December 2025

This is a single-institution retrospective cohort study evaluating computed tomography (CT)-based predictors to determine the need for intraoperative thoracic surgery assistance during thyroidectomy. The authors found that there are several particular CT measurements that strongly predict the need for thoracic surgery involvement during a thyroidectomy. 

Summary: Intrathoracic (substernal) goiters are a heterogeneous subset of thyroid disease that can present significant technical challenges during thyroidectomy. While most can be removed through a cervical approach, a minority require thoracic surgical assistance, making reliable preoperative predictors essential. Existing criteria, such as posterior mediastinal extension or depth below the aortic arch, remain subjective and inconsistently defined.

This retrospective, single-institution study reviewed 7,370 thyroidectomies performed between 2012 and 2023 to identify patients with intrathoracic thyroid glands, defined on CT as extension below the sternal notch. Of 255 patients meeting this criterion, 34 (13.3%) required intraoperative thoracic surgery assistance. The authors calculated comprehensive and standardized CT measurements, including thyroid dimensions in three planes, mediastinal location, relationship to thoracic inlet dimensions, and craniocaudal extension relative to multiple anatomic landmarks. They then used to receive operating characteristics (ROC) and area under the curve (AUC) analyses to determine if the CT measurements were predictive of thoracic surgery assistance. Multivariable regression analysis was also used to evaluate the independent predicting factors for intraoperative thoracic involvement.

ROC analysis demonstrated that craniocaudal extension measured from the inferior thyroid border to the sternal notch was the most accurate predictor of thoracic assistance (AUC 0.94), outperforming measurements that used the aortic arch or sternal angle. Thresholds providing ≥80% sensitivity for predicting thoracic involvement included thyroid extension ≥5.3 cm below the sternal notch, horizontal dimension ≥5.3 cm, and anteroposterior dimension ≥5.1 cm. On multivariable regression, three independent predictors were identified: thyroid enlargement below the sternal notch (OR 10.1, 95% CI 1.96 to 51.63, p = 0.006), craniocaudal extension ≥5.3 cm (OR 5.3, 95% CI 1.78 to 15.85, p = 0.003), and horizontal dimension ≥5.3 cm (OR 3.8, 95% CI 1.13 to 13.00, p = 0.032). Additionally, patients requiring thoracic assistance had longer operative times and hospital stays but did not experience significantly higher rates of hypocalcemia, recurrent laryngeal nerve injury, or mortality.

Limitations of this study include the single-center setting, variability in surgeon experience and thoracic approach selection over time, and small sample size and therefore, limited power to predict the specific thoracic procedure required. These factors may limit generalizability to other practice environments.

Bottom line: Objective CT measurements may be able to reliably identify patients with intrathoracic goiter who should undergo preoperative thoracic surgery consultation.

This triple-blind, randomized, noninferiority trial compared single-dose versus 24-hour antibiotic prophylaxis in 146 patients undergoing reduction mammaplasty. The study found no significant difference in surgical-site infection (SSI) rates or wound complications between groups.

Summary: The optimal duration of antibiotic prophylaxis in reduction mammaplasty remains controversial, with many surgeons extending postoperative antibiotic use beyond current guideline recommendations. This randomized controlled trial was conducted at a Brazilian university hospital to compare the efficacy of a single preoperative dose of cefazolin versus 24 hours of postoperative prophylaxis in preventing SSIs following reduction mammaplasty. This study follows a previous randomized controlled trial from the group demonstrating no significant difference in SSI rates between patients given 24 hours of perioperative antibiotics or 7 days of post-operative antibiotics.

A total of 146 women (aged 18-60 years) with symptomatic breast hypertrophy were randomized 1:1 using sequentially numbered, opaque envelopes to receive either a single dose of cefazolin 1 g at anesthesia induction followed by placebo (sodium chloride solution every 6 hours for 24 hours; n=73), or the same initial dose followed by cefazolin 1 g every 6 hours for 24 hours postoperatively (n=73). All medications were prepared in identical vials with obscured labels to maintain triple-blinding. Patients were admitted the evening before surgery, underwent standardized preoperative chlorhexidine showering, and received reduction mammaplasty via superomedial pedicle technique with inverted-T incision by plastic surgery residents under attending supervision. Patients were discharged after 24 hours and followed weekly for 30 days by a surgeon blinded to group allocation.

