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Effective, narcotic sparing analgesia is a major component of Enhanced Recovery Protocols (ERP), however the risk of poor analgesia and opioid related side effects (ORADE) remains an issue related to poor outcomes and satisfaction, and is strongly related to the risk of narcotic dependence after surgery. A variety of genes can impact narcotic and non-steroidal (NSAID) drug efficacy including: the CYP family (drug metabolism-narcotics and NSAID), or COMT/ABCB1/OPRM1 (functional receptor and transport activity for analgesia vs side effects). The purpose of this study was to perform the first assessment of the impact of a pharmacogenetics (PGx) guided selection of analgesics following major abdominal surgery within an ERP. A consecutive series of open and laparoscopic colorectal resections or major ventral hernia repair (PGx group) had a guided analgesic protocol based upon assessment of CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, COMT, OPRM1, and ABCB1 genes. Study patients were compared to a recent historical series of patients (H group) managed using our well validated ERP. The primary outcome measure was the Overall Benefit of Analgesia Score (OBAS). Pain scores were also assessed. The data demonstrated a similar mix of procedures and gender between groups and more than half of the PGx group had revised analgesia from the standard ERP. The PGx group demonstrated significantly lower OBAS scores (p = 0.0.1) from POD1 (3.8 vs 5.4) through POD 5 (3.0 vs 4.5) Analgesia was also superior for the PGx group from POD1 through POD 5 (p = 0.04). Pharmacogenetics guidance resulted in frequent modifications of the analgesic program, resulting in excellent analgesia with a 50% reduction in narcotic consumption, and a reduced incidence of analgesic related side effects compared to our standard ERP. These data suggest further improvement in ERP resulting from a patient centric analgesic, reduced narcotic regimen which provides early and durable pain control with fewer narcotic related side effects.

Background Despite using laparoscopy and enhanced recovery pathways (ERP), some patients are not ready for early discharge. The goal of this study was to identify predictors for patients who might fail early discharge, so that any defined factors might be addressed and optimized. Methods A prospectively maintained database was reviewed for major elective laparoscopic colorectal surgical procedures. Cases were divided into day of discharge groups: ≤3 days and >4 days. All followed a standardized ERP. Demographic and clinical data were compared using Student’s paired t tests or Fisher’s exact test, with p value < 0.05 statistically significant. Regression analysis was performed to identify significant variables. Results There were 275 ≤3 days patients and 273 >4 days patients. There were significant differences between groups in body mass index ( p  = 0.0123), comorbidities ( p  = 0.0062), ASA class ( p  = 0.0014), operation time ( p  < 0.001), postoperative complications ( p  < 0.001), and 30-day reoperation rate ( p  = 0.0004). There were no significant differences for intraoperative complications ( p  = 0.724), readmissions ( p  = 0.187), or mortality rate ( p  = 1.00). Significantly more patients were discharged directly home in the ≤3-days cohort. Using logistic regression, every hour of operating time increased the risk of length of stay >4 days by 2.35 %. Conclusions Elective colorectal surgery patients with longer operation times and more comorbidities are more likely to fail early discharge. These patients should have different expectations of the ERP, as an expected 1- to 3-day stay may not be achievable. By identifying patients at risk for failing early discharge, resources and postoperative support can be better allocated and patients better informed about likely recovery.

Background and objectives The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. Methods Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. Results Overall, 294 patients were analyzed—116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1–20) LAP, 6 days (range 3–13) CONVERTED, and 8 days (range 1–35) OPEN ( p  < 0.01). More OPEN had postoperative complications ( p  < 0.01)—complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN ( p  = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN ( p  = 0.05), with comparable local recurrence ( p  = 0.07) and OS rates (0.43). Conclusions LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.

Factors influencing recurrence of ileocecal Crohn's disease (CD) after surgical resection may differ between adolescents and adults. CD patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤ 16 years, n = 34) and adult onset (>16, n = 108) patients to evaluate differences in risks of endoscopic and clinical recurrence. In 142 patients, rates of any recurrence, endoscopic recurrence, and clinical recurrence at 5 years were 78%, 88%, and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group. Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD.

