 97% patients. Median followup for this 1 yr cohort was 8 yrs (1.3-16.5 yrs). OS, PFS, RM and NRM at 10 yrs after AHCT are described in Table 1. OS and PFS improved with increasing survival after transplantation. Relapse was the primary cause of death in 1- and 2-yr survivors; cumulative incidence of RM and NRM was low but similar in 5-yr survivors. As expected, in multivariable analyses, lymphoma relapse prior to landmark time was associated with significantly worse OS and PFS for 1-, 2- and 5-yr survivors. Among other patient and disease characteristics evaluated in risk factor analysis, age and duration of AHCT hospitalization were the only factors associated with OS and PFS. Older age (10 yr increments) was associated with greater mortality risk among 1- and 2-yr but not 5-yr survivors. Older age at AHCT was associated with worse PFS in all three survivor cohorts. Prolonged hospital stay, as a surrogate for early post-transplant complications, was also associated with lower OS for all three cohorts, and lower PFS for 2-yr and 5-yr survivors. Survival was lower compared to the general population, although it improved and approached that of healthy peers with increasing post-transplant survival (SMR 4.0, 3.0 and 1.8 among 1-, 2- and 5-yr survivors, respectively, Figure 1).Conclusions: Conditional OS and PFS for DLBCL patients treated with AHCT improves with increasing survival post-transplantation. Relapse is the primary driver of poor survival, although the probability of death due to relapse decreases over time. NRM continues to be an important cause of treatment failure even among patients surviving 5-years after AHCT. Our data provide personalized survivorship information for DLBCL AHCT recipients and identify risk factors for poor survival. Our study also underscores the need for continued research on decreasing relapse risk and for surveillance for prevention and management of late-complications in this population. [Display omitted] DisclosuresKharfan-Dabaja:Incyte: Speakers Bureau; Alexion Pharmaceuticals: Speakers Bureau; Seattle Genetics: Speakers Bureau. Majhail:Anthem, Inc.: Consultancy; Sanofi: Honoraria.

LONG TERM FOLLOW-UP OF PATIENTS WITH COARCTATION OF THE AORTA

With improvements in care, an increasing number of patients with coarctation of the aorta (CoA) are surviving into adulthood. Little is known about the management of late complications in adulthood. A retrospective study of 115 adult patients with a history of CoA was performed at a single

Periaortic Abscess following DeBakey Type-1 Aortic Dissection Repair with Dacron Graft—Early Diagnosis and Management

A 71-year-old male with history of DeBakey type-1 aortic dissection and repair with dacron graft three months prior to presentation was brought to the emergency room with complaints of high-grade fevers, chills, and shortness of breath. Chest X-ray revealed right lower lobe infiltrates and widened superior mediastinum. A follow-up CT chest with contrast showed fluid collection around the aortic graft. He was started on intravenous broad-spectrum antibiotics, and a TEE was done for further evaluation of periaortic fluid collection which showed findings to suggest periaortic abscess. The patient underwent surgical drainage of the abscess and was found to have an abscess around the surgical aortic graft which was drained followed by two weeks of antibiotic treatment. The patient was discharged to a rehabilitation facility and remained asymptomatic at three-month follow-up appointment. Type-1 aortic dissection is a medical emergency requiring acute surgical intervention, and despite significant advancements in diagnosis and management, the immediate and long-term complications remain high leading to increased risk of mortality. Our patient developed spontaneous periaortic abscess three months postoperatively requiring intensive antibiotic therapy along with surgical drainage. Our case emphasizes the importance of early diagnosis and management of late complications of periaortic abscess in patients with aortic dissection repair.

Predictive factors affecting the prognosis and late complications of 73 consecutive cases of esophageal atresia at 2 centers.

