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Effect of Local Versus General Anesthesia in Breast-Conserving Surgery on Cancer Recurrence and Cost. Cancer Control 2022; 29:10732748221083078. [PMID: 35459407 PMCID: PMC9036327 DOI: 10.1177/10732748221083078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The association between the type of anesthesia used and the recurrence of cancer remains controversial. This study aimed to compare the effects of local vs general anesthesia on recurrence-free survival and cost after breast-conserving surgery. Materials and Methods We reviewed the data of 2778 patients who underwent breast-conserving surgery followed by radiation at our center between 1999 and 2014. We analyzed the data of 994 patients with hormone receptor-positive and Her2-negative tumors who underwent breast-conserving surgery without axillary lymph node dissection under local or general anesthesia. Patients were grouped according to whether local or general anesthesia was used for the surgery. Results Of the 994 patients enrolled in this study, 367 received local anesthesia and 627 patients received general anesthesia. The median follow-up duration for all patients was 93 months. The Kaplan–Meier survival curves did not reveal significant differences between the recurrence-free survival of the two groups, with 5-year recurrence-free survival rates of 96.3% (95% CI, 94.3–98.3%) in the local anesthesia group and 97.3% (95% CI, 95.9–98.7%) in the general anesthesia group. The total cost of hospitalization in the local anesthesia group was significantly lower than that in the general anesthesia group (P <.001). The difference in the cost between the two groups remained significant, irrespective of the type of hospitalization, after excluding 165 patients receiving chemotherapy during their hospitalization. Conclusions Our analysis indicated no association between the type of anesthesia used during breast-conserving surgery and the long-term prognosis of breast cancer. However, breast-conserving surgery under local anesthesia may be a less expensive option than that under general anesthesia.
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Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature. Braz J Anesthesiol 2021; 73:316-339. [PMID: 34627828 DOI: 10.1016/j.bjane.2021.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 08/02/2021] [Accepted: 09/19/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting. METHODS A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used). RESULTS One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result. CONCLUSIONS Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.
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Ultrasound-guided bilateral superficial cervical plexus block enhances the quality of recovery of uremia patients with secondary hyperparathyroidism following parathyroidectomy: a randomized controlled trial. BMC Anesthesiol 2021; 21:228. [PMID: 34536993 PMCID: PMC8449502 DOI: 10.1186/s12871-021-01448-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 09/08/2021] [Indexed: 02/07/2023] Open
Abstract
Background Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy. Methods Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded. Results The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000). Conclusion Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy. Trial registration ChiCTR1900027185
. (Prospective registered). Initial registration date was 04/11/2019.
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Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review. Front Endocrinol (Lausanne) 2021; 12:717427. [PMID: 34394008 PMCID: PMC8355596 DOI: 10.3389/fendo.2021.717427] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Outpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines. METHODS This is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines. RESULTS In total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed. CONCLUSION The salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.
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Total Thyroidectomy as an Ambulatory Procedure in Community Practice. OTO Open 2020; 4:2473974X20957324. [PMID: 33062910 PMCID: PMC7534086 DOI: 10.1177/2473974x20957324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Objective Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice. Study Design Retrospective review and national database analysis. Setting A single community otolaryngology practice. Methods Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings. Results A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study. Conclusions Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.
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Vitamin D Status as a Predictor of Postoperative Hypocalcemia after Thyroidectomy. Otolaryngol Head Neck Surg 2020; 163:501-507. [PMID: 32312160 DOI: 10.1177/0194599820917907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether perioperative vitamin D levels are predictive of postoperative hypocalcemia in patients receiving thyroidectomy. STUDY DESIGN Single center retrospective study. SUBJECTS AND METHODS This study included all patients receiving total or completion thyroidectomy between January 2007 and March 2017 at a single tertiary care hospital. 25-Hydroxyvitamin D (25[OH]D) levels were measured within 42 days prior to surgery or 1 day postoperatively. Hypocalcemia was defined as an adjusted serum calcium <8.0 mg/dL (based on albumin levels) or symptomatic hypocalcemia. Univariate analysis was performed with a 2-sample t test and chi-square test, while multivariate analysis was performed with logistic regression analysis to determine whether perioperative 25(OH)D level is a predictor of postoperative hypocalcemia. RESULTS A total of 517 subjects were included in the study, 15.7% (n = 81) of whom experienced postoperative hypocalcemia with a mean ± SD serum calcium level of 7.6 ± 0.5 mg/dL as compared with 8.9 ± 0.5 mg/dL in the normocalcemic population (P < .01). The mean 25(OH)D level for patients with hypocalcemia was 24.4 ± 12.0 ng/mL as compared with 27.5 ± 12.2 ng/mL in patients with normocalcemia (P = .038). Subjects who were hypocalcemic experienced a significantly longer hospital stay (2.9 ± 2.5 vs 1.4 ± 1.1 days, P < .01). After adjusting for preoperative calcium, age, and performance of a neck dissection, subjects with a 25(OH)D level <30 ng/mL were significantly associated with postoperative hypocalcemia (odds ratio, 1.9; P = .041; 95% CI, 1.0-3.3). CONCLUSION Using a single-center retrospective study design, we demonstrated that 25(OH)D level is a significant predictor of postoperative hypocalcemia after thyroidectomy.
