Background Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

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Experiences with three patients with cor triatriatum illustrate the urgent need for early recognition of this obstructing diaphragm in the left atrium. A 4-month old infant died with severe and progressive heart failure before cardiac studies were completed. A 3-year-old girl was under observation for one year prior to death in acute pulmonary edema. In spite of extensive studies the diagnosis was not established. A 16-month-old male had increasing dyspnea and fatigue for 3 weeks prior to referral. The hemodynamic studies revealed marked elevation of pulmonary capillary and pulmonary artery pressures. Unusual features included a continuous murmur high in the left axilla and striking enlargement of the left atrium. Excision of the obstructing membrane was accomplished at open operation with cardiopulmonary bypass, and striking clinical improvement has been maintained for 3 years.

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