Safety of thyroidectomy in hospitalized patients: A descriptive analysis of the NSQIP thyroidectomy-targeted data

BACKGROUND

Some patients undergo thyroidectomy while hospitalized for a related or independent indication. Outcomes have not been described in this group.

METHODS

The 2016-2018 thyroidectomy-targeted NSQIP datasets were queried for patients admitted for ≥1 day preoperatively. 1:1 propensity score matching was employed to compare the outcomes of admitted patients to outpatients, including surgical and thyroidectomy-specific outcomes. Multivariable logistic regression determined factors associated with poor outcomes.

RESULTS

Of 18,078 patients, 312 were admitted at least 1 day prior to surgery. Inpatients had higher ASA classifications and rates of several comorbidities compared to the general population. After propensity score matching, inpatients had higher rates of overall complications, unplanned reoperation, and bleeding. They also experienced higher rates of thyroidectomy-specific complications such as hypocalcemia and neck hematoma. By multivariable regression, admission prior to surgery was associated with development of any complications.

CONCLUSION

Thyroidectomy in hospitalized patients carries an increased risk of complications. Patients requiring thyroidectomy while already hospitalized should be counseled accordingly.

Same-Day Discharge for Pediatric Hemithyroidectomy Patients: Evaluating Safety and Barriers to Discharge

OBJECTIVE

Hemithyroidectomy is often performed in the pediatric population for indeterminate or benign thyroid nodules. Prior studies confirmed the safety of same-day discharge for adults undergoing hemithyroidectomy or total thyroidectomy, but this has not been studied thoroughly in the pediatric population. Our goal was to determine differences in pediatric patients undergoing hemithyroidectomy who were admitted versus discharged for complications or factors to support same-day discharge.

STUDY DESIGN

Retrospective cohort.

SETTING

Pediatric tertiary care hospital.

METHODS

This was a retrospective study of pediatric patients (0-18 years of age) undergoing hemithyroidectomy at a pediatric tertiary care hospital from 2003 to 2022. Perioperative variables and outcomes were gathered via manual chart review.

RESULTS

One hundred five pediatric patients who underwent hemithyroidectomy were identified. Ninety (86%) patients were admitted postoperatively, and 15 (14%) were discharged the same day. There were no differences in patient demographics, including age (P = 0.29) distance from the hospital (P = 0.08) or benign versus malignant pathology (P = 0.93). Surgical time in same-day discharges was significantly shorter (P = 0.0001; 138.6 minutes, SD = 66.0) versus admitted patients (204.2 minutes, SD = 48.6) Hemostatic agents were used more in same-day discharges at 53.3% versus 4.5% (P = 0.0001). Perioperative complications occurred in 2 (2.2%) admitted patients compared to none in the same-day discharge (P = 1.0). There were no readmissions within 30 days for same-day discharges.

CONCLUSION

In pediatric patients undergoing uncomplicated hemithyroidectomy, same-day discharge appears appropriate for those with shorter surgical times and intraoperative use of hemostatic agents with no readmissions or complications in those discharged the same day.

Management of Small Papillary Thyroid Cancers

Thyroid cancer is the most common endocrine malignancy. With increasing imaging utilization, there has been an increase in the recognition of small, indolent cancers that would otherwise go undiagnosed. Historically, the surgical recommendation for all patients with thyroid cancer was a total thyroidectomy. However, over the last 20 years, there have been numerous studies evaluating the de-escalation of interventions for low-risk thyroid cancers, transitioning from total thyroidectomy to thyroid lobectomy or active surveillance when indicated. Here, we review the current literature and recommendations with each of these treatment options.

Assessing the Ambulatory Surgery Center Volume-Outcome Association

Importance

In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US.

Objective

To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity.

Design, Setting, and Participants

This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019.

Main Outcomes and Measures

Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures).

Results

Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity.

Conclusions and Relevance

In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Emergency department use after outpatient thyroidectomy across three states

BACKGROUND

Although outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as "treat-and-release" encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors.

METHODS

Using the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission.

RESULTS

Of the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia-related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3-1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1-1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3-3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1-2.2). We observed no associations between these factors and the odds of readmission.

CONCLUSION

Emergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.