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Feasibility criteria for total thyroidectomy in outpatient surgery. ANNALES D'ENDOCRINOLOGIE 2019; 80:286-292. [DOI: 10.1016/j.ando.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/06/2019] [Accepted: 04/25/2019] [Indexed: 11/19/2022]
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Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations. JAMA Surg 2019; 153:160-168. [PMID: 29049457 DOI: 10.1001/jamasurg.2017.4007] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established. Objective To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations. Design, Setting, and Participants A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017. Main Outcomes and Measures The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes. Results A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001). Conclusions and Relevance Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.
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Thyroidectomy using superficial cervical block: a report of 147 cases over 8 years. Eur Surg 2019. [DOI: 10.1007/s10353-019-00607-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Same day discharge after thyroidectomy is safe and effective. Surgery 2018; 164:887-894. [PMID: 30093278 DOI: 10.1016/j.surg.2018.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/30/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. METHODS This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. RESULTS A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. CONCLUSION Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.
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Central Venous Port Catheters: Evaluation of Patients' Satisfaction with Implantation under Local Anesthesia. J Vasc Access 2018; 10:27-32. [DOI: 10.1177/112972980901000105] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose Evaluation of pain perception and patient satisfaction after implantation of a central venous port catheter system under local anesthesia. Methods A total of 100 consecutive patients (25 outpatients, 75 inpatients) who underwent successful implantation of a port catheter into the internal jugular vein from May through August 2007 were given an 8-item questionnaire. The extent of information about the implantation, the pain perception during implantation and the friendliness of the physician and nurse were evaluated. Furthermore, the patients were asked to assess their degree of anxiety and the pain they experienced during the intervention and to give an appraisal of whether local anesthesia was adequate. Each question was assessed on a 10–point scale (10 = very true to 1 = not at all true). In addition, the overall duration of the intervention (including patient preparation, implantation, patient aftercare, disinfection of the room) was documented. Results Patients felt highly satisfied with the way they were informed (mean score of 9.65) and considered the treating physician (9.89) and nurse (9.9) extremely friendly. Local anesthesia was rated as nearly completely adequate (9.56) and the degree of pain experienced was low (9.05; 10 = no pain). The average anxiety score was 8.56 (10 = not afraid at all). Overall satisfaction with the treatment was very high (9.62; outpatients: 9.72) and patients would recommend port catheter implantation at our department to others (9.77). The mean overall duration of the intervention was 76 min (range 40–120 min). Conclusion Positive patient reactions indicate that radiologic port catheter implantation under local anesthesia is a minimally invasive intervention with high patient satisfaction that can be performed on an outpatient basis and is a valid alternative to surgical implantation.
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Abstract
Use of antibiotic prophylactic (AP) in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach the use of prophylactic antibiotic in thyroid surgery. In thyroid surgery, it is a highly controversial topic primarily due to the lack of evidence in "support" of or "against" antibiotic use. In this review, the authors analyze the literature on the use of AP in thyroid surgery in order to evaluate if the available data support or contradict this use routinely.
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Clinical outcomes after local anesthesia with monitored anesthesia care during thyroidectomy and selective neck dissection: a randomized study. Eur Arch Otorhinolaryngol 2017; 274:3789-3794. [DOI: 10.1007/s00405-017-4707-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/08/2017] [Indexed: 10/19/2022]
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Abstract
BACKGROUND Performance of thyroid surgery as a same day surgery procedure has been a controversial topic. This study aimed to compare the safety and efficacy of outpatient thyroid surgery with inpatient thyroid surgery by meta-analysis of current literature. METHODS Articles were identified from the following keyword searches: outpatient thyroidectomy/thyroid surgery, same day thyroidectomy/thyroid surgery. Outcomes included perioperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, and readmissions. Data were extracted following review of appropriate studies by authors and random effects models were used. RESULTS 34 potentially relevant publications were identified and 14 studies fulfilled the predetermined inclusion criteria, totaling 10,478 patients, 4,565 of whom were discharged the same day following thyroid surgery. There was no difference in malignancy rate between the two groups (95% CI, 0.84-2.31; P=0.196). Inpatient group were 2.23 times (95% CI, 1.36-3.36; P=0.001) more likely to develop transient RLN injury and 2.32 times (95% CI, 1.06-5.06; P=0.034) more likely to have documented transient hypocalcemia compared to outpatients. Inpatient groups were 2.10 times (95% CI, 1.33-3.33; P=0.002) more likely to have documented other complications. The two groups also had similar readmission rates (95% CI, 0.71-1.41; P=1.000). CONCLUSIONS Our meta-analysis suggests that discharging selective patients the same day after a thyroid surgery is as safe, feasible, and efficacious as admitting them for observation. Admitting patients after thyroid surgery is associated with higher reported risk of complications.
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Abstract
AIM The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study. PATIENTS AND METHODS Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis. RESULTS As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge. CONCLUSION On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.
