Faculty Bibliography

BACKGROUND:A 6-food elimination diet in pediatric eosinophilic esophagitis (EoE) is difficult to implement and may negatively affect quality of life (QoL). Less restrictive elimination diets may balance QoL and efficacy. OBJECTIVE:We performed a multisite, randomized comparative efficacy trial of a 1-food (milk) elimination diet (1FED) versus 4-food (milk, egg, wheat, soy) elimination diet (4FED) in pediatric EoE. METHODS:Patients aged 6 to 17 years with histologically active and symptomatic EoE were randomized 1:1 to 1FED or 4FED for 12 weeks. Primary end point was symptom improvement by Pediatric Eosinophilic Esophagitis Symptom Score (PEESS). Secondary end points were proportion experiencing histologic remission (<15 eosinophils per high-power field); change in histologic features (histology scoring system), endoscopic severity (endoscopic reference score), transcriptome (EoE diagnostic panel), and QoL scores; and predictors of remission. RESULTS:Sixty-three patients were randomly assigned to 1FED (n = 38) and 4FED (n = 25). In 4FED versus 1FED, mean PEESS improved -25.0 versus -14.5 (P = .04), but remission rates (41% vs 44%; P = 1.00), histology scoring system (-0.25 vs -0.29; P = .77), endoscopic reference score (-1.10 vs -0.58; P = .47), and QoL scores were similar between groups. The EoE transcriptome normalized in those with histologic response to both diets. Baseline peak eosinophil count predicted remission (odds ratio, 0.975 [95% confidence interval, 0.953-0.999], P = .04; cutoff ≤42 eosinophils per high-power field). The 4FED withdrawal rate (32%) exceeded that of 1FED (11%) (P = .0496). CONCLUSIONS:Although 4FED moderately improved symptoms compared with 1FED, the histologic, endoscopic, QoL, and transcriptomic outcomes were similar in both groups. 1FED is a reasonable first-choice therapy for pediatric EoE, given its effects, tolerability, and relative simplicity.

IMPORTANCE/OBJECTIVE:Despite its frequent use for visualization of ureteral efflux during pelvic/abdominal surgery, there are limited data on indigo carmine pharmacokinetics and duration of blue color in postdose urine. Understanding how long the blue color persists allows the clinician to make accurate assessments of the urinary system during complex surgical procedures. OBJECTIVES/OBJECTIVE:This study observed the plasma and urinary pharmacokinetics of indigo carmine in healthy volunteers and the voided urine color. STUDY DESIGN/METHODS:This study was an open-label, randomized clinical trial in 16 healthy participants who received either a 2.5-mL or a 5.0-mL intravenous injection of indigo carmine. Blood (pre, 2, 5, 7, 10, 15, 20, 30, 40 minutes and 1, 2, 3, 4, 6, 12 hours post) and urine (predose, 0-2, 2-6, 6-12 hours post) were collected. The first postdose stool was collected. RESULTS:Plasma concentration peaked within 5 minutes, and all plasma concentrations were below the limit of quantification by 2 hours postdose. The estimated plasma half-life of indigo carmine was 12 minutes. Voided urine through 2 hours postdose was visibly discolored compared with the matched predose urine. In some cases, urine discoloration persisted through 6 hours (10/16) and 12 hours (1/16). Unchanged indigo carmine eliminated in stool was observed in 4 of 16 participants (25%). CONCLUSIONS:The short half-life and rapid urinary excretion of indigo carmine favor its clinical use for intraoperative cystoscopy and are consistent with the reported median time of 6 minutes postinjection to ureteral efflux in patients undergoing surgical procedures.

BACKGROUND:We present the case of a 74-year-old woman diagnosed with obstructive hypertrophic cardiomyopathy. CASE SUMMARY/METHODS:Amyloidosis was initially considered because she was genotype positive in the transthyretin gene. However, because of 2 negative 99m technetium pyrophosphate radionuclide scans, this diagnosis was considered unlikely, and endomyocardial biopsy was deferred. She had an adverse response to all attempted medical therapies for her left ventricular outflow tract obstruction and ultimately underwent surgical myectomy. Surgical pathology revealed transthyretin (TTR) amyloidosis. DISCUSSION/CONCLUSIONS:This case highlights the limitations of diagnostic testing and reinforces the consideration of more invasive procedures to determine the true underlying cause of disease. This helps clinicians provide the most advanced level of treatment available. TAKE-HOME MESSAGES/CONCLUSIONS:TTR amyloidosis can mimic hypertrophic cardiomyopathy with left ventricular outflow tract obstruction. 99m Technetium pyrophosphate scans are useful to investigate the presence of TTR amyloid, but if suspicion persists despite negative testing, it is reasonable to perform an endomyocardial biopsy.

