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Acute intestinal obstruction occurs when there is an interruption in the forward flow of intestinal contents. This interruption can occur at any point along the length of the gastrointestinal tract, and clinical symptoms often vary based on the level of obstruction. Intestinal obstruction is most commonly caused by intra-abdominal adhesions, malignancy, or intestinal herniation. The clinical presentation generally includes nausea and emesis, colicky abdominal pain, and a failure to pass flatus or bowel movements. The classic physical examination findings of abdominal distension, tympany to percussion, and high-pitched bowel sounds suggest the diagnosis. Radiologie imaging can confirm the diagnosis, and can also serve as useful adjunctive investigations when the diagnosis is less certain. Although radiography is often the initial study, non-contrast computed tomography is recommended if the index of suspicion is high or if suspicion persists despite negative radiography. Management of uncomplicated obstructions includes fluid resuscitation with correction of metabolic derangements, intestinal decompression, and bowel rest. Evidence of vascular compromise or perforation, or failure to resolve with adequate bowel decompression is an indication for surgical intervention.

We tested the hypothesis that abolishing vagal nerve activity will reverse the obesity phenotype of melanocortin 4 receptor knockout mice ( ). In two separate studies, we examined the efficacy of bilateral subdiaphragmatic vagotomy (SDV) with pyloroplasty in the prevention and treatment of obesity in mice. In the first study, SDV prevented >20% increase in body weight (BW) associated with this genotype. This was correlated with a transient reduction in overall food intake (FI) in the preventative arm of the study. Initially, SDV mice had reduced weekly FI; however, FI normalized to that of controls and baseline FI within the 8-week study period. In the second study, the severe obesity that is characteristic of the adult genotype was significantly improved by SDV with a magnitude of 30% loss in excess BW over a 4-week period. Consistent with the first preventative study, within the treatment arm, SDV mice also demonstrated a transient reduction in FI relative to control and baseline levels that normalized over subsequent weeks. In addition to the accompanying loss in weight, mice subjected to SDV showed a decrease in respiratory exchange ratio (RER), and an increase in locomotor activity (LA). Analysis of the white fat-pad deposits of these mice showed that they were significantly less than the control groups. Altogether, our data demonstrates that SDV both prevents gain in BW and causes weight loss in severely obese mice. Moreover, it suggests that an important aspect of weight reduction for this type of monogenic obesity involves loss of signaling in vagal motor neurons.

Although pancreaticoduodenectomy (PD) is feasible in patients greater than or equal to 80 years, little is known about the potential strain on resource utilization. Outcomes and inpatient charges were compared across age cohorts (I: ≤70, II: 71 to 79, III: ≥80 years) in 99 patients who underwent PD (2005 to 2013) at our institution. The generalized linear modeling approach was used to estimate the impact of age. Perioperative complications were equivalent among cohorts. Increasing age was associated with intensive care unit use, increased length of stay (LOS), and the likelihood of discharge to a skilled facility. After controlling for covariates, hospital charges were significantly higher in Cohort III (P = .006) and Cohort II (P = .035) when compared with Cohort I. However, hospital charges between Cohorts II and III were equivalent (P = .374). Complications (P = .005) and LOS (P < .001) were associated with higher hospital charges. Increasing age was associated with increased intensive care unit, LOS, and discharge to skilled facilities. However, octogenarians had equivalent PD charges and outcome measures when compared with septuagenarians and future studies should validate these findings in larger national studies. •Perioperative complications were equivalent among cohorts.•Increasing age was associated with intensive care use, increased length of stay, and the likelihood of discharge to a skilled facility.•Hospital charges between septuagenarians and octogenarians were equivalent.•Complications and length of stay were associated with higher hospital charges

•VP shunt placement with general surgery led to decreased revision rates, operative time, and length of stay.•VP shunt placement via laparoscopic technique led to decreased revision rates, infections, in-hospital complications, and operative time.•Prior shunt or abdominal surgery and lack of general surgery involvement were independent risk factors for distal shunt failure. Ventriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum. To determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion. A retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017−2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure. 331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort. The use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit.

