Faculty Bibliography

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.

BACKGROUND AND AIM/OBJECTIVE:The role of specific environmental and socioeconomic factors associated with significant liver fibrosis in a diverse, multi-ethnic population is underexplored. We leveraged the Mount Sinai Metabolic dysfunction-associated steatotic liver disease/steatohepatitis (MASLD/MASH) Center of Excellence Longitudinal Registry and publicly available data to explore this association. METHODS:Four hundred sixty-three New York City residents (aged 5-90) who were enrolled in the Mount Sinai MASLD/MASH Center of Excellence Longitudinal Registry were stratified for fibrosis stages using Vibration-controlled transient elastography (F0/1: < 8 kPa, F2: 8-10 kPa, F3: 10-14, F4: > 14 kPa). Using both univariable and multivariable logistic regression analyses, the association was evaluated between health disparities/environmental factors as defined by NYC.gov data (income, air quality, high school graduation rate, and access to parks and education per community district tabulation area) and significant fibrosis (kPa > 8). RESULTS:), having nearly double the odds of significant fibrosis (OR 1.85, 95% CI (1.11, 3.09)). No association between lower income and increased fibrosis was observed. Among non-Hispanics, education access was linked to significantly lower odds of fibrosis (OR 0.96, 95% CI (0.927, 1.00)). In adults, alcohol (AUDIT-C score) was associated with lower risk of significant fibrosis (OR 0.75, 95% CI (0.61, 0.92)). CONCLUSION/CONCLUSIONS:Understanding the interaction of health disparities, environmental risk factors, and liver fibrosis in MASLD informs both mechanistic translational studies as well as targeted population screening strategies.

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.

There is limited understanding of the epigenetic drivers of tumor evolution in hepatocellular carcinoma (HCC). Here we characterize the epigenetic contribution of methylation to intra-tumoral heterogeneity (mITH) using regional enhanced reduced-representation bisulfite sequencing DNA methylation data from 47 early stage, treatment-naive HCC biopsies across 9 patients by quantifying regional differential methylation across promoters and CpG islands, while overlapping with methylation age markers. Furthermore, we integrate these data with matching RNA-sequencing, targeted DNA sequencing, tumor-infiltrating lymphocyte (TIL), and hepatitis-B viral expression data. We found substantial mITH signatures in promoter and enhancer sites across 44% of patients in our cohort that highlight a novel axis of ITH that is not otherwise detectable from RNA analysis alone. Additionally, we identify an epigenetic tumoral aging measure that reflects a complex tumor fitness phenotype as a potential proxy for tumor clonality. Associating clinical outcomes with epigenetic tumoral age using 450k array data from 377 patients with HCC in the TCGA-LIHC single-biopsy cohort we found evidence implying that epigenetically old tumors have lower fitness yet higher TIL burden. Our data reveal a novel, unique epigenetic axis of ITH in HCC that merits further exploration.

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.