While the diagnosis and outcomes of esophageal atresia (EA) have improved, associated anomalies, the management of late complications and growth remain major issues. We analyzed factors that affected the prognosis, late complications and growth. We retrospectively reviewed EA patients treated at two centers from 1984 to 2016. Patient characteristics, complications (gastroesophageal reflux [GER], anastomotic stenosis, tracheomalacia, dysphagia) and growth were evaluated. Seventy-three EA patients were treated (overall survival rate:80.8%). The mean birth weight was 2514 ± 509g in the surviving group, and 2453 ± 567g in the fatal group excluded chromosomal abnormality (p = 0.76). Cardiac and chromosomal anomalies significantly affected mortality. Postoperative GER and anastomotic stenosis each occurred in 39% of the patients. Only GER was significantly affected by the Gross classification. The standard deviation (SD) values of the EA patients' growth were all lower than in the normal population. The SD of body weight was significantly lower in patients with extremity anomalies. Associated cardiac and chromosomal anomalies significantly affected the prognosis. GER and anastomotic stenosis were the most common late complications. The growth of the surviving cases was insufficient. These factors will help optimize the therapeutic strategies and postoperative management for EA.

Allogeneic hematopoietic stem cell transplantation using myeloablative conditioning including total body irradiation for pediatric acute lymphoblastic leukemia: a single-center retrospective analysis

This study aimed to investigate the clinical outcomes of hematopoietic stem cell transplantation (HSCT) with total body irradiation-based myeloablative conditioning (TBI-MAC) in pediatric patients with acute lymphoblastic leukemia (ALL). We retrospectively examined patients with ALL who underwent HSCT with TBI-MAC from January 2000 to August 2016 at our institute. We enrolled 67 patients with a median follow-up period of 8 years. The 5-year event-free survival (EFS) and overall survival (OS) were 51.2% and 59.6%, respectively. At the first complete remission, HSCT exhibited significantly superior EFS and OS in our patients than that in patients with other diseases. We encountered 57.9% of patients with at least one late complication. Major late complications were short stature (26.3%) and hypogonadism (18.4%). While late complications were observed in several recipients of HSCT, late complication-related deaths occurred in three patients. The TBI-MAC regimen led to favorable clinical outcomes in pediatric patients with ALL who underwent HSCT. Thus, proper evaluation and management of late complications are mandatory.

Treatment and Management of Late Complications in Hereditary Hemolytic Anemia

Hereditary hemolytic anemia is a very heterogeneous disorder in which abnormalities of red blood cell structural protein, globin protein, or enzyme defect lead to shortened life span. There has been much progress in revealing its pathophysiology and genetic backgrounds, but the lifelong plans for caring these patients are not well established yet. All patients with hereditary hemolytic anemic have three common problems: transfusion dependency, iron overload and iron chelation therapy. Patients with hereditary spherocytosis (HS) usually manifest severe anemia in neonatal period and infancy, but transfusion requirements may decrease in adulthood. But patients with thalassemia or sickle cell disease usually transfusion-dependent throughout life. Maintaining the optimal hemoglobin (Hb) levels in these patients is crucial because correction of anemia and dilution of abnormal Hb helps prevent certain complications that frequently occur in these patients. Frequent transfusion leads to transfusion-mediated infection and hemochromatosis. Iron chelation therapy should be started early to prevent permanent organ damage. Folate therapy can be helpful in patients with hereditary spherocytosis. Regular evaluations for cholestasis should be started at age 5, and splenectomy with concurrent cholecystectomy can be considered if the patient has cholecystitis. Hydroxyurea can be used to reduce transfusion requirements and prevent complications in patients with -thalassemia and sickle cell disease. Consensus on long-term management of patients with hereditary hemolytic anemia is lacking, especially for adult patients. But further efforts to build guidelines for long-term follow-up and management of the patients with hereditary hemolytic anemia in the context of Korean society are needed. pISSN 2233-5250 / eISSN 2233-4580 http://dx.doi.org/10.15264/cpho.2016.23.1.1 Clin Pediatr Hematol Oncol 2016;23:1∼7

Late effects in patients with Fanconi anemia following allogeneic hematopoietic stem cell transplantation from alternative donors.