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Hemithyroidectomy using local or general anaesthesia: Results of a local regional hospital. SURGICAL PRACTICE 2017. [DOI: 10.1111/1744-1633.12224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
INTRODUCTION Post-thyroidectomy bleeding is a low frequency but potentially life threatening event that is very difficult to predict. Given the increasing drive towards thyroidectomy with same day discharge, this study was conducted with the aim of identifying patterns, timing and consequences of post-thyroidectomy bleeding to assess the feasibility of day-case thyroidectomy. METHODS All patients who underwent a thyroidectomy between 2008 and 2015 at our institution were identified. Patterns, timing and consequences in all those who developed post-thyroidectomy bleeding were studied. RESULTS Of the 805 patients included in the study, 14 required re-exploration for bleeding; 7 (50%) of these within 8 hours of surgery, 6 (43%) between 18 and 30 hours, and 1 (7%) at 49 hours. Just under half (43%) of those with post-thyroidectomy bleeding had thyrotoxicosis. CONCLUSIONS A significant number of postoperative haemorrhages occurred beyond the immediate postoperative period. Same day discharge after thyroidectomy cannot therefore be recommended as a routine practice.
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Safety of Outpatient Thyroid and Parathyroid Surgery. Otolaryngol Head Neck Surg 2016; 154:789-96. [DOI: 10.1177/0194599816636842] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/11/2016] [Indexed: 12/15/2022]
Abstract
Objective To test our hypothesis that general and thyroid surgery–specific complications, mortality, and postdischarge utilization for patients undergoing outpatient and inpatient thyroid and parathyroid surgery would not differ when outpatient status was defined as discharge within 8 hours of surgery completion. Study Design Retrospective observational cohort, 2008 to 2013. Setting Kaiser Permanente Northern California and Kaiser Permanente Southern California. Subjects and Methods We used a robust set of variables and propensity score methods to match 2362 patients undergoing hemithyroidectomy, total thyroidectomy, or parathyroidectomy surgery as outpatients to 2362 patients undergoing the same procedures as inpatients. Outcomes assessed were 30-day rates of complications, emergency department visits, all-cause hospital readmissions, and mortality. Results After matching, no statistically significant differences between inpatients and outpatients were found for complication rates or postdischarge utilization. After matching, there was no statistically significant difference between inpatients and outpatients in hematoma rates, which were 0.55% in both groups. In the matched-pair groups, 2 deaths occurred among inpatients (0.09%) and none occurred among outpatients (0.00%), a difference that was not statistically significant. Conclusion Discharge within 8 hours after completion of thyroid and parathyroid surgery is as safe as inpatient surgery.
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Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients. Surgery 2015; 159:518-23. [PMID: 26471720 DOI: 10.1016/j.surg.2015.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/30/2015] [Accepted: 08/05/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Outpatient thyroid surgery is becoming increasingly common. The aim of this study was to clarify the principles for safe outpatient thyroid surgery and review our outcomes with the use of a protocol for outpatient thyroidectomy in a large patient cohort. STUDY DESIGN A systematic analysis of a prospectively maintained database of outcomes of thyroidectomy in a tertiary endocrine surgery practice. SETTING Academic medical center. SUBJECTS AND METHODS A protocol for outpatient thyroidectomy was conceived and refined over 3 years. A prospective analysis of all thyroidectomies accomplished by a single surgeon who used this protocol from May 2006 to November 2013 was then undertaken. Patient demographics, operative and pathologic data, admission status, complications, and readmission rates were recorded. RESULTS A total of 1,311 thyroidectomy procedures were performed during the study period, of which 1,026 (78.3 %) were conducted on an outpatient basis. The readmission rate for outpatients was 0.9%, with only 1 readmission in the last 200 procedures. Inpatients (which included patients in the 23-hour "observation" category) were readmitted more often than outpatients (3.5% vs 0.9%, P < .01). Outpatient management increased steadily throughout the study period (from 59.7% to 92.3%, P < .01), despite a larger mean nodule size and a greater rate of malignancy over time. There were no changes in the complication rate across the study timeframe except for the incidence of temporary hypocalcemia, which decreased over time (P < .01). CONCLUSION Outpatient thyroid surgery is safe in appropriately selected patients using an optimized and systematic protocol.
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Thyroidectomy Under Regional Anaesthesia: An ORL Perspective. J Clin Diagn Res 2015; 9:MC01-4. [PMID: 26557548 PMCID: PMC4625267 DOI: 10.7860/jcdr/2015/16055.6617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use of regional anaesthesia as an effective alternative to general anaesthesia in thyroid surgeries is now being accepted in many parts of the world. In this day of computers and technology, there is an increased awareness among the people of the available options of anaesthesia and the adverse effects of general anaesthesia. They thus have an inclination to avoid general anaesthesia wherever feasible. This study dwells on the use of regional anaesthesia as an alternative tool that can be offered to the patients undergoing thyroidectomy. AIMS This study aims at analysing the effectiveness, safety, ease and patient acceptability of performing thyroidectomies under regional anaesthesia. SETTINGS AND DESIGN This prospective study was performed at a university - affiliated hospital. MATERIALS AND METHODS Twenty nine patients who underwent thyroidectomy for benign thyroid diseases under regional anaesthesia were included in this study: 20 patients under deep cervical plexus block and 9 patients under cervical epidural anaesthesia. STATISTICAL ANALYSIS USED Z-test and validity test. RESULTS In our study, all the 29 patients who underwent thyroidectomy under regional anaesthesia found the anaesthesia effective and were comfortable throughout the procedure. The surgeon too was at ease while performing the surgery. No complications were recorded. CONCLUSION In our present study, regional anaesthesia (Cervical epidural anaesthesia and Cervical plexus block) has been used safely and effectively in 29 thyroid surgeries. We conclude that although regional anaesthesia has been reserved for high risk thyroidectomies it may be offered as effective alternative to general anaesthesia even in routine thyroid surgeries.
