Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study [ISRCTN63623153]

Routine Use of Neck Drains Following Thyroid Operations to Prevent Complications Is No Longer Advisable

BACKGROUND

The use of cervical drains to prevent cervical hematoma or seroma after thyroidectomy remains a controversial issue.

OBJECTIVE

Identify clinical and surgical risk factors for hematoma or seroma and evaluate the usefulness of routine use of drains following thyroid surgery.

MATERIAL AND METHODS

The authors conducted a retrospective multicentric study related to consecutive patients submitted to thyroid surgery in seven Portuguese hospitals between January 2018 and December 2020 (n=945). The data collected included the following parameters: age and gender of the patients, anticoagulation or anti-aggregating therapy, histological diagnoses, type of surgery, the presence or absence of postoperative drains, thyroid weight, length of hospital stay, postoperative complications, and reinterventions. In this study, surgical complications evaluated were limited to the presence of hematoma or seroma. A total of 945 patients who underwent thyroid surgery were included in the study. Twenty-seven patients (2.9%, n=27) experienced complications classified as hematomas or seromas. In the series, significant differences were observed between the two groups according to hypocoagulation or anti-aggregation status (OR=3.62; 95% CI 1.14-11.4) (p=0.001) and the nature of histological diagnosis (toxic vs. non-toxic benign disease) (OR=6.59; 95% CI 1.83-23.7). Hypocoagulation or anti-aggregation status were independently associated with a higher risk of complications. The presence of drains was associated with longer hospitalization periods (p<0.001) and not a decreased need for reintervention.

CONCLUSION

Cervical hematoma or seroma are rare complications associated with both hypocoagulation and anti-aggregation therapy and with the presence of benign toxic pathology. The use of drains does not decrease the need for reintervention and is even associated with a longer length of hospital stay; therefore, their routine use should not be advised.

Predictors and Preventive Strategies of Bleeding After Thyroid Surgery

Postoperative compressive neck hematoma occurs in approximately 0.1% to 1.7% of cases, most occurring within the first six hours after surgery. Thyroid pathology, patient predisposition, and surgical technique are major risk factors for postoperative hematoma. This narrative review describes current perspectives on predicting and preventing bleeding following thyroid surgery. Predictors of bleeding after thyroid surgery include patient-related factors such as male sex and age, surgery-related factors like total thyroidectomy and operations for thyroid malignancy, and surgeon-related factors. Hemostasis is the primary focus after preserving critical structures in thyroid surgery. The clamp-and-tie technique has been the standard method for dividing the thyroid gland's main vascular pedicles for many years. Bipolar electrocautery has been used for vessels of small size. However, advanced bipolar and ultrasound energy and hybrid devices are now available options that may reduce operative time without increasing costs or complications. In cases where small bleeders close to critical structures are present and the clamp-and-tie technique is not feasible, hemostatic agents are commonly used. Drains do not appear to provide any significant benefits in preventing the sequelae of bleeding after thyroid surgery.

Is routine drainage necessary after thyroid surgery? A randomized controlled trial study

Objective

To evaluate whether no drainage has an advantage over routine drainage in patients with thyroid carcinoma after unilateral thyroid lobectomy and central neck dissection.

Methods

A total of 104 patients with thyroid cancer who underwent unilateral thyroid lobectomy and central lymph node dissection were randomly assigned into no drainage tube (n=52) and routine drainage tube (n=52) placement groups. General information of each patient was recorded, including the postoperative drainage volume/residual cavity fluid volume, postoperative complications, incision area comfort, and other data, and the thyroid cancer-specific quality of life questionnaire (THYCA-QoL) and patient and observer scar assessment scale (POSAS) were evaluated after surgery. At the 3-6 month follow-up exam, the differences between the two groups were compared based on univariate analysis.

Results

Significant differences were not observed in the general and pathological information (including sex, age, body weight, body mass index (BMI), incision length, specimen volume, Hashimoto's thyroiditis, and number of lymph nodes dissected), operation time, and postoperative complications (postoperative bleeding, incision infection, lymphatic leakage, and temporary hypoparathyroidism) between the two groups. The patients in the non-drainage group had a shorter hospital stay (2.11 ± 0.33 d) than the patients in the drainage group (3.38 ± 0.90 d) (P<0.001). The amount of cervical effusion in patients in the non-drainage group (postoperative 24h: 2.20 ± 1.24 ml/48 h: 1.53 ± 1.07 ml) was significantly less than that in the drainage group (postoperative 24 hours: 22.58 ± 5.81 ml/48 h: 36.15 ± 7.61 ml) (all P<0.001). The proportion of incision exudation and incision numbness in the non-drainage group was lower than that in the drainage group (all P<0.05), and the pain score (VAS) and neck foreign body sensation score (FBST) decreased significantly (P<0.05). During the 3- and 6-month follow-up exams, significant differences were not observed between the THYCA-QoL and drainage groups and the non-drainage group, although the scarring and POSAS values were lower than those in the drainage group. In addition, the length of stay and cost of hospitalization in the non-drainage group were lower than those in the drainage group (P<0.05).

Conclusion

Routine drainage tube insertion is not needed in patients with unilateral thyroid lobectomy and central neck dissection.

Effect of Drain Output on the Timing of Closed Suction Drain (CSD) Removal After Head and Neck Surgery

Background: A closed suction drain (CSD) is often utilized in head and neck surgical procedures to obliterate dead space. CSDs reduce seroma and hematoma formation, thereby improving skin apposition and wound healing. The use of drains for prolonged periods of time, however, may increase the risk of wound infection. Interestingly, the evidence regarding the need for, and management of, post-operative CSDs after head and neck surgery is scarce. The current criterion of drain removal when output is less than 30 cubic centimeters (cm³) within a 24-hour period and/or on the third post-operative day (POD) is widely utilized. The aforementioned criterion is based on anecdotal evidence from small studies with specific surgical procedures. In this study, we aim to evaluate the criteria for drain removal and to lay the groundwork for an updated paradigm for drain management in head and neck oncologic surgery.

Study Design: Retrospective cohort study

Setting: Academic tertiary care hospital

Methods: A retrospective study was performed. Patients were included if they underwent head and neck surgery at the University of Miami Hospital between January 1, 2019 and July 1, 2020 and had at least one CSD. Volume of drain output on each POD was recorded until the day of drain removal. The development of post-operative wound complications (i.e., seroma, hematoma, infection/abscess, and dehiscence) was also recorded.

Results: From our initial cohort of 302 patients, 145 patients met inclusion criteria. A total of 10 patients developed a post-operative wound complication. Patients had a mean age of 58.3 ± 15.0 years. The median inter-quartile range (IQR) drain output (cm³) on the day of CSD removal from patients who developed a wound complication was similar (15; IQR, 5-37.5) when compared to those who did not develop a wound complication (25; IQR, 10-30). This difference was not statistically significant (p = 0.60). Additionally, the cohort who developed a post-operative wound complication had their drain removed on an earlier POD (1; IQR, 1-1 (Mean 1.2)) when compared to the cohort who did not develop any complications (1; IQR, 1-1 (Mean 1.5)). This difference was also not statistically significant (p = 0.48) .