Unilateral Thyroid Lobectomy as Day Care Procedure: A Cross Sectional Study with Literature Review on the Safety and Cost Effectiveness

Introduction  Thyroid nodules are common globally in almost one fifth of the adult population. The gold standard treatment for thyroid nodule is thyroid lobectomy or total thyroidectomy depending upon the diagnosis. Thyroidectomy has a few known complications but, as per the ATA consensus statement, it is a safe surgery to be done as a day care procedure. Objective  To access the feasibility and safety of thyroid lobectomy as a day care surgery and its effect on decreasing overall financial burdens. Methods  This retrospective chart review was done from 2006 to 2022. A total of 736 patients underwent thyroid lobectomy among which only 56 were done as day care surgery. Data analysis was done using the IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). Results  A total of 40% of the population was male. The mean age of the study population was 42 years. Bethesda II was the most encountered diagnosis, with a rate of 69%. The majority of patients were discharged after 6 hours of postoperative observation. The only complication encountered was seroma, which was seen in two patients. Conclusion  Thyroid lobectomy appears to be a safe procedure with a drastic difference in overall cost as a day care procedure. We recommend switching the practice of inpatient thyroid lobectomy to a day care procedure in carefully selected candidates. The major hurdle in day care lobectomy can be approval from insurance.

The safety, benefits and future development of overnight and outpatient thyroidectomy

With the development of medical care, the safety of thyroidectomy is improving year by year. Due to economic benefits and other advantages of the overnight and outpatient thyroidectomy, more and more patients and medical institutions have favored overnight and outpatient thyroidectomy, and its proportion in thyroidectomy has increased year by year. However, overnight and outpatient thyroidectomy still faces many challenges and remains to be improved. In this review, we focused on the recent progress and the relevant clinical features of overnight and outpatient thyroidectomy, including its safety, economic benefits, etc., which may bring valuable clues and information for further improvements of patient benefits and promotions of overnight or outpatient thyroidectomy in the future.

The ambulatory transoral endoscopic thyroidectomy vestibular approach is safe and economical for patients with thyroid nodules

BACKGROUND

Ambulatory thyroid surgery has been increasingly performed in recent years. However, the feasibility of the ambulatory transoral endoscopic thyroidectomy vestibular approach (TOETVA) has not been evaluated. We aimed to evaluate the safety, economy, and mental health outcomes of ambulatory TOETVA.

METHODS

We retrospectively reviewed the data of patients who underwent TOETVA between March 2019 and August 2022. The procedure was performed by a skilled surgical team from the Department of Thyroid Surgery of the affiliated Yantai Yuhuangding Hospital of Qingdao University. Patients were enrolled in the ambulatory (n=166) and conventional (n=290) groups, based on their chosen procedure. We analyzed patients' clinical characteristics, surgical outcomes, Hamilton Anxiety Rating Scale (HAM-A) scores, and hospitalization costs.

RESULTS

Of 456 patients, 166 underwent ambulatory TOETVA and 290 underwent conventional TOETVA. No significant differences were found in clinical and surgical characteristics between the groups, including sex (P=0.363), age (P=0.077), body mass index (P=0.351), presence of internal diseases (P=0.613), presence of Hashimoto's thyroiditis (P=0.429), pathology (P=0.362), maximum tumor diameter (P=0.520), scope of surgery (P=0.850), or operative time (P=0.351). There were no significant differences in maximum tumor diameter (P=0.349), extrathyroidal tissue invasion (P=0.516), number of retrieved central lymph nodes (P=0.069), or metastatic central lymph nodes (P=0.897) between the groups. No significant differences were found in complications, including transient hypoparathyroidism (P=0.438), transient vocal cord palsy (P=0.876), transient mental nerve injury (P=0.749), permanent mental nerve injury (P=0.926), and other complications (P=1.000). Ambulatory patients had shorter hospital stays (P<0.001) and reduced hospitalization costs (P<0.001). There was no significant difference in HAM-A scores between the groups (P=0.056).

CONCLUSIONS

Ambulatory TOETVA is a safe, feasible, and cost-effective procedure for selected patients. This procedure resulted in shorter hospital stays, decreased medical costs, and did not increase patient anxiety. To ensure patient safety, surgical teams must inform patients of the indications, when to seek help, and how to receive the fastest medical attention.

