August 2024

This large-scale observational study involving over 1 million patients compares the long-term survival outcomes of multiarterial grafting (MAG) versus single-arterial grafting (SAG) in coronary artery bypass grafting (CABG). The results demonstrate that MAG is associated with improved survival across most patient groups, except for those with severe comorbidities or obesity (BMI >40 kg/m²), where SAG may be more beneficial.

Summary: As the debate continues on the optimal surgical approach for symptomatic multivessel coronary artery disease, this study assesses the long-term survival benefit of multiarterial grafting (MAG) compared to single-arterial grafting (SAG) using data from over 1 million patients in the STS Adult Cardiac Surgery Database. Previous research yielded mixed results, with some suggesting MAG's superiority, while others, like the Arterial Revascularization (ART) trial, found no significant difference. This study aimed to evaluate whether MAG's benefits observed in smaller studies could be generalized to a larger national cohort, identify patient subgroups that might not benefit, and determine the minimum center volume required for optimal outcomes.

The retrospective analysis included patients who received ≥2 bypass grafts, one of which was an internal thoracic artery (ITA). To compare groups and adjust for baseline differences, inverse probability treatment weighting was utilized with a primary endpoint of all-cause mortality. Overall, 1,021,632 patients included in this study. They found that MAG conferred a significant survival advantage over SAG, with adjusted hazard ratios showing a 14% reduction in mortality over 12 years (aHR 0.86, 95% CI, 0.85-0.88). MAG was used in 9.83% of patients and was associated with improved unadjusted survival rates at 1 year (97.8% vs. 97.5%), 3 years (95.2% vs. 94.7%), and 5 years (91.8% vs. 90.8%) compared to SAG. However, the survival benefit of MAG was diminished in patients with severe comorbidities such as New York Heart Association (NYHA) functional class IV, severe lung disease, and chronic kidney disease (glomerular filtration rate <45 mL/min/1.73 m²), where the survival between the MAG and SAG groups was similar. In contrast, severely obese patients (BMI >40 kg/m²) experienced better survival with SAG (adjusted HR 1.08, 95% CI, 1.01-1.16).

The study also highlighted the impact of surgical center experience on outcomes. MAG's survival benefit was observed across all program volume categories, with adjusted hazard ratios ranging from 0.75 to 0.91, except in centers performing fewer than 5 multiarterial revascularizations annually, where MAG was associated with worse outcomes (adjusted HR 1.11, 95% CI, 1.05-1.17). Centers performing at least 10 MAG cases annually consistently demonstrated a survival benefit, emphasizing the importance of surgical expertise in achieving optimal outcomes.

While the study's large sample size and comprehensive data linkage provide robust insights, limitations include its retrospective design, potential selection bias, and lack of detailed anatomical and clinical data, such as coronary artery anatomy and patient frailty. These factors may influence the generalizability of the findings and underscore the need for careful patient selection when considering MAG. Nonetheless, the results support the broader adoption of multiarterial grafting in appropriate candidates to improve long-term survival outcomes.

Bottom Line: Multiarterial CABG is associated with superior long-term survival compared to single-arterial CABG, supporting its expanded use in most patients undergoing CABG.

This retrospective study evaluates the impact of the 2015 American Thyroid Association (ATA) guideline changes on thyroid lobectomy rates and the subsequent need for hormone supplementation. The authors observed an increase in lobectomy rates for low-risk thyroid cancer and a corresponding decrease in completion thyroidectomy rates post-guideline change. Additionally, patients with malignancies were more likely to require long-term thyroid hormone supplementation compared to those with benign conditions.

Summary: In 2015, the American Thyroid Association updated its guidelines to recommend lobectomy for small, low-risk, well-differentiated thyroid cancers, with more moderate targets for postoperative thyroid-stimulating hormone (TSH) suppression. Prior studies on the need for thyroid hormone supplementation after lobectomy focused primarily on patients with benign thyroid diseases. Recent studies examining lobectomy in the context of low-risk thyroid malignancy were mainly single-institution studies. This study sought to evaluate the impact of the 2015 guideline change on lobectomy rates and hormone supplementation using a larger, national population.

The study utilized data from the Merative MarketScan Commercial Claims and Encounters Databases and the Medicare Supplemental and Coordination of Benefits Database to identify adult patients (18+ years old) who underwent thyroidectomy for benign nodules or thyroid cancer. Indications for surgery were identified using International Classification of Diseases (ICD) diagnosis codes on the same day or within three months before surgery. 

Out of 81,926 patients who underwent thyroidectomy from 2008 to 2019, 41.2% (n=33,756) underwent thyroid lobectomy. Among those who underwent lobectomy, 81.3% did so for benign disease and 18.7% for malignancy. Additionally, 88.0% (n=29,708) of lobectomy patients were not taking thyroid supplementation prior to surgery. Patients who underwent lobectomy for malignancy were significantly more likely to require hormone supplementation than those with benign disease (59.3% vs. 39.4%, P < .001, adjusted odds ratio [aOR] 2.34, 95% CI 2.20-2.48). Moreover, patients with thyroid cancer were less likely to discontinue supplementation by 18 months compared to those with benign nodules (13.3% vs. 17.9%, P < .001, aOR 0.73, 95% CI 0.65-0.82).