Conclusion: There is no association between drain output (cm³) or day of CSD removal with the development of wound complications. These results warrant further studies to prospectively evaluate earlier CSD removal in head and neck surgery.

Complications of Neck Drains in Thyroidectomies: A Systematic Review and Meta-Analysis

OBJECTIVES

Intraoperative placement of neck drains in thyroidectomy patients remains a widespread practice, despite prevailing evidence discouraging this practice. This systematic review and meta-analysis was conducted to update the currently available evidence base.

METHODS

Two independent investigators performed a comprehensive literature search to identify randomized control trials that evaluated postoperative complications associated with neck drains. This was conducted using four databases: Medline, Web of Science, EMBASE, and Cochrane. Identified articles were then screened using a strict eligibility criterion. Sixteen studies were included in the final quantitative analysis and assessed for risk of bias. All methods were in accordance with recommendations from the Cochrane Review Group, U.K. National Health Service Centre for Reviews and Dissemination, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Our initial search yielded 743 articles. Of those, 16 were included for final quantitative synthesis. The overall analysis demonstrated that postoperative hematomas [pooled odds ratio (OR) = 2.09 (1.04, 4.21); P = .04] and surgical site infections [pooled OR = 3.85 (2.04, 7.28); P < .01] were significantly more likely in the drained group. Furthermore, hospital stays were longer in the drained group [pooled mean difference = 0.88 days (0.56, 1.20); P < .01]. There were no significant differences in fluid volumes within the thyroid bed between study groups [pooled mean difference = -2.30 mL (-4.82, 0.21); P = .07].

CONCLUSION

The drained patient group had overall higher odds of hematomas, surgical site infections, and longer hospital stays. Therefore, we recommend against this practice of neck drain insertions in patients who have undergone thyroidectomies. Laryngoscope, 131:690-700, 2021.

To use indwelling drainage or not in dual-plane breast augmentation mammoplasty patients: A comparative study

To explore the necessity of indwelling drainage in dual-plane breast augmentation mammoplasty patients.Female patients (123 in total) were selected from June 2015 to June 2018 in the Department of Plastic Surgery at Peking Union Medical College Hospital and were randomly divided into 2 different groups: the with drainage group (WD group, 57 patients) and the without drainage group (WOD group, 66 patients). In the 2 groups, the operation time, postoperative stay, and hospitalization expenses were recorded. The BREAST-Q Version 2.0 Augmentation Module Pre- and Postoperative Scales (Chinese Version) were used to evaluate psychosocial well-being, sexual well-being, physical well-being, and satisfaction with breasts preoperatively and postoperatively (1 year after operation).Before the operation, no significant differences were found in psychosocial well-being, sexual well-being, physical well-being, or satisfaction with breasts between these 2 groups. In the WOD group, postoperative stay and hospitalization expenses were remarkably decreased, but the operation time was similar, compared with the WD group. Compared with before the operation, both groups had significantly increased scores in psychosocial well-being, sexual well-being, and satisfaction with breasts after the operation. However, no significant differences were found between the 2 groups. No complications were found in any of the patients.Although the operation time was not significantly decreased, patients without drainage could save much more time and money and simultaneously reach similar postoperative effects in psychosocial well-being, sexual well-being, physical well-being, and satisfaction with breasts. Therefore, drainage may not be necessary in patients who undergo dual-plane breast augmentation mammoplasty.

Redo thyroid surgery without drains

PURPOSE

Redo thyroid surgery is associated with higher risk of hematoma than the initial thyroid surgery. We report a single surgeon's experience of performing redo thyroid surgery without drains.

METHODS

This retrospective single-institutional study evaluates the safety and efficiency of redo thyroid surgery without drains by comparing three groups of patients: those who underwent primary bilateral thyroidectomy (Group 1), those who underwent completion thyroidectomy (Group 2); and those who underwent thyroidectomy for recurrent thyroid diseases (Group 3).

RESULTS

The demographic characteristics did not differ among the groups. Substernal extension and hyperthyroidism were more frequent in group 1, whereas the weight of the resected thyroid gland was lower in groups 2 and 3. Hematoma occurred in 5%, 4%, and 4% of patients in Groups 1, 2, and 3, respectively. Postoperative transient hypocalcemia occurred in 19%, 16%, and 21% of patients in Groups 1, 2, and 3 respectively. The postoperative incidence of transient recurrent laryngeal nerve (RLN) paralysis in Groups 1, 2, and 3, was 6%, 7%, and 8%, respectively. The incidence of permanent unilateral RLN paralysis in Groups 2 and 3 was 1%. The postoperative length of stay was 1 day in 92% of the patients from all groups.

CONCLUSIONS

Avoiding the routine use of drains in redo thyroid surgery is safe and effective, it does not increase overall surgical morbidity, and it reduces the overall length of stay in hospital.

A comparison of the efficacy of three different peak airway pressures on intraoperative bleeding point detection in patients undergoing thyroidectomy: a randomized, controlled, clinical trial

BACKGROUND

Various techniques are used to detect intraoperative bleeding points in thyroid surgery. We aimed to assess the effect of increasing peak airway pressure to 30, 40 and 50 cm H₂O manually in detecting intraoperative bleeding points.

METHODS

One hundred and 34 patients scheduled for total thyroidectomy were included to this prospective randomised controlled clinical study. We randomly assigned patients to increase peak airway pressure to 30, 40 and 50 cm H₂O manually intraoperatively just before surgical closure during hemostasis control. The primary endpoint was the rate of bleeding points detected by the surgeon during peak airway pressure increase.

RESULTS

The rate of detection of the bleeding points was higher in 50 cm H₂O Group than the other two groups (15.9 vs 25.5 vs 40%, P = 0.030), after pressure administration, the HR, SpO₂, and P peak were similar between groups (P = 0.125, 0.196, 0.187, respectively). The median duration of the bleeding point detection after the pressure application was 21.82 s in 30 cm H₂O, 25 s in 40 cm H₂O, and 22.50 s in 50 cm H₂O groups. Postoperative subcutaneous hematomas or hemorrhages requiring surgery were not seen in any patient.

CONCLUSIONS

Manually increasing peak airway pressure to 50 cm H₂O during at least 22.50 s may be used as an alternative way to detect intraoperative bleeding points in thyroid surgery.

CLINICAL TRIAL REGISTRATION

NCT03547648. Registered 6 June2018.

Predictive factors of increased surgical drain output after thyroid lobectomy: a retrospective study

Background

Thyroid lobectomy is one of the most common operations for thyroid lesions. Life-threatening complications can occur; these include post-operative bleeding with airway compression caused by hematoma. Given this risk, prophylactic drains are routinely used in our practice. The aim of this study was to identify factors that influence the total drainage volume (TDV).

Methods

From 2016 to 2017, a total of 89 consecutive patients with thyroid lobectomy performed by the same surgeon were included in the study. The demographic characteristics of the patients, TDV, fine needle aspiration cytology, hospitalization day, operation time, thyroid gland size, and blood test results were retrospectively recorded from the hospital database. Spearman's rank correlation and multivariate regression were used to analyze the association of factors with the TDV.