To evaluate readmissions to determine predictors and patterns of readmission. Prospective database review identified readmitted and non-readmitted patients after colorectal surgery. Variables for the index and readmission episode were examined. A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older (P = .003), had more comorbidities (P < .0001), longer operative times (P < .0001), length of stay (P < .0001), and higher costs (P = .002). At the time of discharge, more readmitted patients required temporary nursing (P < .0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time (P = .05) and LOS were longer (P = .028), and more patients required temporary nursing care at the time of discharge (P = .046). Readmissions caused an additional mean hospital cost of $12,670.89. Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group.

We report the first survey of ecto- and endoparasites of brown bears (Ursus arctos gobiensis) in the Gobi Desert, Mongolia. We collected 40 ticks from 1 female (21 yr old, 48 kg) and 2 males (10 yr, 155 kg; 5 yr, 108 kg) captured for research purposes in May 2018. We found Dermacentor nutalli (n = 35 ticks, 87.5%) on both male bears and Hyalomma asiaticum (n = 5 ticks, 12.5%) on one male. The female had no ticks. We also collected a fecal sample from each captured bear, and an additional 15 fecal samples in the field. Two (11%) of the 18 fecal samples collected contained eggs of Strongyloides spp.; 1 fecal (10-yr-old male) sample had 2 eggs, and 1 fecal sample collected in the field contained 1 egg. This is the first documentation of parasites of wild bears in Mongolia.

Increasingly, patients with multiple co-morbidities undergo surgery for rectal cancer. We aimed to evaluate if decreased psoas muscle area and volume, as measures for sarcopenia, were associated with postoperative morbidity. Retrospective review of patients undergoing rectal cancer resection at a tertiary medical center (2007–2015). Variables included demographics, co-morbidities, preoperative psoas muscle area and volume, and postoperative complications. Among 180 patients (58% male, mean age 62.7 years), 44% experienced complications (n = 79), of which 38% (n = 30) were major complications. Malnourished patients had smaller height-adjusted total psoas area than non-malnourished patients (6.4 vs. 9.5 cm2/m2, p = 0.004). Among patients with imaging obtained within 90 days of surgery, major morbidity was associated with smaller total psoas area (6.7 vs. 10.5 cm2/m2, p = 0.04) and total psoas volume (26.7 vs. 42.2 cm3/m2, p = 0.04) compared to those with minor complications. Preoperative cross-sectional imaging may help surgeons anticipate postoperative complications following rectal cancer surgery.

Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

Information about population demography is crucial for developing and implementing conservation measures. The brown bear in the Gobi desert of southwestern Mongolia (referred to as the Gobi bear) is one of the smallest and most isolated brown bear populations in the world. We conducted genetic sampling (n = 2660 samples collected) using hair corrals around feeding sites at 13 water sources during 2009, 2013, and 2017 to evaluate population size, survival, and population trend. Bears were identified using 13 microsatellite loci and one sex marker. We detected 51 unique individuals (15F and 36M) from our targeted surveys in 2009, 2013, and 2017. Based on capture–mark–recapture robust design, population estimates were 23 (95% CI: 21–32) in 2009, 28 (95% CI: 25–35) in 2013, and 31 (95% CI: 29‐38) individuals in 2017. Spatial capture–recapture analysis suggested abundance was very low (N^ = 27; 95% CI: 22–35), and there was no significant change from 2009 to 2017. The population density was 0.93 bears/1000 km2 (95% CI: 0.74–1.17). Our population estimates suggested a stable population trend. However, the population is still very small, and the sex ratio is skewed toward males, raising concerns for future persistence. Annual survival based on Robust design CMR was 0.85. Low abundance and apparent survival for both sexes in this unhunted population coupled with a skewed sex ratio highlight the need for on‐the‐ground conservation action to conserve this isolated population of bears.