Risk of hematoma after hemithyroidectomy in an outpatient setting: a systematic review and meta-analysis

Purpose

After thyroid surgery, the overriding concern is the risk of post-thyroid bleeding (PTB). This systematic review and meta-analysis aimed to assess the safety of hemithyroidectomy in an outpatient setting compared to an inpatient setting. The objectives were to (1) find the proportion of PTB in patients scheduled for outpatient hemithyroidectomy, (2) examine if outpatient hemithyroidectomy is clinically safe compared to an inpatient setting and (3) evaluate which selection criteria are most relevant for hemithyroidectomy in an outpatient setting.

Methods

A systematic review was conducted using the following databases: MEDLINE (Ovid), EMBASE (Ovid) and the Cochrane Library from inception until September 2021. We included studies reporting on PTB of patients after hemithyroidectomy in an outpatient setting. The risk of bias was assessed using the Newcastle-Ottawa tool. The results were synthesised using Bayesian meta-analysis. Certainty in evidence was assessed using the GRADE approach.

Results

This review included 11 cohort studies and 9 descriptive studies reporting solely on outpatients resulting in a total of 46,866 patients. PTB was experienced by 58 of the 9025 outpatients (0.6%) and 415 of the 37,841 inpatients (1.1%). There was no difference between the PTB rate of outpatients and inpatients (RR 0.715 CrI [0.396–1.243]). The certainty of the evidence was very low due to the high risk of bias.

Conclusion

The risk of PTB in an outpatient setting is very low, and outpatient hemithyroidectomy should be considered clinically safe. The most relevant selection criteria to consider in outpatient hemithyroidectomy are (1) relevant comorbidities and (2) psycho/-social factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-022-07312-y.

Introducing day case thyroid lobectomy at a tertiary head and neck centre

BACKGROUND

Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre.

METHODS

We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery's 5^th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service.

RESULTS

In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre.

CONCLUSIONS

Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: A National Survey of Low- and High-Volume Surgeons

BACKGROUND

The 2015 American Thyroid Association guidelines endorsed lobectomy for patients with low-risk papillary thyroid cancer (PTC) measuring 1-4 cm. Attitudes about the use of lobectomy for these patients are lacking, particularly from low-volume surgeons who perform the majority of thyroidectomies in the US.

METHODS

A survey was mailed to 1000 surgeons stratified by specialty (500 general surgeons and 500 otolaryngologists) registered with the American Medical Association, to evaluate beliefs and practices about the extent of surgery for low-risk PTC. Comparisons examined differences by surgeon volume.

RESULTS

Of 320 respondents who have performed thyroidectomy since 2015 (150 general surgeons, 170 otolaryngologists), 206 (64.4%) were low volume (< 26 thyroidectomies/year). The proportion of surgeons recommending lobectomy for low-risk PTC measuring 1.1 to < 4 cm ranged from 43.1 to 2.6%. High-volume surgeons recommended lobectomy more frequently for PTC measuring 1.1-3 cm, although this was not statistically significant. Thirty-three percent of respondents believed lobectomy is underused for low-risk PTC, while 10.0% believed it is overused. Additionally, 19.6% of respondents believed recurrence is more likely after lobectomy than total thyroidectomy, and 3.3% believed mortality is higher. Few believed quality of life is better after lobectomy (12.3%). Low-volume surgeons were less likely to be aware guidelines support lobectomy for low-risk PTC 1-4 cm (p < 0.001) and less likely to use clinical practice guidelines (p = 0.004).

CONCLUSIONS

Most surgeons do not support lobectomy for patients with low-risk PTC > 1 cm. Awareness of guidelines and concerns about increased risk of recurrence after lobectomy may drive surgeons' preference for total thyroidectomy.

Thyroid cancer, recent advances in diagnosis and therapy

Over the past several decades, the approach to the diagnosis and management of patients with follicular cell-derived thyroid cancer has evolved based on improved classification of patients better matching clinical outcomes, as well as advances in imaging, laboratory, molecular technologies and knowledge. While thyroid surgery, radioactive iodine therapy and TSH suppression remain the mainstays of treatment, this expansion of knowledge has enabled de-escalation of therapy for individuals diagnosed with low-risk well-differentiated thyroid cancer; better definition of treatment choices for patients with more aggressive disease; and improved ability to optimize treatments for patients with persistent and/or progressive disease. Most recently, the advancement of knowledge regarding the molecular aspects of thyroid cancer has improved thyroid cancer diagnosis and has enabled individualized therapeutic options for selected patients with the most aggressive forms of the disease. Guidelines from multiple societies across the world reflect these changes, which focus on taking a more individualized approach to clinical management. In this review, we discuss the current more personalized approach to patients with follicular cell-derived thyroid cancer and point toward areas of future research still needed in the field.

