Questionable safety of thyroid surgery with same day discharge

Early CT scan prevents airway obstruction in a thyroidectomy case complicated by postoperative hematoma: A case report

INTRODUCTION

Among patients undergoing thyroid or head and neck surgery, the incidence of postoperative hemorrhage is reported to range between 0.36 % and 4.2 %. Postoperative bleeding in the neck can lead to severe complications if not promptly addressed.

PRESENTATION OF CASE

The patient in this case was a man in his 50s, who was being treated for T3-dominant Basedow's disease with medication at the endocrinology department of our hospital. However, owing to the ineffectiveness of drug therapy in controlling the condition, the patient was referred to our department for surgery. Approximately 18 h after undergoing a thyroidectomy, the patient suddenly complained of dyspnea. Laryngeal fiberoptic examination showed no signs of laryngeal edema or recurrent nerve palsy. However, a neck CT scan revealed a hematoma at the surgical site, necessitating emergency surgery. During the operation, hematomas were found in both the superficial and deep layers of the surgical area. Arterial bleeding from the left side of the thyroid cartilage was confirmed, and the branches of the superior laryngeal artery were ligated to stop the bleeding.

DISCUSSION

Hematoma formation in a narrow space, particularly in the neck, can obstruct large vessels such as the internal jugular veins, compromising venous return. This may result in laryngeal edema, asphyxia, and, in the worst-case scenario, death.

CONCLUSION

An early neck CT scan revealed a subcutaneous neck hematoma caused by postoperative bleeding, leading to emergency hematoma removal, hemostasis, and tracheotomy, which successfully prevented airway obstruction.

Bimaxillary osteotomies as a less than 24-hour stay procedure

Historically, Le Fort I bimaxillary osteotomy (BMO) in the UK has generally been regarded as a surgical procedure requiring a full day of operating with subsequent hospital stay for several days, including potential intensive care admission and blood transfusions. Following the introduction of the national standards on day case surgery in the UK in 2011, the authors have routinely and successfully performed bilateral sagittal split osteotomy surgery (BSSO) as a day-case procedure, whilst achieving excellent patient satisfaction since 2015. The desire to improve efficiency in the management of patients requiring short-term surgical admission, was also applied to BMO procedures, with aims for a short, less than 24 h (<24-hour) stay admission, for patients with appropriate medical and social circumstances. With day surgery and short stay admission considered fundamental to modern care, this presents multiple benefits for both patients and the National Health Service (NHS). Our aim was to demonstrate that our BMOs conform to current national standards, and could be carried out both successfully and safely, as a <24-hour stay procedure. All patients undergoing BMOs (n = 165) were planned as a <24-hour stay procedure between 2012 and 2023 by the same consultant. Demographic details, operative time, length of stay, and re-admittance rates were reviewed retrospectively. Of these patients, 96.4% (n = 159) were discharged within 24 h of the procedure. Four patients (2.4%) were discharged within 24-48 h, and two (1.2%) within 48-72 h. There were no re-admissions within 48 h of discharge. We concluded that BMOs, along with concurrent wisdom tooth removal, can be carried out successfully and routinely as a single, short stay procedure. However, to reduce the rate of prolonged admission, it is recommended that a strict perioperative protocol be followed.

Safety of thyroidectomy as day care surgery at a rural setting in Eastern Uganda

BACKGROUND

The practice of day care surgery is less embraced in many low-middle-income countries (LMIC), and even less for some procedures considered major such as thyroidectomy. Here we examine the safety of day care thyroidectomy at Kyabirwa Surgical Center, a stand-alone day care surgery center in rural Eastern Uganda.

METHODS

This was a retrospective cohort study conducted between 2019 and 2023. All patients who had day care thyroidectomy were included. Demographics, diagnosis, investigation findings, pathology reports, and surgery outcomes were collected. Postoperative follow-up data up to 30 days were also collected. Data were analyzed using R version 4.3.2.