BACKGROUND:The rapid integration of telemedicine, accelerated by the COVID-19 pandemic, has become an integral part of perioperative care across various surgical specialties. While its role in routine postoperative care is well established, its application in the initial evaluation of complex conditions, such as moderate-to-large ventral hernia, remains unclear. This study investigates the feasibility and outcomes of telemedicine-based preoperative evaluations for patients presenting with ventral hernia measuring more than 4 cm in width. STUDY DESIGN/METHODS:We conducted a single-center, retrospective cohort study comparing patients with moderate-to-large ventral hernia evaluated through telemedicine-based vs traditional in-person encounters. We analyzed demographic, intraoperative, and postoperative factors. The primary goal was to compare perioperative outcomes between patients evaluated entirely virtually preoperatively and patients who had at least 1 in-person encounter. RESULTS:From January 2021 to November 2024, 478 patients underwent ventral hernia repair, of whom 106 (22%) were evaluated entirely virtually before the day of operation. No difference was observed in perioperative outcomes, including complication rates, length of stay, and recurrence rates. One-year surveillance rates were higher in the cohort that was evaluated preoperatively via entirely virtual encounters (62% vs 44%, p = 0.007). CONCLUSIONS:Telemedicine-based preoperative evaluations for moderate-to-large ventral hernia are feasible and safe, with postoperative outcomes comparable with those after traditional in-person new patient consultations. This approach can expand access to specialized care, especially for geographically distant patients. Further prospective studies are needed to refine practices and explore broader applications of telemedicine in complex surgical care.

BACKGROUND:The introduction of evidence-based medicine has challenged many concepts. In analyzing comparative study results, it is common to find narratives highlighting favorable outcomes based on a p-value of < 0.05, without understanding the clinical impact of the observed difference. Given the prevalence of this issue in hernia surgery research, we aimed to evaluate the prevalence of studies reporting a cutoff for clinical relevance in published comparisons of open, laparoscopic, and robotic inguinal hernia repair (IHR). METHODS:We searched Hernia, Surgical Endoscopy, Annals of Surgery, Surgery, World Journal of Surgery, and JAMA Surgery for articles comparing open, laparoscopic, and robotic IHR. Our search was performed according to the recent guidelines, comprising articles published since 2018. Articles analyzing non-clinical outcomes, such as cost-effectiveness, were excluded. Two authors independently screened the articles analyzing the presence of a clinical relevance cutoff definition of statistical significance, and if it suggested a superiority of a technique among others based solely on the p-value. RESULTS:The initial search resulted in 62 articles, of which 8 were excluded, resulting in 54 included manuscripts. Among the included studies, 8 (14.8%) were randomized controlled trials (RCTs), while 46 (85.2%) were comparative cohort studies. Surprisingly, none of the studies defined a clinical relevance cutoff for the outcomes analyzed. Furthermore, only 6 (11.1%) studies highlighted that their findings may not be of clinical relevance. However, even among those 6 studies, 3 (50%) suggested a superiority of the approach based solely on the p-value, while the other 3 (50%) studies, despite finding a statistically significant difference, did not make this suggestion. 16 (29.6%) studies showed no statistically significant differences between the groups, but 2 (12.5%) of those still suggested a superiority of one of the surgical approaches. Among the RCTs, only 1 (12.5%) reported that their findings may not be of clinical relevance, while 1 (12.5%) suggested a benefit despite not finding statistically significant results. CONCLUSION/CONCLUSIONS:Our study, encompassing the main journals in the surgical literature, demonstrated that the distinction between statistical and clinical relevance in hernia surgery, even in RCTs, remains inadequately addressed. There is a need for studies to define what difference in association measure is necessary to achieve clinical relevance for key outcomes in hernia surgery, such as recurrence, wound-related morbidity, and postoperative pain.