Infiltration of nanocarbon suspension into the tracheal cavity during surgical treatment of papillary thyroid carcinoma: a case report

Cervical lymph node metastasis in patients with differentiated thyroid cancer affects postoperative recurrence and survival. Hypoparathyroidism is caused by parathyroid gland injury during thyroidectomy. Carbon nanoparticles can trace stained lymph nodes, aiding in thorough dissection of lymph nodes in the operation area. To reduce postoperative occurrence of hypoparathyroidism, the parathyroid glands and their functions (identified by negative imaging induced by carbon nanoparticles) are retained in situ. However, the safety and adverse effects of nanocarbon suspension in thyroid surgery have rarely been evaluated. In this report, we describe a patient with thyroid cancer who had carbon secretions in the trachea caused by nanocarbon suspension when tracheal intubation was performed under general anesthesia, and the inflatable balloon surface of the tracheal tube was covered with these secretions. The patient recovered without fever, cough, phlegm production, chest pain, hoarseness, or hypocalcemia-induced convulsions. No consensus has yet been reached on the most appropriate injection site, depth, dose, or waiting time for nanocarbons in thyroid cancer surgery. We believe that nanocarbon suspension is safe for use in thyroid cancer surgery, but the most appropriate injection depth should be based on the thickness of the thyroid gland tissue to avoid deep injection into the trachea.

Postoperative Disposition Following Pediatric Sistrunk Procedures: A National Database Query

OBJECTIVE/HYPOTHESIS

Variability exists in the postoperative disposition of children following Sistrunk procedures. Management options include discharge home versus overnight observation, with the latter allowing monitoring for immediate postoperative complications, presumably reducing the need for subsequent readmission. This study investigates the association between overnight observation and ambulatory management of children undergoing Sistrunk procedures and relevant postoperative complication and revisit rates to clarify best practice for these patients.

METHODS

This was a retrospective database review using the Pediatric Health Information System database from 2007 to 2016.

RESULTS

The cited dataset identified 6,434 qualifying patients, categorized into ambulatory versus overnight observation cohorts. The overall 30-day revisit rate was 4.9%; the revisit rate with overnight observation (6.1%) was higher than for ambulatory patients (3.8%, adjusted odds ratio (OR) 1.60; 95% confidence interval (CI): 1.21, 2.12). Revisit rates were significantly higher in patients 2 years of age or younger compared to older patients (6.7% vs. 4.3%). The rates of return to the operating room for the observation versus ambulatory groups were 1.8% and 0.5%, respectively. Cervical fluid collection and neck swelling were among the most common revisit indications in both groups, with a mean time to presentation of 9 days.

CONCLUSIONS

This study demonstrates that ambulatory management following a Sistrunk procedure is not associated with increased rates of common postoperative complications, readmission, or need for secondary surgical intervention. A Sistrunk procedure may be safely performed on an ambulatory basis in select cases.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2352-E2355, 2021.

Analyzing the ATA statement on outpatient thyroidectomy using the NSQIP database

INTRODUCTION

The aim of this study is to examine the outcomes of outpatient thyroidectomy per the American Thyroid Association (ATA) statement on this procedure using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database.

METHODS

A retrospective study using NSQIP database (2016 2017) comparing outpatient (OP) and inpatient (IP) thyroidectomies based on the ATA statement.

RESULTS

There were 382 inpatient and 628 outpatient thyroidectomies. A vessel sealing device and intraoperative nerve monitoring were more commonly used in OP group. Drain use was less common in OP group. There was no difference in the rate of recurrent laryngeal nerve injury, neck hematoma, or postoperative hypocalcemia within 30 days after surgery. IP group had a higher rate of readmissions (3.4% vs 1.8%, p = 0.004). Logistic regression showed OP surgery was associated with a lower risk of readmission OR 0.38 (CI 0.15-0.97; p = 0.04).