Results

The median TDV was 56 mL, and there was a positive correlation between age, weight, blood sugar, gland size, hospitalization day, operation time, and TDV. Multivariate regression analysis revealed that male sex (β=19.684; 95% CI, 7.998-31.371; P=0.001), higher blood sugar (β=0.173; 95% CI, 0.087-0.260; P<0.001), and larger thyroid gland size (β=0.069; 95% CI, 0.008-0.130; P=0.027) were independent risk factors for TDV.

Conclusions

The TDV primarily depends on male sex, larger thyroid gland, and higher blood sugar level. Patients with these factors should undergo meticulous hemostasis and bleeding should be carefully monitored in the perioperative period.

Drain placement in thyroidectomy is associated with longer hospital stay without preventing hematoma

OBJECTIVE

To analyze the effect of drain placement on postoperative hematoma formation and other associated outcomes post-thyroid surgery in a large national cohort.

METHODS

This was a retrospective study that analyzed data from the 2016-2017 National Surgical Quality Improvement Program (NSQIP) public use files. Baseline characteristics and perioperative outcomes were compared between drain and no drain cohorts.

RESULTS

A total of 11,626 patients were included; 3281 had a drain placed intraoperatively and 8345 did not. Otolaryngologists were 6.98 times more likely to place a drain after thyroidectomy than general surgeons (P < .001), and patients undergoing subtotal or total thyroidectomy were 2.17 times more likely to have a drain placed than if undergoing partial thyroidectomy (P < .001). Drain placement did not reduce hematoma formation on both univariate and multivariate analyses (adjusted OR = 0.93, P = .696). A slightly larger proportion of patients underwent unplanned intubation postoperatively among those who had a drain placed (0.76% vs. 0.29%, P < .001). Patients who received a drain were on average 4.63 times as likely to remain in the hospital for 2 or more days compared to those who did not receive a drain.

CONCLUSION

Drain placement did not significantly affect postoperative hematoma formation following thyroidectomy. Drain placement should not be routinely employed in these patients. However, surgeon judgement and intraoperative considerations should be taken into account, as to when to place a drain.

LEVEL OF EVIDENCE

N/A Laryngoscope, 130:1349-1356, 2020.

Impact of drains on nausea and vomiting after thyroid and parathyroid surgery: a randomized controlled trial

OBJECTIVE

Nausea and vomiting are common side effects following thyroid and parathyroid surgery. In a prospective controlled randomized trial, postoperative nausea and vomiting (PONV) and the number of episodes of vomiting were defined as two primary endpoints. We analysed whether the placement of drains after thyroid or parathyroid surgery enhances PONV and/or influences vomiting.

PATIENTS AND METHODS

From November 2007 to January 2012, 136 consecutive patients were included for thyroid or parathyroid surgery and were randomly assigned to group A (drain, n = 69) or group B (no drain, n = 67). PONV was assessed with visual analogue scale (VAS; range 0 to 10) measurements. Furthermore, episodes of vomiting as well as analgetic and antiemetic therapies were recorded. Difference in neck circumference was compared pre- and postoperatively.

RESULTS

Patients' characteristics did not differ between group A and B. Postoperative VAS values for pain were 2.4 ± 0.3 (group A) and 2.6 ± 0.2 (group B) (p = 0.62), and for nausea 1.4 ± 0.2 (group A) and 1.1 ± 0.2 (group B) (p = 0.57). The relative occurrences of episodes for postoperative vomiting were equal in both groups 0.3 ± 0.1 (p = 1.0). Antiemetic drugs were administered 37 times (group A) and 18 times (group B) (p = 0.099). The total number of treatments of patients with antiemetic drugs was 23 (33.3%) in group A vs. 13 (19.4%) in group B (p = 0.081). The neck circumference postoperatively was significantly larger in group B (p = 0.0025).

CONCLUSIONS

Drains after surgery do not enhance postoperative pain, nausea and vomiting. The placement of drains in thyroid surgery is recommended to avoid relevant fluid collection. Drains however may influence the amount of antiemetic drug requirements.

TRIAL REGISTRATION

CLINICALTRIALS.

GOV IDENTIFIER

NCT01679418.

Independent predisposing factors for subcutaneous and deep wound collection after total thyroidectomy, a prospective cohort study

BACKGROUND

The literature contains diverse and sometimes contradicting results about wound seroma following thyroidectomy. This is probably due to the subjective clinical estimation of seroma, or due to failure to differentiate between the occurrence of subcutaneous (SC) and deep wound collections. This work aimed at objectively investigating the factors affecting subcutaneous and deep wound seroma after thyroidectomy.

METHODS

The relation between various operative and clinico-pathological factors and the collection formation was prospectively analyzed in a cohort of 100 patients after conventional thyroidectomy. Wound seroma was assessed clinically and via high-resolution ultrasonography at 24 h, 48 h and two weeks postoperatively. Sonographically detected collections were expressed as SC and/or deep wound collections according to the relation to strap muscles.

RESULTS

Operative duration was the only independent factor significantly affecting the incidence of clinical seroma. Older patients (>40ys) showed significantly larger volumes of early SC collections. Early postoperative pain was significantly related to drain insertion, to the occurrence of clinical seroma and to the volume of SC collections.Sonographically, suction drains and shorter operative durations resulted in significantly less amount of deep collections. Suction drains did not result in less amount of SC collections or in a lower incidence of clinical seroma.

CONCLUSIONS

Operative duration is the only independent factor significantly related to clinically-detected postoperative seroma with its subsequent postoperative pain. Especially in elderly patients, a flapless technique would be recommended as these patients developed larger volumes of SC collections with subsequent higher pain scores, even if seroma was not clinically detected.

Efficacy of Drainless Total Thyroidectomy in Intrathyroidal Lesions of Thyroid

Introduction  There is difference of opinion about the placement of the drain in thyroid surgeries, and, to the best of our knowledge, the efficacy of drainless total thyroidectomy regarding various parameters of thyroid lesions has not been well-established.

Objective  To report our experience with drainless total thyroidectomy, and to define an appropriate patient population for its performance.

Methods  This is a retrospective case analysis of the patients who underwent total thyroidectomy for intrathyroidal lesions with or without central neck dissection in a tertiary referral hospital (number = 74). The patients, who had undergone total thyroidectomy without any drain insertion, were analyzed, and the relationships among various parameters of thyroid lesions were noted in relation to seroma and hematoma formation.

Results  Seroma formation was noted only in 5 out of 74 patents (6.75%). All of the seromas that occurred were observed in patients with thyroid lesions < 4 cm, and 4 out of 5 seromas were observed in patients with a malignant pathology. There was no statistically significant difference in seroma formation between patients younger or older than 50 years of age.

The nature of the lesion, whether benign or malignant, did not affect the formation of seroma. Of interest is the fact that none of the 10 patients who had central neck dissection performed as part of their treatment developed seroma.

