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Department of Surgery Research Symposium: Ground Truth from Bench to Bedside

By Tiffany Fox

Screen grab of meeting

Many will remember this year's UC San Diego Department of Surgery Research Symposium for the unique venue in which it was held: Everywhere and nowhere. 

Both the symposium's keynote address and research presentations were not delivered from podiums but instead  – per established pandemic protocols  – Zoomed from desks, dining room tables and yes, the operating room. If surgeons know one thing well, it's how to adapt past whatever obstacles COVID might throw in the way. 

Contrary to expectation, there wasn't so much a feeling of "return to research" at the annual symposium -– surgical research at UC San Diego had, after all, continued throughout the pandemic, despite periodic hiccups related to supply chain and social distancing requirements within laboratory environments and research teams. Instead, the mood was more one of reassurance that research still has a significant role to play in the world of surgery and will continue to drive, inform, and improve clinical practice in the decades to come. 

Echoing this sentiment, Department Chair Bryan M. Clary, MD, MBA, noted that the Department of Surgery "is robustly engaged across the breadth of research arenas, including basic and translational science, clinical trials and outcomes, health services, engineering and devices, global surgery and education. 

"This diverse portfolio of innovation keeps our researchers on the cutting edge – making significant strides towards improving surgery outcomes for both patients and doctors," he continued. 

Expanding on these ideas at the symposium was Dr. E. Shelley Hwang, MD, MPH, the Mary and Daryl Hart Professor of Surgery and Vice Chair of Research in the Department of Surgery at Duke University. Dr. Clary described her as "an extraordinary example of how surgeon scientists and researchers in general, can make a real difference for patients through practice-changing research."

In addition to giving the evening keynote, Dr. Hwang also presented at Grand Rounds the following morning. Her presentation, entitled "On the Shoulders of Giants: One Surgeon's Adventures as a Physician Scientist," was inspired by two quotes – the first, by Isaac Newton: "If I have seen, it is by standing on the shoulders of giants," and the second by Edwin Hubble: "Equipped with his five senses, a (wo)man explores the world around (her) and calls the adventure Science."

In her talk, Dr. Hwang acknowledged the many hurdles surgeons face in prioritizing research, but emphasized the primacy of the surgeon-scientist and "the opportunities and responsibilities we have to practice surgery at the highest level and advance it for the next generation of patients and surgeons." 

Advancing surgery, Dr. Hwang said, does not always mean performing surgery. By way of illustration, she cited the oft-quoted truism: "Good surgeons know how to operate, better ones when to operate and the best when not to operate."

This approach is reflected in research Hwang's cited illustrating the effectiveness of treatment modalities for Ductal Carcinoma In Situ (DCIS), or pre-invasive breast cancer, which now makes up a substantial proportion (20 percent) of mammographically diagnosed cancers. Previously, patients with DCIS were treated with surgical and radiotherapeutic approaches, much as if they already had the type of invasive cancers physicians were trying to avoid.

"I think we were always hampered by this approach because we just didn't know very much about the disease," Dr. Hwang admitted. "I think this is one situation where you can intervene almost too early."

Noting that "It's not just in cancer where we're looking for opportunities to do less on patients." Dr. Hwang cited a recent paper in the New England Journal of Medicine, which found that for the treatment of appendicitis, antibiotics are actually non-inferior to intervening with an appendectomy. 

"It used to be you never let the sun set on appendicitis, and we would operate at all hours of the day and night," said Dr. Hwang. "But this is the power of research, in that now we have new treatment paradigms and we're able to treat patients in a much more patient-centered and personalized way."

Dr. Hwang also referenced a trio of studies from 2016 on treatments for early-stage prostate cancer. The research – which was ultimately practice-changing – showed that active monitoring of early-stage prostate cancer is as effective as aggressive surgical or radiotherapy interventions, making treatment "more of a preference-sensitive decision because the outcomes are the same in terms of survival."

"This changed things almost overnight," said Dr. Hwang. "Just 10 to 15 percent of early-stage prostate cancers were treated by active surveillance prior to the study, and after publication, 40 to 50 percent (of patients) were making a choice… based on a complete change of treatment paradigm."

"Many of the ideas and inspirations that one obtains for research are really found at the bedside," added Dr. Hwang. "What we bring to research as surgeons is that we understand the patients, we understand the course of the disease and we understand what the important questions are in the field."

This perspective was also echoed in Dr. Hwang's keynote presentation, "Ground Truth: Surgeons at the Interface of Clinical Care and Basic Sciences." 

Despite a difficult funding climate, a lack of protected time for research, a "dearth of surgeon-scientist mentors" and other challenges, Dr. Hwang emphasized the importance of surgeons serving as a source of "ground truth."

"Surgeons are in a unique position to define ground truth because they engage with patients, touch disease and know the right questions to ask," she added. Dr. Hwang encouraged the Department to see these patient encounters – and the resulting data gathered  – as rich sources of curated information for research initiatives. She shared several examples of such initiatives out of Duke University, including a risk-prediction model called Pythias and the Duke/Verily Video Repository Initiative, which she described as "like Waze for the operating room."

The influence of the surgeon scientist was in full effect throughout the Symposium's main program, which included a total of 99 abstracts – one abstract from each of the Department's 13 clinical divisions. The submissions represented each of the Department's research areas, from clinical and basic/translational research to education, health services, engineering/robotics and global surgery. 

In addition, a total of 32 oral presentations were presented by researchers within the Department, including the following highlights:

  • "Heterogeneity of Hepatic Stellate Cells in a mouse model of non-alcoholic steatohepatitis (NASH)" by Sara Brin Rosenthal (Hepatobiliary & Transplant Surgery)
  • "Doubts About Cutting It Out: Systematic Review and Meta-analysis of Patient-centered Outcomes in Nonoperative Management Versus Surgery in Acute Uncomplicated Appendicitis in Adults" by William Yu Luo (Colon and Rectal Surgery)
  • "The Surgical Hair Fastener – A Novel Device to Save Intraoperative Time to Fasten Hair Together" by David Hom (Otolaryngology/Head & Neck Surgery)
  • "Impact Of Increasing Trends Of Endovascular Aneurysm Repair Cases On Surgical Training In Open Aneurysm Repair" by Nadin Elsayed (Vascular & Endovascular Surgery)
  • "Electronic Health Record Artificial Intelligence Model Predicts Trauma Inpatient Mortality in Real-Time by Zongyang "Tom" Mou (Trauma, Surgical Critical Care, Burns and Acute Care Surgery)

Jason Sicklick, MD, FACS, the Department's Vice Chair for Research and himself a surgeon-scientist, praised the Department for "taking up these challenges on behalf of current and future patients," adding that "it's clear our Department is passionate about research and the excitement inherent in discovery.

"We strive to challenge and reinvent the standard of care in an effort to improve patient outcomes, better utilize resources and advance surgical science," added Dr. Sicklick. "As evidenced by the abstracts presented at the Symposium, the department's diverse approach toward innovation keeps our researchers on the cutting edge – making significant strides towards improving surgery outcomes for both patients and doctors."



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