CONCLUSION

The ATA criteria can be used to identify good candidates for outpatient thyroidectomy.

Perioperative Analgesia for Thyroid and Parathyroid Surgery: A Review of Current Practices

This article discusses the algorithms and published practice patterns on perioperative analgesia for thyroid and parathyroid surgery. This includes medications and techniques used for general anesthesia, local anesthesia including nerve block methods, and oral medication used for postoperative pain control. The authors also discuss multimodality pain control and the increased trend to reduce opioid analgesics without inadequate pain control or patient satisfaction.

Day-case thyroid lobectomy parameters at a tertiary referral head and neck centre: a sensitivity and cost analysis

PURPOSE

Day-case thyroid surgery has been endorsed by the American Thyroid Association and the British Association of Day Surgery. Despite the many benefits of day surgery, day-case thyroid surgery is not widely practiced. We describe the use of sensitivity analysis modelling and cost analysis in determining and refining the patient cohort that safely meet the threshold for a new day-case thyroid lobectomy service at a tertiary referral head and neck centre.

METHODS

All cases of first-time thyroid lobectomy were identified between 2015 and Q2 2019. Patients suitable for day-case thyroid lobectomy were identified retrospectively, according to the following criteria: Age < 65 years, ASA grade < 3, BMI < 30 kg/m² and distance from tertiary unit < / = 30 min. Sensitivity analysis was undertaken, manipulating each parameter in turn to assess the effect on eligibility and associated cost-savings.

RESULTS

259 Thyroid lobectomy procedures were performed, 173 of these met inclusion criteria. Sensitivity analysis revealed that after increasing all day-case parameters by four increments, eligibility increased from 47 (27%) to 112 patients (64.7%), with only one outpatient to inpatient conversion. Multivariate logistical regression analysis found that age was the only variable to increase the risk of adverse outcomes (OR = 1.10, p < 0.05). Using data from the NHS reference costs, if 60% of all thyroid lobectomies nationally were undertaken as day-case, this would have amounted to savings of £26.3 m over five years.

CONCLUSION

Through sensitivity analysis, we determined that we could safely offer day-case thyroid lobectomy to 64.7% of our patient cohort.

Performance of Air Seal of Flexible Reinforced Laryngeal Mask Airway in Thyroid Surgery Compared With Endotracheal Tube: A Randomized Controlled Trial

BACKGROUND

Flexible reinforced laryngeal mask airway (FLMA®) has gained popularity in thyroid surgery, but air leak and displacement are still concerns.

METHODS

In this randomized, single-blinded, noninferiority, controlled trial, we randomized patients scheduled for elective radical thyroidectomy to an endotracheal tube (ETT) group or a FLMA group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (PetCO2). Data for primary outcomes were collected after insertion of ETT/FLMA, at incision, and at 10-minute intervals during surgery. Ten milliliters, 5 cm H2O, and 10 mm Hg were used as the noninferiority deltas for ventilation leak volume, peak airway pressure, and PetCO2, respectively. We assessed noninferiority of FLMA to ETT on the primary outcomes over time using the results of a linear mixed-effects model. The position of FLMA mask was evaluated before and after surgery, and the airway complications were recorded.

RESULTS

A total of 132 patients were included: 65 in ETT group and 67 in FLMA group. Differences (FLMA group minus ETT group) of ventilation leak volume, peak airway pressure, and PetCO2 from the mixed-effects models were 2.09 mL (98.3% confidence interval [CI], -6.46 to 10.64), -0.60 cm H2O (98.3% CI, -2.15 to 0.96), and 1.02 mm Hg (98.3% CI, 0.04-1.99), respectively. Score of fiber-optic position of FLMA was significantly higher after surgery than before. There was no severe shift, loss of the mask seal, regurgitation, or aspiration in the FLMA group. One patient in the FLMA group experienced brief and easily controlled laryngospasm.

CONCLUSIONS

In thyroid surgery, FLMA is noninferior to ETT in the peak airway pressure and PetCO2 although mild to moderate mask shift could occur during surgical manipulation. There is no evidence for a higher complication rate when FLMA is used.