Conclusions  Drainless total thyroidectomy is safe across all age groups for patients harboring either benign or malignant thyroid pathologies. However, caution is to be observed in opting for drainless total thyroidectomy in patients with large lesions (> 5 cm)

[Should surgeons keep performing drainage after breast reduction?]

OBJECTIVE

Despite the absence of "evidence-based medicine", the use of closed suction drainage in breast surgery is currently the standard practice. Its goal is to minimize the amount of fluid at the operation site, the dead space that can involve postoperative complications. The purpose of this study is to demonstrate that with or without drainage the complication rate is unchanged.

METHODS

We conducted a retrospective and comparative study of two groups of breast reduction with and without drainage. Every complication has been recorded and statistically analyzed: seroma and hematoma, infections, wound breakdown, skin flap or nipple-areola complex necrosis, fat necrosis and reoperation.

RESULTS

A total of 138 breast reductions were performed (37 drained patients and 32 non-drained). Data collection of complications was done on average 10months after the operation (1-15). There was no statistical difference between the two groups regarding the complication rate. Our results confirm the ones found in the literature.

CONCLUSION

Except for specific cases (e.g. gigantomasty), this study demonstrates that after breast reduction, drainage is not appropriate. Drains do not reduce postoperative complications and can increase hospitalization length of stay (inducing higher costs). Furthermore, it is often source of pain, anxiety and discomfort for patients.

Intraoperative Valsalva maneuver: a narrative review

The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented.

The effect of no drainage in patients who underwent thyroidectomy with neck dissection: A systematic review and meta-analysis

BACKGROUND

To evaluate the effect of no drainage in patients who underwent thyroidectomy and neck lymph node dissection.

METHODS

We followed the methodological standard expected by Cochrane. We searched the following databases by March 23, 2017: PubMed, The Cochrane Library, EMBASE via Ovid SP, and Medline via Ovid SP. Two reviewers screened the studies and extracted the data. Randomized controlled trials (RCTs) or nonrandomized interventional studies assessing the effect of no drainage following thyroidectomy with lymph node dissection were included.

RESULTS

Three studies with 387 participants were included. There was no statistical difference between groups for the overall perioperative complications (2 RCTs, n = 234, RR 1.56, 95% CI 0.53-4.64), or specific complications such as seroma (2 RCTs, n = 234, RR 1.81, 95% CI 0.46-7.07), hematoma (2 RCTs, n = 234, RR 0.72, 95% CI 0.11-4.83) or hemorrhage (1 RCT, n = 69, RR 0.29, 95% CI 0.01-6.87). One case required reoperation due to hemorrhage in the drainage group was reported in 1 study (n = 32). No mortality was reported. Two studies (n = 234) stated a longer hospital stay in the drainage group than that in the group without drainage. There was moderate or serious bias for the risk of bias of included studies.

CONCLUSION

The effect of no-drainage in patients with thyroid cancer who received thyroidectomy with neck dissections remains uncertain, since there are very few studies that addressed the question. Drainage may lead to longer hospital stay than nondrainage. More randomized or nonrandmized studies are required to address this issue.

What adds Valsalva maneuver to hemostasis after Trendelenburg's positioning during thyroid surgery?

Background

Bleeding after thyroidectomy is life-threatening. The aim of the study was to evaluate whether controlling of further bleeding with Valsalva maneuver following Trendelenburg's positioning has an impact on hemostasis.

Methods

This prospective study included 68 consecutive patients undergoing thyroidectomy. Study protocol consisted of performing manual intra-abdominal pressure increase and Valsalva maneuver to check hemostasis and treating any bleeding point identified, after Trendelenburg's positioning. All identified bleeding points and treatments were recorded.

Results

Total number of bleeding points identified in Trendelenburg's tilt was 49, while it was 41 when using Valsalva maneuver. Abdominal pressure increase, carried out before Valsalva maneuver, identified 14 bleeding points, which was less than bleeding after Trendelenburg's positioning and Valsalva maneuver (P<0.05). All bleeding points, except 1 for Trendelenburg's positioning and 1 for Valsalva maneuver, were minor (<2 mm). Only 4.4% bleeding vessels required ties or stitching.

Conclusions

Valsalva maneuver helps to detect any further bleeding following Trendelenburg's positioning.

The application of drains in thyroid surgery

It has been shown that the use of drain in thyroid surgery does not reduce the reoperation rate for hemorrhage. The aim of this systematic review was to update the knowledge of the role of drain in thyroid surgery in term of postoperative complications, pain and hospital length of stay (LOS). A systematic search was performed in the PubMed and Embase database to identify all randomized controlled trials (RCTs) comparing clinical outcomes in patients who underwent thyroidectomy or lobectomy with or without drainage. The primary outcome was reoperation rate for bleeding; the secondary outcomes were development of hematoma, seroma, and wound infection; postoperative pain evaluated by Visual Analogue Scale (VAS) at the postoperative day (POD) 1, and hospital LOS. Risk ratios (RRs) and 95% confident intervals (95% CI) were used for dichotomous variables; mean differences (MDs) and 95% CI for continuous variables. Statistical heterogeneity was evaluated and its degree was quantified by the I2 statistic. Twenty RCTs were included, with 2,204 patients enrolled. No difference was found between the two groups in term of reoperation [RR 1.13 (0.43, 2.95); I2 =0%], hematoma [RR 1.18 (0.71, 1.95); I2 =0%], and seroma [RR 0.82 (0.44, 1.53); I2 =0%]. Patients with drain had higher postoperative pain [MD 1.91 (1.30, 2.53); I2 =97%], prolonged hospital LOS [MD 1.34 (0.91, 1.76) days; I2 =98%], and increased wound infection rate [RR 2.82 (1.36, 5.86); I2 =0%], even though the latter was not confirmed in the sensitivity analysis including only studies with ≥100 patients per trial. The use of drain after thyroid surgery increase postoperative pain and hospital LOS, with no decrease of reoperation rate, hematoma and seroma formation. An increased wound infection rate in patients with drain is suggested, but a large RCT should be performed to confirm this correlation.

Perioperative practices in thyroid surgery: An international survey

BACKGROUND

Perioperative practices in thyroid surgery vary from one specialty, institution, or country to the next. We evaluated the preoperative, intraoperative, and postoperative practices of thyroid surgeons focusing on preoperative ultrasound, vocal cord evaluation, wound drains, and hospitalization duration, among others.

METHODS

A survey was sent to 7 different otolaryngology and endocrine/general surgery associations.

RESULTS

There were 965 respondents from 52 countries. Surgeon-performed ultrasound is practiced by more than one third of respondents. Otolaryngologists perform preoperative and postoperative vocal cord evaluation more often than endocrine/general surgeons (p < .001). Sixty percent of respondents either never place drains or place drains <50% of the time in thyroid lobectomies (43% for total thyroidectomies). Outpatient thyroid surgery is most frequently performed by surgeons in the United States (63%).

CONCLUSION

This epidemiologic study is the first global thyroid survey of its kind and clearly demonstrates the variability and evolving trends in thyroid surgery. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1296-1305, 2017.