Hematopoietic stem cell transplantation (HSCT) is curative for hematological manifestations of Fanconi anemia (FA). We performed a retrospective analysis of 22 patients with FA and aplastic anemia, myelodysplastic syndrome or acute myelogenous leukemia who underwent a HSCT at Memorial Sloan Kettering Cancer Center and survived at least one year post-HSCT. Patients underwent either a total body irradiation (TBI) (N=18) or busulfan (N=4) based cytoreduction followed by T-cell depleted transplants from alternative donors. Twenty patients were alive at time of study with a 5 and 10 year overall survival of 100% and 84% and no evidence of chronic GVHD. Among the 18 patients receiving a TBI-based regimen, 11 (61%) had persistent hemochromatosis, four (22%) developed hypothyroidism, seven (39%) had insulin resistance and five (27%) developed hypertriglyceridemia after transplant. Eleven of 16 evaluable patients (68%), receiving TBI, developed gonadal dysfunction. Two patients who received a TBI-based regimen died of squamous cell carcinoma. One patient developed hemochromatosis, hypothyroidism, and gonadal dysfunction after Busulfan-based cytoreduction. TBI appears to be a risk factor for malignant and endocrine late effects in the FA host. Multidisciplinary follow-up of patients with FA (including cancer screening) is essential for early detection and management of late complications, and improving long-term outcomes.

Long-term follow-up study of allogeneic hematopoietic stem cell transplantation

The need for guidance regarding appropriate systematic long-term follow-up (LTFU) of hematopoietic cell transplantation (HCT) survivors has been recognized. Guidelines for screening and preventive practices for HCT survivors were published in 2006. An international group of transplantation experts updated the recommendations in 2011. Several points regarding the management of late complications must be addressed. Therefore, it is difficult to assess them all at routine visits to the hospital. We herein report the LTFU system employed in the Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital. The main purposes include the assessment of chronic GVHD severity, the management of late complications, and patient education for the prevention of infections. We created handbooks for the management of late complications. The questionnaire answered by patients revealed that 93% could understand the necessity for screening of second malignancies and that 84% were satisfied with the LTFU system. The LTFU system is used to provide long-term support according to the patients' social circumstances.

Late Effects Following Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) From Alternative Donors In Patients With Fanconi Anemia (FA)

Hematopoietic Stem Cell Transplantation is the only curative approach for the hematological complications of Fanconi Anemia. However, patients with FA remain at increased risk for HSCT-specific late effects and FA-associated complications including solid tumors, which may affect their long-term outcome.We performed a single-institutional, retrospective review of late effects and long-term outcome in patients with FA who underwent HCST from alternative donors at MSKCC from March 1999 to December 2012. This review was approved by MSKCC IRB/Privacy Board. Twenty-two patients including 14 males and 8 females who underwent T-cell depleted HSCT and survived more than one-year post-transplant were eligible for inclusion in this study. The hematologic diagnoses of these patients were: severe aplastic anemia (SAA, n=11), myelodysplastic syndrome (MDS n=6) and acute myelogenous leukemia (AML n=5). Cytoreduction regimens included Total Body Irradiation (TBI), Cyclophosphamide (CY) and Fludarabine (FLU) (n=18) or Busulfan, CY and FLU (n=4). Donors were unrelated matched (n=9), unrelated mismatched (n=5) or related mismatched (n=8).The median post transplant follow-up for the 22 patients was 6.7 years (range 1.1- 15.1 years). Of the 22 patients who survived more than 1 year post HSCT, 20 are alive and 19 are alive disease-free, with overall survival and disease-free survival rates of 90.9% and 86.3% respectively for this patient group. Two female patients died of complications related to squamous cell carcinoma of the tongue and the vulvo-vaginal area respectively; one patient developed a relapse of MDS and is alive following a second transplant. Full donor chimerism was present in 18 of 20 evaluable patients. No chronic GVHD was observed in any of the 22 patients who received grafts from alternative donors. Of the 18 patients who received a TBI based regimen, 4 patients (22%) developed hypothyroidism post transplant, 7 patients (39%) developed insulin resistance (HOMA-IR >2.6) and one patient developed Insulin dependent diabetes mellitus, a year after transplant. Germ cell dysfunction was noted in 8 of 11 evaluable males and 4 of 5 evaluable females following a TBI based regimen. Among 4 patients receiving a Busulfan-based regimen, only one patient developed hypothyroidism. Prior to transplant, 13 patients (59%) had elevated ferritin levels (>500ng/ml) and seven of these 13 patients had received >20 transfusions. Post transplant, 12 patients had persisting high ferritin levels and six underwent phlebotomy. None of the patients had documented adverse cardiac or pulmonary late outcomes post-transplant.In summary, patients with FA are at risk for treatment-related late effects, and multidisciplinary follow up of patients with FA (including cancer screening) is essential for the early detection and management of late complications. Patients with FA who survive greater than one year post transplant have a very good outcome. However, these patients remain at risk for solid tumors of the head and neck and anogenital area post transplant. It is hoped that newer regimens that minimize radiation exposure and the use of T-cell depletion associated with minimal GvHD will further decrease the risks of solid tumors and other adverse late effects in patients with FA post transplant. Disclosures:No relevant conflicts of interest to declare.