Extent of Surgery for Low-Risk Differentiated Thyroid Cancer

Although the incidence of thyroid cancer is increasing, survival remains unchanged. Due to concern for overtreatment, surgical management of thyroid cancer has evolved. Papillary thyroid microcarcinoma measuring 1 cm or smaller are considered very low risk and can be managed with either thyroid lobectomy or active surveillance. Total thyroidectomy is no longer recommended for these cancers unless there is evidence of metastasis, local invasion, or aggressive disease. Recommendations for low-risk differentiated thyroid cancer measuring 1 cm to 4 cm remain controversial. This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer.

The evidence-based preoperative assessment for the otolaryngologist

There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.

American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence-based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules

BACKGROUND

Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality.

METHODS

Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.

RESULTS

A consensus-based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty-one panelists achieved consensus on 16 statements about workflow-embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care.

CONCLUSION

A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.

Thermal ablation of thyroid nodules: are radiofrequency ablation, microwave ablation and high intensity focused ultrasound equally safe and effective methods?

OBJECTIVES

This study compares volume reduction of benign thyroid nodules three months after Radiofrequency Ablation (RFA), Microwave Ablation (MWA) or High Intensity Focused Ultrasound (HIFU) to evaluate which of these methods is the most effective and safe alternative to thyroidectomy or radioiodine therapy.

MATERIAL AND METHODS

Ninety-four patients (39 male, 55 female) with a total of 118 benign, symptomatic thyroid nodules were divided into three subgroups. HIFU was applied to 14 patients with small nodules. The other 80 patients were divided up into two groups of 40 patients each for RFA and MWA in the assumption that both methods are comparable effective. The pre-ablative and post-ablative volume was measured by ultrasound.

RESULTS

RFA showed a significant volume reduction of nodules of 50 % (p<0.05), MWA of 44 % (p<0.05) and HIFU of 48 % (p<0.05) three months after ablation. None of the examined ablation techniques caused serious or permanent complications.

CONCLUSION

RFA, MWA and HIFU showed comparable results considering volume reduction. All methods are safe and effective treatments of benign thyroid nodules.

KEY POINTS

• Thermal Ablation can be used to treat benign thyroid nodules • Thermal Ablation can be an alternative to thyroidectomy or radioiodine therapy • Radiofrequency Ablation, Microwave Ablation, High Intensity Focused Ultrasound are safe and effective.

Is Outpatient Thyroid Surgery for Everyone?

Thyroidectomy is a common surgical procedure. Traditionally, surgeons have performed thyroidectomy on an inpatient basis. However, consistent with current trends in surgery, some practices are transitioning thyroidectomy to an outpatient setting. Although concerns for hypocalcemia and postoperative bleeding exist regardless of surgeon experience, multiple studies demonstrate that outpatient thyroidectomy is safe in the hands of high-volume surgeons. Indeed, experienced thyroid surgeons who perform thyroidectomy in an outpatient setting experience excellent patient outcomes and reduced costs. However, outpatient thyroidectomy may not be suitable for all surgeons, hospitals, or patients. When evaluating whether to implement an outpatient thyroid program, a practice should consider a number of important factors including the team performing the procedure, the hospital, and the patient. With the appropriate staff education and experience, hospital setting, and patient selection, practices in a multitude of settings can successfully develop a safe, cost-effective outpatient thyroid program.

Outpatient Total Thyroidectomy is Safe for Moderate-Volume Surgeons

Traditionally, total thyroidectomy (TT) was an inpatient procedure, but recent trends indicate that patients are often discharged on the day of surgery. This has been proven safe for high-volume surgeons but has not been studied for low (<10 TT per year) and moderate volume surgeons (<24 TT per year). Retrospective review was performed for 414 total thyroidectomies between 2005 and 2013. Emergency department visits and readmissions within 30 days of surgery were captured, but were considered the same for the purpose of this analysis. Patients were identified as outpatient if the day of discharge matched the day of surgery. The groups were compared based on demographic variables, comorbidities, postop calcium supplementation, and serum calcium. We found that moderate-volume surgeons were more likely to perform outpatient TT than low-volume surgeons (31.6% vs 6.0%, P < 0.001), but there was no correlation between length of stay and readmission (P = 0.688). Readmitted patients had lower postop serum calcium (8.3 mg/dL) than patients who were not readmitted (8.8 mg/dL, P = 0.006). Our data show that moderate-volume surgeons performing outpatient TT have an acceptable safety profile with respect to emergency department visits and hospital readmissions, and that same day discharge had no bearing on readmission.