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Daycare thyroidectomy surgery – Our experience. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Evaluating the Incidence, Cause, and Risk Factors for Unplanned 30-Day Readmission and Emergency Department/General Practitioner Visit After Short-Stay Thyroidectomy. World J Surg 2015; 40:329-36. [DOI: 10.1007/s00268-015-3215-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Risk factors for 30-day hospital readmission after thyroidectomy and parathyroidectomy in the United States: An analysis of National Surgical Quality Improvement Program outcomes. Surgery 2014; 156:1423-30; discussion 1430-1. [DOI: 10.1016/j.surg.2014.08.074] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 08/21/2014] [Indexed: 11/23/2022]
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Cost-effectiveness of FDG-PET/CT for cytologically indeterminate thyroid nodules: a decision analytic approach. J Clin Endocrinol Metab 2014; 99:3263-74. [PMID: 24873995 DOI: 10.1210/jc.2013-3483] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Patients with thyroid nodules of indeterminate cytology undergo diagnostic surgery according to current guidelines. In 75% of patients, the nodule is benign. In these patients, surgery was unnecessary and unbeneficial because complications may occur. Preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was found to have a very high negative predictive value (96%) and might therefore avoid futile surgery, complications, and costs. In the United States, two molecular tests of cytology material are routinely used for this purpose. OBJECTIVE Five-year cost-effectiveness for routine implementation of FDG-PET/CT was evaluated in adult patients with indeterminate fine-needle aspiration cytology and compared with surgery in all patients and both molecular tests. DESIGN A Markov decision model was developed to synthesize the evidence on cost-effectiveness about the four alternative strategies. The model was probabilistically analyzed. One-way sensitivity analyses of deterministic input variables likely to influence outcome were performed. SETTING AND SUBJECTS The model was representative for adult patients with cytologically indeterminate thyroid nodules. MAIN OUTCOME MEASURES The discounted incremental net monetary benefit (iNMB), the efficiency decision rule containing outcomes as quality-adjusted life-years and (direct) medical cost, of implementation of FDG-PET/CT is displayed. RESULTS Full implementation of FDG-PET/CT resulted in 40% surgery for benign nodules, compared with 75% in the conventional approach, without a difference in recurrence free and overall survival. The FDG-PET/CT modality is the more efficient technology, with a mean iNMB of €3684 compared with surgery in all. Also, compared with a gene expression classifier test and a molecular marker panel, the mean iNMB of FDG-PET/CT was €1030 and €3851, respectively, and consequently the more efficient alternative. CONCLUSION Full implementation of preoperative FDG-PET/CT in patients with indeterminate thyroid nodules could prevent up to 47% of current unnecessary surgery leading to lower costs and a modest increase of health-related quality of life. Compared with an approach with diagnostic surgery in all patients and both molecular tests, it is the least expensive alternative with similar effectiveness as the gene-expression classifier.
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Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients. Ann Surg Oncol 2014; 22:429-36. [PMID: 24841353 DOI: 10.1245/s10434-014-3785-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.
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Experience of 1166 thyroidectomy without use of prophylactic antibiotic. BIOMED RESEARCH INTERNATIONAL 2014; 2014:758432. [PMID: 24900986 PMCID: PMC4037569 DOI: 10.1155/2014/758432] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/23/2014] [Accepted: 03/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although the procedure requires a small surgical incision and a short duration, incision infection rate is very low in thyroidectomy; however, doctors still have misgivings about infection events. AIM We retrospectively analyzed the prevention of incision infection without perioperative use of antibacterial medications following thyroidectomy. MATERIALS AND METHODS 1166 patients of thyroidectomy were not administered perioperative antibiotics. Unilateral total lobectomy or partial thyroidectomy was performed in 68.0% patients with single-side nodular goiter or thyroid adenoma. Bilateral partial thyroidectomy was performed in 25.5% patients with nodular goiter or Graves' disease. The mean time of operation was 80.6 ± 4.87 (range: 25-390) min. RESULTS Resuturing was performed in two patients of secondary hemorrhage from residual thyroid following bilateral partial thyroidectomy. Temporally recurrent nerve paralysis was reported following right-side total lobectomy and left-side subtotal lobectomy in a nodular goiter patient. One case had suppurative infection in neck incision 5 days after bilateral partial thyroidectomy. CONCLUSIONS Thyroidectomy, which is a clean incision, involves a small incision, short duration, and minor hemorrhage. If the operation is performed under strict conditions of sterility and hemostasis, antibacterial medications may not be required to prevent incision infection, which reduces cost and discourages the excessive use of antibiotics.