Management of late complications after allogeneic hematopoietic stem cell transplantation

Management of late complications after allogeneic hematopoietic stem cell transplantation

Atrial Switch Operation in the Current Era

Although rarely performed today, atrial switch operations continue to have an important role in the management of some forms of congenital heart disease. In developing countries, delayed diagnosis and presentation of patients with transposition of the great arteries is not uncommon. For some patients who are referred for surgery beyond the newborn period, the atrial switch operations are still considered to be the best option. Also, as part of surgical repair of congenitally corrected transposition, an atrial switch operation is combined with arterial switch or the Rastelli procedure as an alternative to physiologic repair. In isolated ventricular inversion (atrioventricular discordance with ventriculoarterial concordance), the atrial switch operation alone leads to complete anatomical correction. Finally, management of late complications of atrial switch operations requires a thorough understanding of the procedures.

The Value of Periodic Follow-up in the Detection of Recurrences after Radical Treatment in Locally Advanced Head and Neck Cancer

Aims To determine the value of routine follow-up in detecting and salvaging recurrence after radical treatment of locally advanced head and neck squamous cell carcinoma and to identify clinical or pathological prognostic factors that predicted for survival. Materials and methods A retrospective medical chart review was conducted at the Odette Cancer Centre between January 2000 and May 2006. Two hundred and twenty-three patients with advanced (stage III or IV) squamous cell carcinoma of the head and neck who were treated with curative intent were reviewed. Recurrences were divided into local, regional or distant recurrences. The detection method for each recurrence was categorised as self or physician detected. A self-detected recurrence arose from symptoms that led to investigations that confirmed a recurrence (even if initiated at the time of a routine visit), whereas a physician-detected recurrence was found during the routine follow-up examination and was asymptomatic. Results There was no evidence to suggest a significant improvement in disease-free or overall survival in the physician-detected versus patient-detected groups. Regional and distant recurrences were only detected by physicians in one-fifth of cases and, overall, patients self-detected their own recurrence in two-thirds of the cases that experienced disease progression within the sample. Of the 12 clinical/pathological variables considered, only the response to treatment and perineural invasion were associated with survival. Conclusions Current surveillance methods do not appear to improve cancer control in the stage III/IV head and neck squamous cell carcinoma population. However, technological advances and biomarker development may lead to surveillance technique enhancements. Also, post-treatment follow-up remains important for the evaluation of treatment results, emotional support and management of late complications. Among the clinical and pathological factors considered, only the treatment response and perineural invasion predicted survival.

Vitrectomy in Diabetic Retinopathy

Pars plana vitrectomy (PPV) is integral to the management of late complications in diabetic retinopathy. As a greater understanding of the pathophysiology of diabetic eye disease has developed, so the role of PPV has evolved. This article reviews the current indications for PPV in diabetes (vitreous haemorrhage, tractional retinal detachment and combined rhegmatogenous and tractional retinal detachment) and the evidence for potential future applications, such as in diabetic macular oedema. The role of pharmacological adjuncts, such as antivascular endothelial growth factor (VEGF) agents, to reduce intraocular complications, improve success rates and minimise post-operative complications is examined. Drug-induced vitreolysis as a tool in achieving complete vitreoretinal separation, thus reducing progression of diabetic retinopathy, is discussed. It has already become routine practice for endolaser photocoagulation to be employed during PPV and, in the future, vitreolytic and antiproliferative agents may also be important as adjuncts to achieve good outcomes.