[Application of fibrin sealant in patients operated on for differentiated thyroid cancer. What do we improve?]

BACKGROUND

In recent years, several publications have shown that new adhesives and sealants, like Tissucol(®), applied in thyroid space reduce local complications after thyroidectomies.

STUDY AIMS

To demonstrate the effectiveness of fibrin glue Tissucol(®) in reducing the post-operative hospital stay of patients operated on for differentiated thyroid carcinoma in which total thyroidectomy with central and unilateral node neck dissection was performed (due to the debit drains decrease), with consequent cost savings.

MATERIAL AND METHODS

A prospective randomised study was conducted during the period between May 2009 and October 2013 on patients with differentiated thyroid carcinoma with cervical nodal metastases, and subjected to elective surgery. Two groups were formed: one in which Tissucol(®) was used (case group) and another where it was not used (control group). Patients were operated on by surgeons specifically dedicated to endocrine surgical pathology, using the same surgical technique in all cases.

RESULTS

A total of 60 total thyroidectomies with lymph node dissection were performed, with 30 patients in the case group, and 30 patients in control group. No statistically significant differences were observed in most of the studied variables. However, the case group had a shorter hospital stay than the control group with a statistically significant difference (p<0.05).

CONCLUSION

Implementation of Tissucol(®) has statistically and significantly reduced the hospital stay of patients undergoing total thyroidectomy with neck dissection, which represents a significant reduction in hospital costs. This decrease in hospital stay has no influence on the occurrence of major complications related to the intervention.

Systematic review and meta-analysis of wound drains after thyroid surgery

BACKGROUND

Drainage after routine thyroid and parathyroid surgery remains controversial. However, there is increasing evidence from a number of randomized clinical trials (RCTs) suggesting no benefit from the use of drains.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. A literature search was carried out, and RCTs comparing the use of drains versus no drains in patients who underwent thyroid or parathyroid surgery were included. Trials including patients who underwent lateral neck dissection were excluded. Methodological quality was graded and data were extracted by independent reviewers. Risk ratio (RR) or mean difference (MD) with 95 per cent confidence interval (c.i.) was calculated and heterogeneity was assessed.

RESULTS

Twenty-five RCTs were included in the meta-analysis comprising 2939 patients. There was no significant difference between the two groups in rate of reoperation for neck haematoma (RR 1·90, 95 per cent c.i. 0·87 to 4·14), ultrasound-assessed fluid volume on day 1 after surgery (MD 2·30 (95 per cent c.i. -0·73 to 5·34) ml), wound collection requiring intervention (RR 0·64, 0·38 to 1·09) or not (RR 0·93, 0·66 to 1·30), transient voice change (RR 2·33, 0·91 to 5·96) and persistent recurrent laryngeal nerve palsy (RR 1·67, 0·22 to 12·51). Length of hospital stay was significantly greater in the drain group (MD 1·25 (0·83 to 1·68) days), as were wound infection rates (RR 2·53, 1·23 to 5·21) and pain score measure using a visual analogue scale from 1 to 10 on day 1 after surgery (MD 1·46 (0·67 to 2·26) units).

CONCLUSION

The results indicate that drain use after routine thyroid surgery does not confer a benefit to patients.

Total thyroidectomy without the use of drainage - case series of 66 patients

Aim: The aim of this series is to study the need of drainage use after total thyreoidectomy. Material and Methods: Retrospective study of a series of patients who underwent total thyroidectomy from 2005 up to 2013. The presence or not of hematomas, seromas and hemorrhage were recorded. Results: Out of the 66 patients included in this series, only one case of post-operative hematoma was recorded. Neither a hemorrhage nor a seroma were identified despite the volume, the underlying pathology and the co-morbidity of the patients involved. Conclusion: In our experience a thyroidectomy with adequate hemostasis does not require the use of drains.

Classic clamp-and-tie total thyroidectomy for large goiters in the modern era: To drain or not to drain

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.

To drain or not to drain after thyroid surgery: a randomized controlled trial at a tertiary Hospital in East Africa

INTRODUCTION

In many facilities, drains are routinely inserted after thyroidectomy with the aim of preventing hematoma formation and accumulation of seroma. The continued use of drains may be based more on tradition rather than proven scientific evidence.

OBJECTIVE

To assess the benefit of drain use after thyroidectomy by determining; length of hospital stay, post operative pain and wound sepsis.

METHODS

This was a randomized controlled trial, carried out at a tertiary national referral hospital (Mulago, Kampala). Over a 6 month period in 2011, we recruited 68 patients. Socio-demographic information and clinical parameters were recorded. Outcomes measures were evaluated. Data were double entered into epidata version 3.1.1 and analyzed using STATA version 10.0. Ethical approval was secured.

RESULTS

Mean age of participants was 46 and 43.7 years in drain and no drain arm respectively. Most participants were female. Mean duration of hospital stay after thyroidectomy was significantly higher among the drain arm as compared with the no drain arm [2.41 (± 0.89) vs 1.71 (± 0.76) days (p = 0.0008)]. One patient (drain arm) had wound infection. The pain score on the postoperative day was statistically higher among in the drain arm than the no drain arm [5.71 vs 2.53 (p = 0.001)].

CONCLUSION

Not inserting a drain post operatively after thyroid surgery was associated with short hospital stay and less operative pain. Results of this study do not support routine drainage after thyroid surgery.

Is the use of a drain for thyroid surgery realistic? A prospective randomized interventional study

Background. The use of a suction drain in thyroid surgery is common practice in order to avoid hematomas or seromas. The aim of this study was to determine the efficacy of routine drainage after thyroid surgery. Methods. In this prospective randomized trial, 400 patients who underwent either a total thyroidectomy or lobectomy for thyroid disorders were randomly allocated to either the nondrainage (group 1) or the drainage (group 2) group. The volume of fluid collection in the operative bed, postoperative pain, complications, and length of hospital stay were then recorded. Results. Both groups were homogeneous according to age, gender, thyroid volume, type of procedure performed, and histopathological diagnosis. After assessment by USG, no significant difference was found between the groups in the fluid collection of the thyroid bed (P = 0.117), but the length of hospital stay was significantly reduced in group 1 (P = 0.004). Conclusions. In our experience, the use of drain for thyroid surgery is not a routine procedure. However, it should be used in the presence of extensive dead space, particularly when there is retrosternal or intrathoracic extension, or when the patient is on anticoagulant treatment. This trial was registered with clinical Trials.gov NCT01771523.

Timing of drainage tube removal after thyroid surgery: a retrospective study

PURPOSE

The aim of this study was to evaluate the chronological changes in the amount of drainage fluid after thyroidectomy, and to establish standard indications for the drain to be removed.

METHODS

We examined a cohort of 249 patients undergoing thyroid surgery. The patients were divided into four groups: a Graves' group, a non-dissection group, a central-dissection group and a lateral-dissection group. The amount of drainage was measured every 6 h, and the drain was removed postoperatively when the drainage decreased in amount and contained serous fluid after a meal.