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Predictors of 30-day readmission after outpatient thyroidectomy: an analysis of the 2011 NSQIP data set. Am J Otolaryngol 2014; 35:332-9. [PMID: 24602456 DOI: 10.1016/j.amjoto.2014.01.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 01/26/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE With enhancements in patient safety and improvements in anesthesia administration, outpatient thyroidectomy is now frequently undertaken as an outpatient procedure, with several peer-reviewed reports of safe implementation totaling over 4500 procedures since 2006. However, robust statistical analyses of predictors for readmission are lacking. METHODS The 2011 NSQIP data set was queried to identify all patients undergoing thyroidectomy on an outpatient basis. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify the predictors of these events. RESULTS In total 5121 patients were identified to have undergone an outpatient thyroidectomy in 2011. Overall 30-day morbidity was rare with only 47 patients (0.92%) experiencing any perioperative morbidity. One hundred eleven (2.17%) patients were readmitted within 30 days of the operation. A history of COPD was the only preoperative comorbid medical condition that significantly increased a patient's risk for readmission (OR 3.73 95% CI 1.57-8.85, p=0.003). Patients with a surgical complication were more than 7 times as likely to be readmitted (OR 2.08-25.28, p=0.002), and those with a medical complication were over 19 times as likely to be readmitted (OR 7.32-50.78, p<0.001). CONCLUSIONS Readmission after outpatient thyroidectomy is infrequent, and compares well with other outpatient procedures. The main identified risks include preoperative COPD and any of the generic postoperative complications tracked in NSQIP. As procedures continue to transition into outpatient settings and financial penalties associated with readmission become a reality, these findings will serve to optimize outpatient surgery utilization.
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Classic clamp-and-tie total thyroidectomy for large goiters in the modern era: To drain or not to drain. World J Otorhinolaryngol 2014; 4:1-5. [DOI: 10.5319/wjo.v4.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 09/18/2013] [Accepted: 12/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the role of drains in clamp-and-tie total thyroidectomy (cTT) for large goiters.
METHODS: A hundred patients were randomized into group D (drains maintained for 24 h) and ND (no drains). We recorded epidemiological characteristics, thyroid pathology, hemostatic material, intraoperative events, operative time and difficulty, blood loss, biochemical and hematological data, postoperative vocal alteration and pain, discomfort, complications, blood in drains, and hospitalization.
RESULTS: The groups had comparable preoperative characteristics, pathology, intraoperative and postoperative data. Hemostatic material was used in all patients of group ND. Forty patients in group D and 9 in ND felt discomfort (P < 0.001).
CONCLUSION: Drains in cTT for large goiters give no advantage or disadvantage to the surgeon. The only “major disadvantage” is the discomfort for the patient. Inversely, drains probably influence surgeons’ serenity, especially when cTT is performed in nonspecialized departments.
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Costs of outpatient thyroid surgery from the University HealthSystem Consortium (UHC) database. Otolaryngol Head Neck Surg 2014; 150:762-9. [PMID: 24496743 DOI: 10.1177/0194599814521583] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers. STUDY DESIGN Cross-sectional analysis of a national database. SETTING The University HealthSystem Consortium (UHC) data collected from discharge summaries. SUBJECTS AND METHODS Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy. RESULTS During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P < .0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation. CONCLUSION Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.
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Barriers to Same-Day Discharge of Patients Undergoing Total and Completion Thyroidectomy. Otolaryngol Head Neck Surg 2014; 150:770-4. [DOI: 10.1177/0194599814521568] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Describe barriers to same-day surgery for patients undergoing total and completion thyroidectomy. Study Design Case series with chart review. Setting Academic health sciences center. Subjects and Methods The subjects were patients who underwent total thyroidectomy or completion thyroidectomy and remained in hospital overnight or longer. A review was performed on patients who were operated on by a single surgeon from July 2005 through June 2013. Results Two hundred and sixty-eight cases were planned for same-day surgery. One hundred patients were not discharged on the same day (37%). Patients observed overnight or admitted to hospital had significantly lower postoperative calcium levels, 8.4 mg/dL ( P < .0001), and lower intraoperative parathyroid hormone (PTH), mean 6.0 pg/mL ( P < .0001). Those significantly more likely to require overnight observation were male patients ( P = .0117), black patients ( P = .0045), those with completion thyroidectomy ( P = .0039), and those with a complication of surgery ( P = .003). Conclusion Intraoperative PTH less than 10 pg/mL was the most frequent factor (25.7%) precluding same-day discharge, followed by admission for social/financial/transportation reasons (22.6%), large dead space from goiter (15.5%), multiple comorbidities (13.4%), multiple surgical reasons (5.2%), airway observation (5.2%), pain management (3.1%), and intractable nausea due to general anesthetic (2.1%). Hypocalcemia and postoperative bleeding still remain obstacles to outpatient thyroid surgery; however, the use of rapid PTH testing, modern hemostatic techniques, appropriate calcium prophylaxis, and experienced clinical decision making can effectively stratify which patients require overnight observation.