Bile duct injuries: management of late complications

Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature. In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method. Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%. Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.

Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome

This study was undertaken to report on the prevalence and management of late complications in twin-to-twin transfusion syndrome (TTTS) treated by laser therapy when both twins are alive 1 week after surgery. A total of 151 consecutive TTTS cases were treated by selective fetoscopic laser therapy. Cases in which both twins were alive 1 week after surgery were followed up with ultrasound and Doppler examination, including middle-cerebral artery peak systolic velocity measurement (MCA-PSV). In the 151 cases treated with laser, both twins were still alive 7 days after the procedure in 101 cases. Intrauterine death of 1 and both twins occurred in 7 and 1 cases, respectively. Recurrence of TTTS with the polyhydramnios-oligohydramnios sequence occurred in 14 (14%) cases. In another 13 (13%) cases, amniotic fluid remained normal in both sacs, but MCA-PSV increased above 1.5 MoM in 1 twin and decreased concomitantly below 0.8 MoM in the co-twin. This was related to anemia and polycythemia, respectively, and resulted from unidirectional feto-fetal blood transfusion, mainly from former recipients into former donors. Late complications were managed accordingly by repeat laser, amnioreduction, cord coagulation, intrauterine blood transfusion, or elective delivery. MCA-PSV Doppler measurements are useful in the follow-up of double survivors to detect and manage late complications after selective laser therapy.

Management of biliary problems after liver transplantation.

1. Biliary complications of some type occur in approximately one of every eight liver transplant recipients. Although they are uncommon causes of mortality, they are significant sources of morbidity. 2. Leaks and strictures that occur early after transplantation have technical causes. Late strictures and obstruction are more likely to be complex and have multiple causes, including hepatic artery occlusion, preservation injury, rejection, and recurrent disease. 3. Diagnosis relies on abdominal imaging and cholangiographic studies. Patency of the hepatic artery must be proven when a complication of the donor biliary tree occurs. 4. Management of late complications is largely influenced by the nature and extent of strictures. Percutaneous and endoscopic treatment of anastomotic strictures offers a significant prospect of successful long-term management. 5. Nonsurgical management of more complex hilar and intrahepatic strictures is less successful, and surgical revision or retransplantation may be required for definitive treatment.

Management of late complications after classic Fontan procedure by conversion to total cavopulmonary connection

Classic Fontan procedures, such as atriopulmonary connection or atrioventricular connection, are associated with right atrial dilatation and several late complications. Seven patients with univentricular heart who presented with exercise intolerance ( n=7), severely dilated right atrium ( n=7) with pulmonary vein compression ( n=3), atrial arrhythmias resistant to medical treatment ( n=4), cyanosis ( n=4), diffuse effusions and oedema ( n=1), and protein-losing enteropathy ( n=1), underwent conversion to total cavopulmonary connection 5.8–14.4 years after a previous atriopulmonary connection ( n=6) or atrioventricular connection ( n=1). A 14-year-old boy who, preoperatively, was in ventricular failure and a very poor state died early after conversion because of low cardiac output. All survivors had either marked or partial clinical improvement with regression of cardiomegaly, absence of pulmonary vein compression or cyanosis, and recovery of sinus rhythm. Conversion to total cavopulmonary connection appears to be effective in the treatment of late complications after classic Fontan procedures. It should be considered early in symptomatic patients, before significant ventricular dysfunction and clinical deterioration ensue.

Management of late complications of Teflon sling repair for rectal prolapse.

Recurrent rectal prolapse or postoperative rectal stricture occurred in four of 88 patients (4.5 per cent) who underwent Teflon sling repair at the Lahey Clinic during the past 15 years. Management of these and six other similar patients referred for treatment suggests that young men appear to be at a higher risk for recurrence. Strictures may be more likely to develop in patients with a long history of prolapse or problems with constipation. Teflon sling repair followed by recurrent prolapse or stricture formation should probably be treated by low anterior resection.