RESULTS

In all four groups, the most drainage occurred in the first 6 h after surgery. The total amount of drainage from the operation to the time of drain removal was significantly higher in Graves' group and in the lateral-dissection group than in the other two groups. The median wound drainage significantly decreased from 12 to 18 h after surgery in all four groups. In the lateral-dissection group, the wound drainage significantly decreased again in the first 24-30 h.

CONCLUSION

The findings of this study suggest that drains can be removed postoperatively if the drainage was less than 15 mL during a 6-h period and contain serous fluid.

Comparison of natural drainage group and negative drainage groups after total thyroidectomy: prospective randomized controlled study

PURPOSE

The aim of this study was to compare a negative pressure drain with a natural drain in order to determine whether a negative pressure drainage tube causes an increase in the drainage volume.

MATERIALS AND METHODS

Sixty-two patients who underwent total thyroidectomy for papillary thyroid carcinoma (PTC) were enrolled in the study between March 2010 and August 2010 at Gyeongsang National University Hospital. The patients were prospectively and randomly assigned to two groups, a negative pressure drainage group (n=32) and natural drainage group (n=30). Every 3 hours, the volume of drainage was checked in the two groups until the tube was removed.

RESULTS

The amount of drainage during the first 24 hours postoperatively was 41.68 ± 3.93 mL in the negative drain group and 25.3 ± 2.68 mL in the natural drain group (p<0.001). After 24 additional hours, the negative drain group was 35.19 ± 4.26 mL and natural drain groups 21.53 ± 2.90 mL (p<0.001). However, the drainage at postoperative day 3 was not statistically different between the two groups. In addition, the vocal cord palsy and temporary and permanent hypocalcemia were not different between the two groups.

CONCLUSION

These results indicate that a negative pressure drain may increase the amount of drainage during the first 24-48 hours postoperatively. Therefore, it is not necessary to place a closed suction drain when only a total thyroidectomy is done.

Postoperative use of drain in thyroid lobectomy - a randomized clinical trial conducted at Civil Hospital, Karachi, Pakistan

Background

Thyroidectomy is a common surgical procedure, after which drains are placed routinely. This study aims to assess the benefits of placing postoperative drains, its complications and affects on postoperative stay, in thyroid lobectomy.

Methodology

Randomized Clinical Trial of 60 goitre patients undergoing lobectomy was conducted at Civil Hospital Karachi, during July’11-December’11. Patients were randomly assigned into drain and non drain groups. Patient demographics, labs and complications were noted. Ultrasound of neck was performed on both groups. For drain group, the amount of fluid present in the surgical bed and redivac drain was added to calculate fluid collection while in non drain group it was calculated by ultrasound of neck on first and second post-op days. Data was entered and analyzed on SPSS v16 using Independent T tests.

Result

The mean total drain output for 2 days in non-drain group was significantly lower 10.67 (±9.072) ml while in drain group was 30.97 (±42.812) ml (p = 0.014). The mean postoperative stay of drain group (79.2 ±15.63 hours) was significantly higher, as compared to mean postoperative stay of non drain group (50.4 ±7.32 hours). Mean Visual Analogue Score (VAS) for pain day 1 (6.2 ±0.997) and day 2 (4.17 ±0.95) in drain group were significantly higher compared to day 1 (2.6 ±1.163) and day 2 (1.3 ±0.877 ) of non drain group. From drain group, 2 patients complained of stridor, dyspnea on Day 1 which subsided by Day 2 and 1 case of voice change, with no such complains in non drain group. No patients from both groups developed seroma, wound infection or hematoma.

Conclusion

In uncomplicated surgeries especially for lobectomy, use of drain can be omitted.

Comparison of incidence of postoperative seroma between flapless and conventional techniques for thyroidectomy: a case-control study

OBJECTIVES

The incidence of seroma after thyroidectomy has been reported between 1.3% and 7%. We hypothesised that a flapless thyroidectomy technique would reduce the incidence of seroma.

DESIGN

Observational case-control study with comparison between retrospective cohort of patients undergoing thyroidectomy with raising of conventional skin flaps and prospective cohort undergoing flapless surgery.

SETTING

Academic Teaching Hospital.

PARTICIPANTS

Hundred and seventy-five consecutive patients undergoing thyroidectomy performed by a single surgeon. After the first 85 cases, a change in practice took place, from raising of conventional skin flaps to performing flapless surgery wherever feasible.

MAIN OUTCOME MEASURES

Occurrence of postoperative seroma, defined as central neck swelling in postoperative period, confirmed by aspiration of serous fluid, and other complications.

RESULTS

Eight patients who underwent concomitant lateral (jugular) neck dissection were excluded. Among the remaining 167 patients, there were eight seromas (5%). Following the change in practice to flapless surgery, there was a significant reduction in the incidence of seroma (P = 0.025). There was no significant difference in other complications (haematoma; recurrent laryngeal nerve injury; and hypocalcaemia). Among the entire group, the association between seroma and flapless surgery tended towards significance (P = 0.07). Other variables studied, including use of drain and concomitant central compartment neck dissection, had no effect on seroma.

CONCLUSION

Flapless technique for thyroid surgery may reduce the incidence of postoperative seroma.

Safety of thyroidectomy and cervical neck dissection without drains

BACKGROUND

Many studies have reported that drainage after thyroidectomy does not decrease the rate of local postoperative complications. We sought to review the safety of thyroidectomy combined with cervical neck dissection (CND) without drainage.

METHODS

The medical records of consecutive patients who underwent thyroidectomy without drainage were retrospectively reviewed. Two groups were defined depending on whether CND was or was not performed. The main outcome was identification of patients with cervical bleeding, hematoma or seroma.

RESULTS

We included 1127 patients (139 who had CND and 988 who did not). Of these, 207 patients (18%) had transient postoperative hypocalcemia, 9 (0.8%) had permanent postoperative hypoparathyroidism, 56 (5%) had transient postoperative hoarseness and 7 (0.6%) had permanent vocal cord paralysis. A total of 44 patients (4%) experienced postoperative hematoma and/or seroma: 8 patients (6%) who had CND and 36 (4%) who did not. There was no major bleeding in the 2 groups; all patients had minor bleeding or seroma not requiring surgical intervention. The postoperative stay in hospital for both groups was 1 day in 92% of patients. Wound infection occurred in 0.8% of all patients: 1 (0.7%) who had CND and 8 (0.8%) who did not. There was no significant difference between the groups in overall perioperative complications or in time of hospital discharge.

CONCLUSION

Thyroidectomy without drains is safe and effective, even in combination with CND.

Efficacy of fibrin sealant for drainage reduction in total thyroidectomy with bilateral central neck dissection

OBJECTIVE

To investigate the efficacy of fibrin sealant (FS) for reducing postoperative drainage in patients who underwent total thyroidectomy (TT) with bilateral central neck dissection (CND) for papillary thyroid cancer.

STUDY DESIGN

Prospective randomized trial.

SETTING

Tertiary care institution.