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Ambulatory thyroid surgery: do the risks overcome the benefits? Presse Med 2014; 43:291-6. [PMID: 24485830 DOI: 10.1016/j.lpm.2014.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/06/2014] [Indexed: 11/16/2022] Open
Abstract
With appropriate selection, ambulatory thyroid surgery is feasible. Thyroid surgery is unique amongst ambulatory procedures in that it is associated with a small but unpredictable risk of rapid onset compromising cervical haematoma that may require immediate treatment. Reports of "safety" are frequently from series which are too small to give complete assurance. Postoperative haemorrhage is the only issue that makes day case surgery questionable because other risks (hypocalcaemia, nerve injury) can be mitigated. Studies suggest 20-60% bleed will occur after 6 hours but the clinical severity of later bleeds is unclear. The reliability of more specific data from complications occurring at home is liable to under-reporting. The need for a tracheostomy is considerably higher when there is a delay in the recognition of symptoms (as it could be at home) and re-intervention; this underlies the increased morbidity with laryngeal and supraglottic oedema that may accompany a delay in the treatment of post-thyroidectomy bleeds. The estimated cost savings from ambulatory thyroid surgery may be an over-estimate given that true costs may be reduced by optimisation of ward staffing.
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Thyroid Surgery without Antibiotic Prophylaxis: Experiences with 1,030 Patients from a Teaching Hospital in China. World J Surg 2014; 38:878-81. [DOI: 10.1007/s00268-014-2453-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for outpatient thyroidectomy and to explore preoperative, intraoperative, and postoperative factors that should be considered in order to optimize the safe and efficient performance of ambulatory surgery. SUMMARY A series of criteria was developed that may represent relative contraindications to outpatient thyroidectomy, and these fell into the following broad categories: clinical, social, and procedural issues. Intraoperative factors that bear consideration are enumerated, and include choice of anesthesia, use of nerve monitoring, hemostasis, management of the parathyroid glands, wound closure, and extubation. Importantly, postoperative factors are described at length, including suggested discharge criteria and recognition of complications, especially bleeding, airway distress, and hypocalcemia. CONCLUSIONS Outpatient thyroidectomy may be undertaken safely in a carefully selected patient population provided that certain precautionary measures are taken to maximize communication and minimize the likelihood of complications.
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Patient information ahead of thyroid surgery. Guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL). Eur Ann Otorhinolaryngol Head Neck Dis 2013; 130:363-8. [PMID: 23953935 DOI: 10.1016/j.anorl.2013.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/09/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The authors present the guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) on patient information ahead of thyroid surgery. METHODS A multidisciplinary medical team was tasked with a scientific literature review on this topic. The texts retrieved were analyzed by an independent committee. A joint meeting drew up the final guidelines. The strength of the recommendations (grade A, B or C) was based on levels of evidence. RESULTS It is recommended that the results of preoperative exploration and the indications for surgery should be explained to the patient. Patients should be informed as to the type of surgery, surgical objectives, risks and consequences. It is mandatory to obtain the patient's written consent before surgery. CONCLUSION Appropriate medical information is a critical step in patient management.
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Ambulatory thyroidectomy: Recommendations from the Association Francophone de Chirurgie Endocrinienne (AFCE). Investigating current practices. J Visc Surg 2013; 150:165-71. [DOI: 10.1016/j.jviscsurg.2013.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tracheal Resection With Patient Under Local Anesthesia and Conscious Sedation. Ann Thorac Surg 2013; 95:e63-5. [DOI: 10.1016/j.athoracsur.2012.08.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 07/25/2012] [Accepted: 08/14/2012] [Indexed: 11/17/2022]
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Same-day thyroidectomy program: Eligibility and safety evaluation. Surgery 2012; 152:1133-41. [DOI: 10.1016/j.surg.2012.08.033] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 08/20/2012] [Indexed: 11/29/2022]
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Abstract
INTRODUCTION Over the last two decades increasing numbers of surgical procedures have been performed on an outpatient basis. In 2000 the National Health Service in England set the target of performing 75% or more of all elective surgical procedures as day cases and in 2001 the British Association of Day Surgery added thyroidectomy to the list of day case procedures. However, same day discharge following thyroidectomies has been adopted by only a very small number of UK centres. The aim of this review was to establish the evidence base surrounding same day discharge thyroid surgery. METHODS The British Association of Endocrine and Thyroid Surgeons commissioned the authors to perform a review of the best available evidence regarding day case thyroid surgery as a part of a consensus position to be adopted by the organisation. A MEDLINE(®)review of the English medical literature was performed and the relevant articles were collated and reviewed. RESULTS There are limited comparative data on day case thyroid surgery. It is feasible and may save individual hospitals the cost of inpatient stay. However, the risk of airway compromising and life threatening post-operative bleeding remains a major concern since it is not possible to positively identify those patients most and least at risk of bleeding after thyroidectomy. It is estimated that half of all post-thyroidectomy bleeds would occur outside of the hospital environment if patients were discharged six hours after surgery. CONCLUSIONS Same day discharge in a UK setting cannot be endorsed. Any financial benefits may be outweighed by the exposure of patients to an increased risk of an adverse outcome. Consequently, 23-hour surgery is recommended.