RESULTS

A total of 51 patients underwent same-day thyroidectomy, with an average age of 44.9 ± 12.1 years and 98% female. Procedures included total thyroidectomy (5, 9.8%), subtotal thyroidectomy (26, 51.0%), and lobectomy (20, 39.2%). Average size of the glands was 7.9 ± 2.21 cm. The majority 46 (90.2%) were of benign pathology. All patients were discharged by the evening of the same day. Complications encountered included hypocalcemia (1), hypertrophic scar (1), seroma (2), and transient recurrent laryngeal nerve injury (1). Overall complications rate was 9.8%. Gland size was statistically significant between patients with no complications (7.68 ± 2.06 cm) versus complications (9.90 ± 2.82, p < 0.05).

CONCLUSION

With overall low complication rates, these findings suggest that thyroidectomy can safely be performed on a day care basis in a rural LMIC setting with suboptimal health care delivery.

Clinical outcomes of outpatient thyroidectomy: A systematic review and single-arm meta-analysis

BACKGROUND

The aim of this meta-analysis is to investigate the safety of outpatient thyroidectomy based on 24-h and same-day discharge criteria.

METHODS

CENTRAL, Embase, PubMed, and Scopus were searched. A meta-analysis of selected studies was performed. The review was registered prospectively with PROSPERO (CRD42022361134).

RESULTS

Thirty-one studies met the eligibility criteria, with a total of 74328 patients undergoing thyroidectomy in an outpatient setting based on 24-h discharge criteria. Overall postoperative complications after outpatient thyroidectomies were 5.7% (95%CI: 0.049-0.065; I2 ​= ​97.3%), consisting of hematoma (0.4%; 95%CI: 0.003-0.005; I2 ​= ​83.4%), recurrent laryngeal nerve injury (0.4%; 95%CI: 0.003-0.006; I2 ​= ​93.5%), and hypocalcemia (1.6%; 95%CI: 0.012-0.019; I2 ​= ​93.7%). The rate of readmission was 1.1% (95%CI: 0.007-0.015; I2 ​= ​95.4%). Results were similar for same-day criteria.

CONCLUSIONS

Our analysis demonstrated that outpatient thyroidectomy is a safe procedure in the management of thyroid disease for selected patients.

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.

Outpatient endocrine surgery practice patterns are highly variable among US endocrine surgery fellowship programs

BACKGROUND

Current studies and guidelines have reported that outpatient endocrine surgery is safe. However, none recommend specific postoperative protocols.

METHODS

An internet-based survey, developed using expert input, was distributed to current (2021-2022) endocrine surgery fellows in American Association of Endocrine Surgeons-accredited programs (n = 23). Programs with ≤2% same-day discharge rate were compared with those with ≥2% same-day discharge rate.

RESULTS

The survey response rate was 91% (21/23), representing 20 United States institutions performing >15,000 cervical endocrine operations annually. The same-day discharge rate after total thyroidectomy was not normally distributed across institutions (P < .0001) but appeared bimodal, highlighting dogmatic differences in the pursuit of same-day discharge. Nine programs had ≤2% same-day discharge rate, whereas seven had ≥90% same-day discharge rate. Fourteen (70%) reported minimum observation periods before discharge, without consistency across procedures or institutions. Total thyroidectomy patients were observed longer. Fourteen (70%) reported no geographic restrictions for same-day discharge. In programs with >2% same-day discharge (n = 11), clinical and operative factors inconsistently influenced same-day discharge after thyroidectomy. Living alone precluded same-day discharge in 3 programs. Lateral neck dissection and chronic anticoagulation each greatly reduced same-day discharge in one program and precluded same-day discharge in another. Central neck dissection, Graves' disease, substernal goiter, continuous positive airway pressure use, difficult/bloody operation, and signal on nerve stimulation had no or minimal effect on same-day discharge. Postoperative medication recommendations varied among programs. Although anticoagulation/antiplatelet agents were similarly held preoperatively across programs, resumption varied. Narcotics were routinely prescribed in 35%.