SUBJECTS AND METHODS

Seventy-eight patients with papillary thyroid cancer were enrolled and randomized to either the FS application group (FS+, 38 patients) or no FS application group (FS-, 40 patients). In both groups, postoperative drainage amounts were measured by a negative suction system until the criterion of drain removal was met. Drainage amounts as well as the time to drain removal, postoperative complications, and chemical profile assay of drain fluids between the 2 groups were performed.

RESULTS

Drainage amounts at the initial 24 hours as well as total amounts of the FS+ group tended to be lower than those of the FS- group; however, they were not statistically different (at initial 24 hours, 64.3 ± 17.5 mL vs 73.0 ± 18.0 mL, P = .06; total amounts, 93.5 ± 30.7 mL vs 105.7 ± 31.2 mL, P = .05). The FS application did not shorten the time to drain removal even when different criteria for drain removal were applied (criteria of <20 mL/d or <30 mL/d). When chemistry profiles of collected drain fluids were analyzed in patient subgroups, the level of triglycerides in the FS+ group was significantly lower than in the FS- group.

CONCLUSION

Fibrin sealant has no additional advantage in terms of drainage reduction and early discharge despite the additional medical cost.

Effectiveness of a drain in surgical treatment of sacrococcygeal pilonidal disease. Results of a randomized and controlled clinical trial on 803 consecutive patients

PURPOSE

The aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses.

METHODS

The study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results.

RESULTS

On comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results.

CONCLUSIONS

The use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.

Timing of removal of neck drains following head and neck surgery

Studies of the volume of drainage over a 24-hour period that is sufficient to allow for the removal of a neck drain after head and neck surgery have not been reported, and thus the timing of drain removal varies among surgeons and institutions. We conducted a prospective study of 47 patients who had undergone major head and neck surgery to determine the safety and cost-effectiveness of removing a neck drain when the amount of drainage over a 24-hour period fell to 50 ml or less. When the volume reached that point in any given patient, the drain was clamped, and if no fluid collection was observed the following day, the drain was removed. We found that drain removal according to this protocol was successful in 91% of cases, as only 4 patients (9%) developed a seroma following removal. No other complications were observed. In a separate analysis, we retrospectively reviewed the cases of 22 other patients who had undergone surgery at a different institution. Their drains were not removed until the drainage volume fell to 25 ml over 24 hours. It took a median of 1.3 days (range: 1 to 3) for drainage to fall from 50 ml to less than 25 ml over 24 hours. We conclude that drains can be removed safely when the volume falls to 50 ml or less over a 24-hour period. This would result in less morbidity, shorter hospital stays, and significant cost savings.

Thyroid drains and postoperative drainage

OBJECTIVE: To evaluate postoperative drainage in patients undergoing thyroid lobectomy versus total thyroidectomy and to establish a correlation between intraoperative blood loss and postoperative drainage.

STUDY DESIGN: Case series with planned data collection.

SETTING: Tertiary medical center.

SUBJECTS AND METHODS: Consecutive patients (n = 100) undergoing thyroid surgery from October 2006 through November 2008 were examined. Data collected included age, gender, postoperative drainage, estimated intraoperative blood loss, type of surgery, length of hospital stay, pathology, and postoperative complications. Standard descriptive statistics were used to summarize characteristics of subjects, surgical procedures, and outcomes. Spearman rank correlation was used to evaluate association of drainage with blood loss and Kruskal-Wallis test to compare results by surgery type.

RESULTS: There were 100 surgeries performed: 52 lobectomies and 48 total thyroidectomies. Total postoperative drainage ranged from 0 to 230 mL, median was 32 mL. Estimated intraoperative blood loss ranged from 10 to 300 mL, median was 20 mL. We noted a statistically significant association of postoperative drainage with intraoperative blood loss ( r = 0.39, P = 0.001), but substantial variability in drainage was observed even among patients with similar blood loss. Although there was significantly less drainage among thyroid lobectomies ( P = 0.012), the distributions were quite similar apart from 10 patients (9 lobectomy) with exceptionally low drainage.

CONCLUSION: There was a statistically significant association of postoperative drainage with intraoperative blood loss and significantly less postoperative drainage among patients undergoing thyroid lobectomies. However, the observed associations do not appear to be strong enough to accurately predict patients who will experience substantial drainage.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Haemostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt

INTRODUCTION

The aim of the study was to identify whether Trendelenburg position helps detect any further bleeding points following Valsalva manoeuvre in order to achieve adequate haemostasis in head and neck surgery.

PATIENTS AND METHODS

Fifty consecutive patients undergoing major head and neck surgical procedures were included. The protocol consisted in performing Valsalva manoeuvre to check haemostasis and treated any bleeding points identified. The operating table was tilted 30 degrees and haemostasis was checked again and treated accordingly. The number of vessels identified and the treatment was recorded.

RESULTS

Twelve male and 38 female patients were included. The median age was 53 years and 74% had an ASA of 1. Twelve patients had complicating features such as retrosternal extensions or raised T4 levels pre-operatively. Thyroid resections were the most common operations performed. The total number of bleeding vessels identified in Trendelenburg tilt was significantly greater than when using Valsalva manoeuvre (P < 0.0001). All bleeding points found on Valsalva manoeuvre were minor (< 2 mm) and dealt with using diathermy. In Trendelenburg position, 11% of bleeding vessels required ties or stitching. The time taken during Valsalva manoeuvre was 60 s on average and 360 s in Trendelenburg position.

CONCLUSIONS

The results show that the Trendelenburg position is vastly superior to the Valsalva manoeuvre in identifying bleeding vessels at haemostasis. It has become our practice to put patients in Trendelenburg tilt routinely (we have discontinued the Valsalva manoeuvre), to check its adequacy before closing the wound. We have not noticed any intracranial complications using a tilt angle of 30 degrees .

Drainage after total thyroidectomy or lobectomy for benign thyroidal disorders

OBJECTIVE

This prospective randomized clinical trial was conducted to evaluate the necessity of drainage after total thyroidectomy or lobectomy for benign thyroidal disorders.

METHODS

A total of 116 patients who underwent total thyroidectomy or lobectomy for benign thyroidal disorders were randomly allocated to be drained or not. Operative and postoperative outcomes including operating time, postoperative pain assessed by visual analogue scale (VAS), total amount of intramuscular analgesic administration, hospital stay, complications, necessity for re-operation and satisfaction of patients were all assessed.

RESULTS

The mean operating time was similar between two groups (the drained and non-drained groups). The mean VAS score was found to be significantly low in the non-drained group patients in postoperative day (POD) 0 and POD 1. The mean amount of intramuscular analgesic requirement was significantly less in the non-drained group. One case of hematoma, two cases of seroma and three cases of transient hypoparathyroidism occurred in the non-drained group, whereas one case of hematoma, two cases of seroma, two cases of wound infections and two cases of transient hypoparathyroidism occurred in the drained group. No patient needed re-operation for any complication. The mean hospital stay was significantly shorter and the satisfaction of patients was superior in the non-drained group.

CONCLUSION

These findings suggest that postoperative complications cannot be prevented by using drains after total thyroidectomy or lobectomy for benign thyroid disorders. Furthermore, the use of drains may increase postoperative pain and the analgesic requirement, and prolong the hospital stay. In the light of these findings, the routine use of drains might not be necessary after thyroid surgery for benign disorders.