The primary outcome was SSI occurrence according to CDC criteria, with secondary outcomes including other postoperative complications. The two groups were well-matched at baseline, with median age of 33 years, BMI 25.2 kg/m2, excised tissue weight 925g, and surgery duration 220 minutes. The overall SSI rate was 5.5% with 4 infections in each group (P=1.000). All SSIs were superficial incisional infections. Superficial dehiscence occurred in 30 patients (20.5%): 16 in the placebo group and 14 in the antibiotic group (P=0.682). Other complications including epidermolysis, partial nipple-areola complex necrosis, and seroma showed no significant between group differences. Logistic regression analysis identified increasing age as protective against wound dehiscence (OR 0.938, 95% CI 0.897-0.982, P=0.006), with approximately 5% decreased odds per additional year of age. 

Strengths of this study include the rigorous triple-blind design and standardized protocols. The main limitation is generalizability—strict exclusion criteria (BMI >30 kg/m2, smokers, significant comorbidities) and the 30-day follow-up period may not reflect real-world reduction mammaplasty populations, particularly given that most patients undergoing this procedure have higher BMIs.

Bottom Line: Extending antibiotic prophylaxis beyond a single preoperative dose does not reduce SSI or wound dehiscence rates in reduction mammaplasty in low comorbidity patients, supporting single-dose prophylaxis as a safe antibiotic stewardship practice.

Synopsis: This is a retrospective analysis of national EPA microassessment data collected for general surgery residents during their final year of training (2023-2024). Authors found that entrustment increased over the year and by the end of training nearly ¾ of chief residents achieved practice-ready entrustment. Operative skills were entrusted at a slower rate than nonoperative skills, particularly for renal replacement therapy, thyroid and parathyroid disease, and benign and malignant colon conditions. As more EPA microassessment data becomes available, future studies will be needed to monitor the distribution of EPA ratings and define resident learning curves over the duration of training to facilitate early identification of trainees who may not reach practice readiness by graduation.  

Summary: Entrustable Professional Activities (EPAs) are workplace-based assessments designed to provide frequent, formative feedback about trainee performance and represent a framework for competency-based assessment. The American Board of Surgery (ABS) developed 18 EPAs for general surgery which were rolled out to residency programs in July 2023 and will be part of the admissibility requirements for ABS general surgery certification beginning in 2028. This study sought to examine EPA data of chief residents across US general surgery programs to better understand the performance of this population and identify potential gaps in preparedness for independent practice. 

Authors retrospectively analyzed de-identified chief resident EPA data that had been prospectively collected from July 1, 2023 – May 31, 2024 across 3 platforms (SIMPL, Firefly, SEPA). For each microassessment, residents were scored 1-4 based on entrustment level (1=limited participation, 2=direct supervision, 3=indirect supervision, 4=practice-ready). Not all residents were evaluated on every EPA. Data were analyzed using descriptive statistics and bivariate analyses.  

A total of 12,611 EPA microassessments were collected, corresponding to 1032 chief residents (67%) from 265 programs (75.7%). The mean number of EPA assessments per resident was 12.2 +/- 19.5 with a mode of 1. The overall proportion of chief residents rated as practice-ready increased significantly over the year from 43.5% to 74.5% (p<0.001). Residents were more likely to receive practice-ready entrustment in nonoperative (nonoperative/preoperative and postoperative) compared with intraoperative phases of care and this gap narrowed but remained significant over the year (nonoperative practice-ready: 59% → 84.9%, intraoperative practice-ready: 36.8% → 70.8%; p<0.001). The proportion of residents rated as practice-ready varied inversely with case complexity but increased for all levels of complexity over the year (straightforward: 54% → 81%, moderate: 34% → 71%, complex: 42% → 1%; p<0.001). At the end of the year, the median entrustment was practice-ready for the nonoperative phases of all EPAs and for the intraoperative phases of all EPAs except for renal replacement therapy, thyroid and parathyroid disease, and management of benign and malignant colon disease. By the end of chief year, a total of 85 EPA microassessments from 51 unique residents were rated as direct supervision or limited participation. 

Limitations of this study include selection bias as the class of 2024 was not required to participate in EPA assessments therefore included residents may not be representative of all chief residents. There also may be selection bias on the individual resident level; EPAs are designed to be used as frequent microassessments but most chief residents in this study only had 1 assessment which may have not been representative of the resident’s true or overall performance. Additionally, because programs progressively began using EPAs and not all included trainees had July 2023 assessment, it is possible that the highest performing trainees are disproportionately represented, resulting in an overestimation of practice-ready residents at the start of their chief year. 

Bottom Line: In this nationwide study of general surgery residents who received EPA microassessments during their chief year, nearly ¾ achieved practice-ready entrustment by the end of training with slower entrustment of operative skills compared with nonoperative skills. These findings illustrate how EPA microassessment data can provide insight into longitudinal trainee performance. Future studies are needed to define individual, program, and national level learning trajectories to facilitate early detection of trainees who may not achieve practice readiness by the end of training.