INTRODUCTION/BACKGROUND:Ventral hernias remain a challenging surgical condition with long-term complications and recurrences. This study evaluates whether standardized telemedicine-based follow-up improves long-term surveillance following ventral hernia repaiI METHODS: A retrospective cohort study compared telemedicine-based surveillance with traditional in-person follow-up for patients undergoing ventral hernia repair at a tertiary hernia center. Follow-up adherence at 6-, 12-, and 24-months were the primary outcomes of interest. RESULTS:Telemedicine-based surveillance significantly improved follow-up adherence; 79 ​% vs. 44 ​% at 6 months, 69 ​% vs 42 ​% at 12 months, and 44 ​% vs 14 ​% at 24 months. There was no significant difference in recurrence rates, but telemedicine helped identify patient concerns (24 ​%) early, leading to select additional interventions such as cross-sectional imaging or supplemental in-person evaluation (10 ​% CONCLUSIONS: Telemedicine improves follow-up adherence and early detection of complications after ventral hernia repair. It offers an affordable solution for long-term patient care, though further research is needed to optimize protocols.

Liver cancer is the third leading cause of cancer-related deaths globally, with incident cases expected to rise from 905,700 in 2020 to 1.4 million by 2040. Hepatocellular carcinoma (HCC) accounts for about 80% of all primary liver cancers. Viral hepatitis and chronic excessive alcohol consumption are major risk factors for HCC, but metabolic dysfunction-associated steatotic liver disease is also becoming a dominant cause. The increasing numbers of cases of HCC and changes in risk factors highlight the urgent need for updated and targeted prevention strategies. Preventive interventions encompass strategies to decrease the burden of chronic liver diseases and their progression to HCC. These strategies include nutritional interventions and medications that have shown promise in preclinical models. Although prevailing approaches focus on treating chronic liver disease, leveraging a wider range of interventions represents a promising area to safeguard at-risk populations. In this Review, we explore existing evidence for preventive strategies by highlighting established and potential paths to reducing HCC risk effectively and safely, especially in individuals with chronic liver diseases. We categorize the preventive strategies by the mechanism of action, including anti-inflammatory, antihyperglycaemic, lipid-lowering, nutrition and dietary, antiviral, and antifibrotic pathways. For each category, we discuss the efficacy and safety information derived from mechanistic, translational, observational and clinical trial data, pinpointing knowledge gaps and directions for future research.

BACKGROUND:With the advent of advanced imaging and endoscopy, we hypothesized that IOC resident training has declined and is currently insufficient. To this end, we evaluated the national general surgery resident experience with laparoscopic cholecystectomy both with and without intraoperative cholangiography. METHODS:The National Accreditation Council for Graduate Medical Education (ACGME) operative logs were evaluated from 2012 to 2023 for general surgery residents. The number of completed laparoscopic cholecystectomy (CCY) operations and CCY with cholangiogram were evaluated and compared by postgraduate year, program (academic, community, hybrid, military), and resident role (first assistant, surgeon junior, and surgeon chief). ANOVA testing was used to analyze the data. RESULTS:The cholecystectomy case volumes of graduating general surgery residents in all cholecystectomies increased between the 2012-2013 and 2022-2023 academic years (123.9 v 143, p < 0.01). The number of performed CCY + IOC declined significantly over this period (25.1 v 21.6, p = 0.02). University-affiliated programs demonstrated statistically lower numbers of IOCs than community-based (19.3 v 34.1, p < 0.01), hybrid (24.0, p < 0.01), or military programs (26.3, p < 0.01). Community-based programs performed more CCY with IOC than any other group (p < 0.01). Despite the number of CCY + IOC declining during the study period, an increasing percentage of the CCY + IOC were performed by chief (PGY5) residents (p < 0.01). CONCLUSION/CONCLUSIONS:Trainee experience with IOC is declining. The decreased rate and number of IOCs performed by residents has correlated with a "seniorization" of resident experience. This change may result in a future general surgeon workforce with inadequate IOC experience and ultimately impact patient safety. To bolster experience with both technique and interpretation, liberal IOC should be advocated for in training environments. A national IOC assessment may be necessary to address this looming deficit.