Is the routine pressure dressing after thyroidectomy necessary? A prospective randomized controlled study

Background

An acute complication of thyroidectomy is fatal hematoma, which can produce an upper airway obstruction needing immediate intubation or tracheostomy. After neck surgery, we usually apply a pressure dressing with a non-woven, adhesive fabric to reduce bleeding and fluid collection at the operative bed. We conducted a prospective, randomized, controlled study to evaluate a pressure vs. a non-pressure dressing after thyroid surgery by monitoring blood and serum in the operative bed.

Methods

We studied 108 patients who underwent 116 thyroid surgeries at Srinagarind Hospital, Khon Kaen University, between December 2006 and September 2007. The patients were randomized to either the pressure dressing or non-pressure dressing group. Ultrasound of the neck was performed 24 ± 3 hours after surgery. The volume of fluid collection in the operative bed was calculated. All patients were observed for any post-operative respiratory distress, wound complications, tingling sensation or tetany.

Results

The distributions of age, sex, surgical indications and approaches were similar between the two groups. There was no statistically significant difference in the volume of fluid collection in the operative bed (p = 0.150) and the collected drained content (p = 0.798). The average time a drain was retained was 3 days. One patient in the pressure dressing group suffered cutaneous bruising while one patient in the non-pressure dressing group developed immediate hemorrhage after the skin sutures.

Conclusion

Pressure dressing after thyroidectomy does not have any significant impact on decreasing fluid collection at the operative bed. The use of pressure dressing after thyroidectomy may not therefore be justified.

Trial Registration

NCT00400465, ISRCTN52660978

Surgery for thyroid cancer

A technique of thyroidectomy that facilitates resection of the thyroid, preserves the parathyroid glands with their blood supply, and preserves the recurrent and the superior laryngeal nerves is described. This technique provides a simple and versatile means of complete extracapsular thyroidectomy for lesions of the thyroid gland and minimizes postoperative complications.

Wound drains following thyroid surgery

BACKGROUND

The nature and indications for thyroid surgery vary and a perceived risk of haemorrhage post-surgery is one reason why wound drains are frequently inserted. However when a significant bleed occurs, wound drains may become blocked and the drain does not obviate the need for surgery or meticulous haemostasis. The evidence in support of the use of drains post-thyroid surgery is unclear therefore and a systematic review of the best available evidence was undertaken.

OBJECTIVES

To determine the effects of inserting a wound drain during thyroid surgery, on wound complications, respiratory complications and mortality.

SEARCH STRATEGY

We searched the following databases: Cochrane Wounds Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2007); MEDLINE (2005 to February 2007); EMBASE (2005 to February 2007); CINAHL (2005 to February 2007) using relevant search strategies.

SELECTION CRITERIA

Only randomised controlled trials were eligible for inclusion. Quasi randomised studies were excluded. Studies with participants undergoing any form of thyroid surgery, irrespective of indications, were eligible for inclusion in this review. Studies involving people undergoing parathyroid surgery and lateral neck dissections were excluded. At least 80% follow up (till discharge) was considered essential.

DATA COLLECTION AND ANALYSIS

Studies were assessed for eligibility and data were extracted by two authors independently, differences were resolved by discussion. Studies were assessed for validity including criteria on whether they used a robust method of random sequence generation and allocation concealment. Missing and unclear data were resolved by contacting the study authors.

MAIN RESULTS

13 eligible studies were identified (1646 participants). 11 studies compared drainage with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infections. Post-operative wound collections needing aspiration or drainage were significantly reduced by drains (RR 0.51, 95% CI 0.27 to 0.97), but a further analysis of the 4 high quality studies showed no significant difference (RR 1.82, 95% CI 0.51 to 6.46). Hospital stay was significantly prolonged in the drain group (WMD 1.18 days, 95% CI 0.73 to 1.63).Eleven studies compared suction drain with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infection rates. The incidence of collections that required aspiration or drainage without formal re-operation was significantly less in the drained group (RR 0.48, 95% CI 0.25 to 0.92). However, further analysis of only high quality studies showed no significant difference (RR 1.78, 95% CI 0.44 to 7.17). Hospital stay was significantly prolonged in the drain group (WMD 1.20 days, 95% CI 0.77 to 1.63). One study compared open drain with no drain. No participant in either group required re-operation. No data were available regarding the incidence of respiratory distress, wound infection and pain. The incidence of collections needing aspiration or drainage without re-operation was not significantly different between the groups and there was no significant difference in length of hospital stay. One study compared suction drainage with passive closed drainage. None of the participants in the study needed re-operation and data regarding other outcomes were not available. Two studies (180 participants) compared open drainage with suction drainage. One study reported wound infections and minor wound collections, both were not significantly different. The other study reported wound collections requiring intervention and hospital stay; both were not significantly different. None of the participants in either study required re-operation. Data regarding other outcomes were not available.

AUTHORS' CONCLUSIONS

There is no clear evidence that using drains in patients undergoing thyroid operations significantly improves patient outcomes and drains may be associated with an increased length of hospital stay. The existing evidence is from trials involving patients having goitres without mediastinal extension, normal coagulation indices and the operation not involving any lateral neck dissection for lymphadenectomy.

A randomised controlled trial of routine suction drainage after elective thyroid and parathyroid surgery with ultrasound evaluation of fluid collection

OBJECTIVE

To determine the need for suction drainage after elective thyroid and parathyroid surgery.

DESIGN

Randomised controlled trial.

SETTING

University teaching hospital.

PARTICIPANTS

Patients requiring elective thyroid or parathyroid surgery were recruited and informed consent was obtained (n = 100). Before wound closure, patients were randomised into either group A (to remain without suction drainage) or group B (to receive suction drainage). Excluded patients were those requiring associated neck dissection and those with bleeding diatheses, all of whom would necessarily require drainage in our unit.

MAIN OUTCOME MEASURES

Primary - ultrasound evaluation of any collection in the thyroid bed, performed 1-day postoperatively. Secondary - postoperative complications; length of in-patient stay.

RESULTS

One hundred patients completed the study, and groups A and B comprised 50 patients each. Patients in each group exhibited a mean age of 49 years, and a male to female ratio of 1 : 9. Both groups were also well-matched regarding type of operation, size of tumour and histopathological diagnosis. Modal and median postoperative neck collection volume on ultrasound examination was 0 and 0 cm(3) respectively (range 0-16 cm(3)) in group A and was 0 and 0 cm(3) (range 0-70 cm(3)) in group B. This difference was not statistically significant, but three patients with a haematoma were all in the suction drainage group. Difference in complication rates between groups was also not statistically significant. Modal and median length of in-patient stay was 2 and 2 days respectively (range 2-3 days) in group A and 3 and 3 days (range 2-4 days) in group B, and this difference was statistically significant (P = 0.0006).

CONCLUSION

Routine suction drainage after uncomplicated elective thyroid and parathyroid surgery appears unnecessary, and prolongs in-patient stay.