Background The role of neoadjuvant stereotactic body radiation therapy (SBRT) in the treatment of pancreatic adenocarcinoma (PDAC) is controversial and the optimal target volumes and dose-fractionation are unclear. The aim of this study is to report on treatment outcomes and patterns of failure of patients with borderline resectable (BL) or locally advanced (LA) pancreatic cancer following preoperative chemotherapy and SBRT. Methods We conducted a single-institution, retrospective study of patients with BL or LA PDAC. Patients received neoadjuvant chemotherapy and SBRT was prescribed to 30 Gy over 5 fractions to the pancreas planning tumor volume (PTV). A subset of patients received a simultaneous integrated boost to the high risk vascular PTV and/or elective nodal irradiation (ENI). Following neoadjuvant chemoradiation, all patients underwent subsequent resection. Overall survival (OS), progression-free survival (PFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMPFS), and locoregional control (LRC) estimates were obtained using Kaplan-Meier analysis. Results Twenty-two patients with BL (18) or LA (4) PDAC were treated with neoadjuvant chemotherapy and SBRT followed by resection from 2011–2022. Following neoadjuvant treatment, 5 patients (23%) achieved a pathologic complete response (pCR) and 16 patients (73%) had R0 resection. At 24 months, there were no isolated locoregional recurrences (LRRs), 9 isolated distant recurrences (DRs), and 5 combined LRRs and DRs. Two LRRs were in-field, 2 LRRs were marginal, and 1 LRR was both in-field and marginal. 2-year median LRC, LRRFS, DMPFS, PFS, and OS were 77.3%, 45.5%, 31.8%, 31.8%, and 59.1%, respectively. For BL and LA cancers, 2-year LRC, DMPFS, and OS were 83% vs. 75%, (p = 0.423), 39% vs. 0% (p = 0.006), and 61% vs. 50% (p = 0.202), respectively. ENI was associated with improved LRC (p = 0.032) and LRRFS (p = 0.033). Borderline resectability (p = 0.018) and lower tumor grade (p = 0.027) were associated with improved DMPFS. Conclusions Following preoperative chemotherapy and SBRT, locoregional failure outside of the target volume occurred in 3 of 5 recurrences; ENI was associated with improved LRC and LRRFS. Further studies are necessary to define the optimal techniques for preoperative radiation therapy.

Background: Published success rates for surgical intervention in gastroesophageal reflux disease exceed 90%. The goal of this study was to determine if any preoperative factors could accurately predict postoperative symptom relief. Methods: One hundred consecutive patients undergoing laparoscopic antireflux surgery completed a detailed preoperative questionnaire, and underwent endoscopy, manometry, and 24-hour esophageal pH monitoring. Two surgeons performed all procedures in a standardized fashion. At least 2 months following operative intervention, a single interviewer, blinded to all preoperative information and procedure performed, recorded Visick and Gastroesophageal Reflux Disease–Health-Related Quality of Life scores for all patients. All follow-up was performed within 3 years of antireflux procedure. Results: The surgical success rate, as defined by Visick scores of 1-2, was 91%. Three variables were predictive of postoperative success: age <50, presence of typical symptoms at presentation, and complete resolution of symptoms with acid suppression therapy. Conclusion: The study shows that surgical strategies can reproducibly control gastroesophageal reflux disease symptoms in more than 90% of patients. The optimal surgical candidate is a patient under the age of 50 whose typical symptoms completely resolve with acid suppression therapy.

This article examines the practice of youthful unmarried cohabitation among heterosexual couples, most of whom later married. It attempts to identify the contingencies leading to cohabitation, the forms of adaptation to actual or perceived reactions by family to the relationship, and the consequences of these adaptations for the cohabiters and their relations with family. The analysis suggests that cohabitation can be understood as a gradual movement characterized by drift in a situation of opportunity isolated from immediate social controls. The form of adaptation to family varies by the awareness context (Glaser and Strauss, 1964) existing between cohabiters and family. The study points out the sources of change in awareness contexts and concludes that the enactment of traditional role obligations or marriage is generated by actual or perceived reactions of others, problems associated with various forms of awareness contexts, and other factors.

This article examines the practice of youthful unmarried cohabitation among heterosexual couples, most of whom later married. It attempts to identify the contingencies leading to cohabitation, the forms of adaptation to actual or perceived reactions by family to the relationship, and the consequences of these adaptations for the cohabiters and their relations with family. The analysis suggests that cohabitation can be understood as a gradual movement characterized by drift in a situation of opportunity isolated from immediate social controls. The form of adaptation to family varies by the awareness context (Glaser and Strauss, 1964) existing between cohabiters and family. The study points out the sources of change in awareness contexts and concludes that the enactment of traditional role obligations or marriage is generated by actual or perceived reactions of others, problems associated with various forms of awareness contexts, and other factors.