Use of Quantile Regression to Determine the Impact on Total Health Care Costs of Surgical Site Infections Following Common Ambulatory Procedures

OBJECTIVE

To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution.

BACKGROUND

Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs.

METHODS

We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution.

RESULTS

The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile).

CONCLUSIONS

SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.

Ambulatory thyroidectomy: an anesthesiologist's perspective

Thyroidectomy has been performed on an inpatient basis because of concerns regarding postoperative complications. These include cervical hematoma, bilateral recurrent laryngeal nerve injury and symptomatic hypocalcemia. We have reviewed the current available evidence and aimed to collate published data to generate incidence of the important complications. We performed a literature search of Medline, EMBASE and the Cochrane database of randomized trials. One hundred sixty papers were included. Twenty-one papers fulfilled inclusion criteria. Thirty thousand four hundred fifty-three day-case thyroid procedures were included. Ten papers were prospective and 11 retrospective. The incidences of complications were permanent vocal cord paralysis 7/30259 (0.02%), temporary hypocalcemia 129/4444 (2.9%), permanent hypocalcemia 405/29203 (1.39%), cervical hematoma 145/30288 (0.48%) and readmission rate 105/29609 (0.35%). Analysis of cervical hematoma data demonstrated that in only 3/14 cases the hematoma presented as an inpatient, and in the remaining 11/14, it occurred late, with a range of 2–9 days. There is a paucity of data relating to anesthetic techniques associated with ambulatory thyroidectomy. Cost comparison between outpatient and inpatient thyroidectomy was reported in three papers. Cost difference ranged from $676 to $2474 with a mean saving of $1301 with ambulatory thyroidectomy. There is a body of evidence that suggests that ambulatory thyroidectomy in the hands of experienced operating teams within an appropriate setting can be performed with acceptable risk profile. In most circumstances, this will be limited to hemithyroidectomies to reduce or avoid the potential for additional morbidity. We have found little evidence to support the use of one anesthetic technique over another. The rates of hospital admission and readmission related to anesthetic factors appear to be low and predominantly related to pain and postoperative nausea and vomiting. A balanced anesthetic technique incorporating appropriate analgesic and antiemetic regimens is essential to avoid unnecessary hospital admission/readmission.

Six-Year Experience of Outpatient Total and Completion Thyroidectomy at a Single Academic Institution

Outpatient thyroidectomy has become slowly accepted with various published reports predominantly examining partial or subtotal thyroidectomy. Concerns regarding the safety of outpatient total and completion thyroidectomy remain, especially with regard to vocal fold paralysis, hypocalcemia, and catastrophic hematoma. We aimed to evaluate the safety of outpatient thyroid surgery in a large cohort by retrospectively comparing outcomes in those who underwent outpatient (n = 251) versus inpatient (n = 291) completion or total thyroidectomy between February 2009 and February 2015. Outpatient completion and total thyroidectomy had lower rates of temporary hypocalcemia (6% vs 24.4%; P < 0.001) and no significant difference in rates of return to emergency department (1.2% vs 1.4%), hematoma formation (0.8% vs 0.7%), temporary (2% vs 4.1%) or permanent (0.4% vs 0.7%) vocal fold paralysis, or permanent hypocalcemia (0.4% vs 0%) compared with the inpatient group. Outpatients requiring calcium replacement had shorter duration of postoperative calcium supplementation (44.4 ± 59.3 days vs 63.3 ± 94.4 days; P < 0.001). Our data demonstrate similar safety in outpatient and inpatient total and completion thyroidectomy.

Application of carbon nanoparticles in lymph node dissection and parathyroid protection during thyroid cancer surgeries: a systematic review and meta-analysis

Purpose

To investigate whether carbon nanoparticles (CNs) are helpful in identifying lymph nodes and metastatic lymph nodes and in parathyroid protection during thyroid cancer surgery.