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Bilateral superficial cervical plexus block with or without low-dose intravenous ketamine analgesia: effective, simple, safe, and cheap alternative to conventional general anesthesia for selected neck surgeries. Local Reg Anesth 2012; 5:1-7. [PMID: 22915895 PMCID: PMC3417975 DOI: 10.2147/lra.s28360] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background General anesthesia is commonly used for surgery in the neck region. Superficial cervical plexus block is adequate to produce anesthesia in the anterior and anterolateral aspects of the neck. Our aim was to observe the effectiveness of bilateral cervical plexus block for surgery in this region of the neck. Methods A total of 136 neck surgery cases were enrolled in this prospective uncontrolled study. All patients were administered ropivacaine 0.5% as a bilateral cervical plexus block. The incision line was infiltrated with lignocaine 1% and adrenaline 1:100,000. For thyroglossal cyst and thyroglossal fistula, an additional 1.5 mL of LA solution was deposited over the hyoid bone on both sides of the midline. Any anesthetic inadequacy was corrected using ketamine 25 mg intravenously and repeated if necessary. Results Of 37 patients with thyroglossal cyst, the block was sufficient in 36 patients, and one patient required ketamine. Block was adequate in 23 of 24 patients with thyroglossal fistula, and one patient required ketamine. Among the branchial cyst and branchial fistula cases, six of 16 patients required ketamine supplementation. Of three thyroidectomy patients, one required ketamine supplementation, and one was converted to conventional general anesthesia. For lymph node excision and lymph node biopsy patients, LA block was sufficient in all 31 cases. In the last group, one of 25 patients required ketamine supplementation. Conclusion The overall success of bilateral cervical plexus block as a sole method of anesthesia in these selected neck surgeries was 91.9% and with low-dose ketamine supplementation it approached more than 99%. However, cervical plexus block was not a good method of anesthesia for thyroid surgery in this study. For the remainder of cases, bilateral cervical plexus block alone or in conjunction with ketamine appeared to be a cheap, safe, and effective alternative to conventional general anesthesia.
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Characteristics of Inpatient Thyroid Surgery at US Academic and Affiliated Medical Centers. Otolaryngol Head Neck Surg 2011; 146:210-9. [DOI: 10.1177/0194599811428030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. Describe data from patients undergoing thyroid surgeries for benign and malignant disease at US academic medical centers. Study Design. Retrospective, database search. Setting. The University Health System (UHC) Consortium (Oak Brook, Illinois) data compiled from discharge summaries. Subjects and Methods. Discharge data were collected from the first quarter of 2002 through the fourth quarter of 2009. Searching strategy was based on diagnosis of thyroid disease and patients undergoing thyroid surgery across all UHC facilities. Demographic information was collected as well as length of stay (LOS) and costs. Complications were evaluated in this analysis. Results. During the study period, 68,014 thyroidectomies were performed, with 27,200 for thyroid cancer. During the same period 6365 neck dissections were performed, with 1539 as stand-alone procedures. Total thyroidectomy was the procedure of choice for malignant disease. More total thyroidectomies and fewer hemithyroidectomies were being performed for benign thyroid disease in the inpatient setting. Almost all postoperative complications were more frequent after surgery for cancer except myocardial infarction and aspiration pneumonia. On average, LOS was longer for benign disease, but costs were higher for malignant disease. Conclusion. This is the largest series reporting inpatient LOS and mortality for thyroid surgery. The limitation of this study is that it reports patients whose stays were more than 23 hours, leaving out a significant number of thyroid surgeries that are performed as outpatients. Although the results contribute greatly to characterizing inpatient surgery, the results may not reflect current US trends for thyroid surgery.
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Thyroidectomy and parathyroidectomy in patients with high body mass index are safe overall: Analysis of 26,864 patients. Surgery 2011; 150:950-8. [DOI: 10.1016/j.surg.2011.02.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Randomized clinical trial on Harmonic Focus shears versus clamp-and-tie technique for total thyroidectomy. Am J Surg 2011; 202:168-74. [PMID: 21810497 DOI: 10.1016/j.amjsurg.2010.07.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Revised: 07/26/2010] [Accepted: 07/26/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Harmonic Focus is the last ultrasonic device designed for thyroid surgery. The aim is to assess its efficacy and safety compared with traditional dissection in a prospective randomized trial of total thyroidectomy procedures. METHODS Total thyroidectomy was performed in 34 patients using the Harmonic Focus, and in 34 patients using the clamp-and-tie technique. RESULTS In the Harmonic Focus group, relative reductions of 29% and 46% were observed in surgical time and blood loss, respectively. The number of intraoperative instrument exchanges also decreased by 70%, and use of specific materials required to achieve hemostasis decreased significantly. Safety was found to be similar in both patient groups. CONCLUSIONS Our study showed beneficial effects of Harmonic Focus use in thyroid surgery. Further studies therefore are needed to evaluate cost in the light of savings made in surgical time, materials needed for hemostasis, and human resources.
