How to isolate a high output enteroatmospheric fistula in the open abdomen with negative pressure therapy: an institution's step by step guide to the VAC donut.

There is multiple evidence to suggest that isolation techniques of high output enteroatmospheric fistulas (EAF) in open abdomens can be advantageous in controlling fistula effluent while allowing time for abdominal wall to granulate. The large loss of proteins, electrolytes and fluid, and the distressing nature of the open abdomen for both patients and doctors, make managing these EAFs a clinical challenge. We present our experience with a high output mucosal protruding EAF and the creation of a 'VAC donut' allowing a successful diversion of the enteric content whilst promoting granulation of the tissue bed.

Surgery for parathyroid microadenomas: patient characteristics, localization success and operative cures.

BACKGROUND: In recent years, patients with primary hyperparathyroidism (PHPT) are being diagnosed earlier, with milder elevations in parathyroid hormone (PTH) and serum calcium. We aimed to investigate whether adenoma size reflects biochemical severity of presentation and influences localization of pre-operative scans. METHODS: A total of 630 consecutive patients undergoing parathyroidectomy for PHPT were recruited into either the microadenoma (≤200 mg) or macroadenoma (>200 mg) group. Pre-operative serum calcium, PTH, rates of minimally invasive parathyroidectomy and bilateral neck exploration, localization of adenomas with pre-operative ultrasound and sestamibi (MIBI) scans, cure rates and other demographic parameters were compared. The data were analysed using Student's t-test, Chi-squared test, linear and multiple regression analyses. RESULTS: Patients in the microadenoma group had significantly lower pre-operative serum calcium (P < 0.001) and PTH (P < 0.001), less accurate MIBI (P < 0.001) and ultrasound (P < 0.001), lower cure rates (P = 0.04) and were more likely to undergo bilateral neck exploration (P = 0.001). However, multivariate analysis revealed that microadenomas are most strongly associated with the findings of less accurate MIBI (P = 0.03) and lower pre-operative calcium (P = 0.04). CONCLUSION: In conclusion, smaller adenomas are strongly associated with biochemically milder PHPT and less accurate localization studies. Therefore, microadenomas continue to present as a challenge in both diagnosis and management.

Gastric band connection tube results in small bowel obstruction: an acute emergency.

The laparoscopic adjustable gastric band (LAGB) is a widely performed procedure for the morbid obesity epidemic. Despite its low mortality compared with other mainstream bariatric surgeries, it is not without its complications. The authors report a late and rare complication of a small bowel obstruction in a 52-year-old woman from an LAGB placed for 2 years. She was diagnosed clinically and radiologically with a small bowel obstruction. However, in the setting of an LAGB, this became a closed-loop obstruction. She proceeded to an emergency laparoscopy, which revealed that the port connection tube had formed dense adhesions to the jejunum causing an obstructive band. This is only the fifth reported case in Australia; as bariatric surgery continues to rise, these patients may present unannounced to any emergency department and as such should be treated as a closed-loop obstruction with immediate resuscitative and surgical management instituted.