The study found that the proportion of patients who underwent lobectomy for malignancy from 2016-2019, following the guideline change, was higher compared to the period before the change (34.3% vs. 30.3%, P < .001, aOR 1.19, 95% CI 1.12-1.27). The largest percentage increase in lobectomy rates for patients with thyroid cancer occurred between 2018 and 2019, consistent with typical delays in the implementation of new guidelines. In contrast, lobectomy rates for benign nodules remained consistent. Among those who underwent lobectomy, fewer patients required a completion thyroidectomy (25.6% vs. 29.8%, P < .001, aOR 0.79, 95% CI 0.70-0.88) and fewer required thyroid hormone supplementation (56.9% vs. 60.1%, P = .04, aOR 0.88, 95% CI 0.77-0.997) in the 2016-2019 post-guideline change period compared to the 2008-2015 period.

These findings align with prior studies showing increased hormone supplementation in patients with malignancy and an overall increase in lobectomy rates. However, the study has several limitations. The database used lacks detailed information, such as sociodemographic data and clinical parameters like TSH levels, which are important for assessing the postoperative need for hormone supplementation. Additionally, since the database only includes patients with employer-provided health insurance, the generalizability of the findings to the broader population is limited. Lastly, statistically, an interrupted time series analysis might have been more appropriate for comparing pre- and post-guideline implementation trends.

Bottom Line: Patients with low-risk thyroid cancer can safely undergo lobectomy according to the updated 2015 guidelines from the American Thyroid Association. The study found an increase in lobectomy rates and a decrease in completion thyroidectomy rates following the guideline changes.

This study used a voluntary, anonymous survey administered after the 2019 ABSITE to evaluate factors associated with general surgery residents’ perceptions of meaningful mentorship, programmatic variation in mentorship, and associations between mentorship and resident education and wellness. The authors found that more than one-third of general surgery residents lack meaningful mentorship, particularly racial and ethnically minoritized residents. Meaningful mentorship was associated with improvements in resident education and wellness. These findings underscore the importance of facilitating equitable mentorship to support resident education and wellness, as well as the diversification of the surgical workforce.

Summary: Despite the documented benefits of mentorship in clinical training—such as improved career satisfaction, better work-life balance, reduced burnout, and enhanced recruitment and retention of a diverse workforce—there is a lack of generalizable data on surgical trainees’ experiences with mentorship and its impact on resident education and wellness. This study aimed to examine factors associated with surgical residents’ perceptions of meaningful mentorship, describe programmatic variation in mentorship, and define the associations between mentorship and resident education and wellness.

A voluntary, anonymous survey was administered to US surgical residents following the 2019 ABSITE exam. Meaningful mentorship was assessed by residents’ perception of whether they had “a mentor in the department of surgery who genuinely cares about me and my career.” Educational experience was captured through residents’ perceptions of clinical autonomy and operative autonomy. Wellness was evaluated using questions about career satisfaction, burnout, thoughts of attrition, and suicidality. Survey results were analyzed using univariate analyses and multivariable regression models, adjusting for resident and program covariates and clustering within programs.

A total of 6,956 residents from 301 programs responded (86.5% response rate), with 6,373 residents (40.3% female, 39.8% non-White or Hispanic) answering all questions and included in the analysis. Of these, 4,256 residents (66.8%) reported having meaningful mentorship. At the program level, the rates of residents reporting meaningful mentorship varied widely (20-100%), with the median program reporting 66.7% (mean 67.4%, SD 14.9%). After adjusting for resident and program factors, non-White or Hispanic residents were significantly less likely to report meaningful mentorship than non-Hispanic White residents, with an odds ratio (OR) of 0.81 (95% CI 0.71-0.90, P < .001). Clinical postgraduate year (PGY) was associated with meaningful mentorship in a dose-response manner; PGY1 residents were significantly less likely than PGY2/3 (OR 1.88, 95% CI 1.62-2.18, P < .001) and PGY4/5 (OR 3.08, 95% CI 2.59-3.62, P < .001) to report meaningful mentorship. In cluster-adjusted multivariable models, residents with meaningful mentorship were significantly (P < .001) more likely to report clinical autonomy (OR 4.47, 95% CI 3.78-5.29), operative autonomy (OR 3.87, 95% CI 3.35-4.46), and satisfaction with career choice (OR 3.39, 95% CI 2.94-3.91), and less likely to report burnout (OR 0.52, 95% CI 0.46-0.59), thoughts of attrition (OR 0.42, 95% CI 0.36-0.50), and suicidality (OR 0.47, 95% CI 0.37-0.60).

Limitations of the study include recall bias and the influence of post-ABSITE stress, variation in residents’ definitions of mentor and autonomy, and the inability to draw causal conclusions from cross-sectional measurements. Additionally, the authors were unable to account for unmeasured trainee and hospital factors influencing education and wellness outcomes.

Bottom Line: More than one-third of clinically active US general surgery residents reported a lack of meaningful mentorship, particularly among non-White or Hispanic and more junior residents. Meaningful mentorship was associated with improvements in resident education and wellness. Efforts to facilitate equitable formation of meaningful mentorship relationships during surgical residency are imperative to support resident education and wellbeing, as well as the diversification of the surgical workforce.