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Medical and surgical risks in thyroid surgery: lessons from the NSQIP. Ann Surg Oncol 2011; 18:3551-8. [PMID: 21769463 DOI: 10.1245/s10434-011-1938-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Indexed: 01/18/2023]
Abstract
BACKGROUND To assess whether perioperative surgical outcomes associated with thyroid operations were different in those with benign or malignant conditions, we queried the NSQIP, a multi-institutional, risk-adjusted, prospective U.S. database. METHODS A total of 10,838 patients who underwent initial thyroid surgery as their principal operation during 2005-2007 were analyzed. Analysis focused on demographics, preoperative risk factors, operative details, postoperative complications, return to the operating room, and length of surgical stay. RESULTS Thirty-three percent of patients had a postoperative diagnosis of malignancy. Mean operating time was 121.8 min (119.3 min benign, 123.0 min malignant, P = .004) and average length of stay 1.16 days (1.12 days benign, vs. 1.21 days malignant, P = .007). Overall morbidity (return to the operating room plus medical complications) was 3.8% for the entire cohort, significantly higher in patients with malignant disease (4.9 vs. 3.3%, respectively, P < .001). On multivariate analysis, American Society of Anesthesiologists class, congestive heart failure (odds ratio [OR] 6.83, 95% confidence interval [CI] 1.81-25.80), dyspnea, and return to the operating room (OR 5.41, 95% CI 3.1-9.45) were significant risk factors for complications, while malignant disease (OR 2.25, 95% CI 1.75-2.9), outpatient status (OR 3.16, 95% CI 2.4-4.17), and other complications (OR 6.46, 95% CI 3.61-11.54) were risk factors for returning to the operating room. CONCLUSIONS Patients undergoing thyroid surgery for malignancy have a longer length of stay (1.21 days), longer operation times, and return to the operating room at higher rates compared to those with benign disease. Malignancy itself is only an independent risk factor for return to the operating room and not other complications; surgeons may consider keeping those patients overnight for observation.
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Same-Day Thyroidectomy: A Review of Practice Patterns and Outcomes for 1,168 Procedures in New York State. Ann Surg Oncol 2010; 18:1035-40. [DOI: 10.1245/s10434-010-1398-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Indexed: 11/18/2022]
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Postoperative Recovery Advantages in Patients Undergoing Thyroid and Parathyroid Surgery Under Regional Anesthesia. Semin Cardiothorac Vasc Anesth 2010; 14:49-50. [DOI: 10.1177/1089253210363010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thyroid or parathyroid surgery may be performed using general anesthesia or regional anesthesia. Ninety-five (95) patients underwent thyroid or parathyroid surgery using general anesthesia (n=64) or bilateral superficial cervical plexus block with sedation (n=31) and completed a postoperative questionnaire regarding the perioperative experience. Patients undergoing parathyroid surgery under regional anesthesia (n=24) were more likely to experience better energy levels (p=0.012) and earlier return to work (p=0.045) postoperatively. Overall, 96% of patients undergoing either type of surgery with either type of anesthetic reported satisfaction with the anesthetic.
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Outpatient Thyroidectomy Is Safe and Reasonable: Experience with More than 1,000 Planned Outpatient Procedures. J Am Coll Surg 2010; 210:575-82, 582-4. [DOI: 10.1016/j.jamcollsurg.2009.12.037] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 12/30/2009] [Indexed: 11/19/2022]
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Neuromonitoring of the external branch of the superior laryngeal nerve during minimally invasive thyroid surgery under local anesthesia: a prospective study of 10 patients. Laryngoscope 2009; 119:597-601. [PMID: 19160384 DOI: 10.1002/lary.20071] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Avoiding alterations of the voice is a challenge in thyroid surgery. Identification and preservation of the external branch of the superior laryngeal nerve (EBSLN) is paramount for normal vocal function preservation after thyroidectomy. Conventional nerve monitoring requires a general anesthesia and placement of a special endotracheal tube equipped with electrodes to evoke the laryngeal nerves. This study aims to assess feasibility and efficacy of a novel technique of neuromonitoring of the EBSLN under local anesthesia during minimally invasive thyroidectomy. STUDY DESIGN; PROSPECTIVE STUDY This study is a prospective trial to evaluate the efficacy of nerve monitoring of the EBSLN during minimally invasive thyroidectomy under local anesthesia. Patient self-assessment of changes in perceived voice severity prior to and 3 weeks after surgery was assessed with the Voice Handicap Index-10 (VHI-10). RESULTS Thyroidectomy was successfully completed under local anesthesia in all cases. The recurrent laryngeal nerve(s) was identified and preserved in each patient as demonstrated by normal perioperative transnasal flexible laryngoscopy. A total of 15 EBSLNs were at risk, but only 8 EBSLNs (53%) were definitively identified. Neuromonitoring demonstrated preservation of the EBSLN in 100% of cases. The analysis of the results of the VHI-10 questionnaire before and 3 weeks after surgery indicated no significant change in patients' perception of voice severity. CONCLUSION Monitoring of the EBSLN during thyroidectomy under local anesthesia is a feasible alternative to conventional nerve monitoring under general anesthesia. This technique may be useful for the preservation of voice quality during a minimally invasive thyroidectomy under local anesthesia.
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