Methods

English and Chinese literature in PubMed, Cochrane Database of Systematic Reviews, EMBASE, ClinicalTrials.gov, China Biology Medicine Database, China National Knowledge Infrastructure, China Master’s and Doctoral Theses Full-Text Database, Wanfang database, and Cqvip database were searched (till March 22, 2016). Randomized controlled trials (RCTs) that compared the use of CNs with a blank control in patients undergoing thyroid cancer surgery were included. Quality assessment and data extraction were performed, and a meta-analysis was conducted using RevMan 5.1 software. The primary outcomes were the number of retrieved central lymph nodes and metastatic lymph nodes, and the rate of accidental parathyroid removal.

Results

We obtained 149 relevant studies, and only 47 RCTs with 4,605 patients (CN group: n=2,197; blank control group: n=2,408) met the inclusion criteria. Compared with the control group, the CN group was associated with more retrieved lymph nodes/patient (weighted mean difference [WMD]: 3.39, 95% confidence interval [CI]: 2.73–4.05), more retrieved metastatic lymph nodes (WMD: 0.98, 95% CI: 0.61–1.35), lower rate of accidental parathyroid removal, and lower rates of hypoparathyroidism and hypocalcemia. However, the total metastatic rate of the retrieved lymph nodes did not differ between the groups (odds ratio: 1.13, 95% CI: 0.87–1.47, P=0.35).

Conclusion

CNs can improve the extent of neck dissection and protect the parathyroid glands during thyroid cancer surgery. And the number of identified metastatic lymph nodes can be simultaneously increased.

Postoperative Calcium Management in Same-Day Discharge Thyroid and Parathyroid Surgery

Objective

To describe a safe and effective postoperative prophylactic calcium regimen for same-day discharge thyroid and parathyroid surgery.

Study Design

Case series with chart review.

Setting

Tertiary referral academic institution.

Subjects and Methods

In total, 162 adult patients who underwent total thyroidectomy, completion thyroidectomy, unilateral parathyroidectomy, parathyroidectomy with bilateral neck exploration, or revision parathyroidectomy were identified preoperatively to be candidates for same-day discharge. All patients in this study were successfully discharged the same day on our standard prophylactic calcium regimen.

Results

Less than 1% (1/162) of patients re-presented to the hospital within 30 days of surgery, and that patient was successfully discharged from the emergency department after negative workup for hypocalcemia. There was no significant difference between preoperative and postoperative calcium levels in the total/completion thyroidectomy groups (9.3 vs 9.2 mg/dL, respectively; P = .14). The average postoperative calcium level in the parathyroid group was well within normal limits (9.5 mg/dL), and the difference in postoperative calcium levels between revision and primary parathyroidectomy cases was not significantly different ( P = .34).

Conclusion

The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery in appropriately selected patients.

An Evaluation of Postoperative Complications and Cost After Short-Stay Thyroid Operations

BACKGROUND

Concern for postoperative complications causing airway compromise has limited widespread acceptance of ambulatory thyroid surgery. We evaluated differences in outcomes and hospital costs in those monitored for a short stay of 6 h (SS), inpatient observation of 6-23 h (IO), or inpatient admission of >23 h (IA).

METHODS

We retrospectively reviewed all patients undergoing thyroidectomy from 2006 to 2012. The incidence of postoperative hemorrhage, nerve dysfunction, and hypocalcemia were evaluated, as well as cost data comparing the SS and IO groups.

RESULTS

Of 1447 thyroidectomies, 880 (60.8 %) were performed as SS, 401 (27.7 %) as IO, and 166 (11.5 %) as IA. Fewer patients in the SS group (59 %) underwent total thyroidectomy than IO (73 %) and IA (71 %; p < 0.01), and SS patients had smaller thyroid weights (27.9 g) compared with IO and IA (47.2 and 98.9 g, respectively; p < 0.01). Ten (0.69 %) patients developed hematomas requiring reoperation, five of the ten patients received antiplatelet or anticoagulant therapy perioperatively. Only one patient in the IA group bled within the 6- to 23-h period, and no patients with bleeding who were discharged at 6 h would have benefitted from 23-h observation. Twenty-four (1.66 %) recurrent laryngeal nerve injuries were identified, 16 with temporary neuropraxias. In addition, 24 (1.66 %) patients had symptomatic hypocalcemia, which was transient in 17 individuals. Financial data showed higher payments and lower costs associated with SS compared with IO.

CONCLUSIONS

Selective SS thyroidectomy can be safe and cost effective, with few overall complications in patients undergoing more complex operations involving larger thyroids who were admitted to hospital.