CONCLUSION

Same-day discharge is not uniform across endocrine surgery training programs and is likely primarily driven by surgeon preference. Factors influencing same-day discharge vary significantly among programs.

Feasibility and Safety of Ambulatory Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)

Background

In search of an ideal cosmesis, transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has recently been introduced to avoid a visible scar. Although ambulatory thyroid surgery is considered safe in carefully selected patients, this remains unclear for TOETVA.

Methods

All consecutive adult patients who underwent ambulatory TOETVA or open thyroid surgery at a French university hospital were prospectively enrolled from 12/2020 until 11/2021. The primary outcome was postoperative morbidity (recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, wound morbidity, or hospital readmission). The secondary outcome was quality of life (QoL), measured by a survey including a validated questionnaire (SF-12) and a modified thyroid surgery questionnaire six weeks after surgery.

Results

Throughout the study period, 374 patients underwent a unilateral lobectomy or isthmectomy in ambulatory setting, of which 34 (9%) as TOETVA (including 21 (62%) for a possible malignancy). In the TOETVA group, younger age (median 40 (IQR 35–50) vs. 51 (40–60) years, P < 0.001) and lower BMI (median 23.1 (20.9–25.4) vs. 24.9 (22.1–28.9) kg/m², P = 0.001) were noted. No cases were converted to open cervicotomy. TOETVA was at least as good as open cervicotomy with nil versus four (1%) re-interventions for bleeding, one temporary (5%) versus 13 (4%) (temporary) RLN palsies, and one (<1%) wound infection (open cervicotomy group). No hospital readmissions occurred in all ambulatory surgery patients. No differences were found in physical (P = 0.280) and mental (P = 0.569) QoL between TOETVA and open surgery.

Conclusions

In carefully selected patients, the feasibility and safety of ambulatory TOETVA are comparable to open surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06666-y.

Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia

PURPOSE

Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia.

METHODS

Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H₀), after removal of the gland (H_drop), 6 h (H₆) and one day (D₁) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times.

RESULTS

The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H₆, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant.

CONCLUSION

The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

Quality of life and patient satisfaction in outpatient thyroid surgery

In the last three decades surgeons have begun to perform outpatient thyroid surgery (OTS). Important outcome measures of a day-hospital procedure are the patient's quality of life (QoL) and satisfaction, but information on these issues in the OTS setting is scanty. The aim of this pilot study was to explore how early discharge after thyroidectomy affects patients' QoL and satisfaction. Postoperative QoL and satisfaction were assessed retrospectively by giving each patient a self-report questionnaire specifically created in our center for OTS and derived from the post-discharge surgical recovery (PSR) scale to assess physical and mental well-being. Twenty-three of 24 patients (96%), 16 women and 7 men with a median age of 48 years (range 16-72), completed the questionnaire, answering 92% of the questions. QoL based on this scale gave a median score of 81.8% (range 62-98.8%). No major or minor complications occurred in the study group. Regarding QoL eight patients (35%) reported feeling "tired all the time" and six patients (26%) reported mild pain, which in two cases resolved spontaneously. Regarding patient satisfaction two-thirds of patients judged OTS positively while the remaining one-third would not recommend it. Our study showed very good uptake by patients of a new questionnaire dedicated to OTS as a possible aid in the identification of areas for improvement of OTS management. However, to be considered a safe procedure with maximum patient compliance and satisfaction, OTS was found to require considerable effort by hospital staff and patients' caregivers compared to inpatient thyroid surgery.

Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery

Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri‐operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high‐quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post‐thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post‐haematoma evacuation care; day‐case thyroid surgery; training; consent and pre‐operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.

A Population-Based Analysis of Outpatient Thyroidectomy: Safe and Under-Utilized

OBJECTIVES/HYPOTHESIS

Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought to assess the uptake and safety of outpatient thyroidectomy in Ontario.

STUDY DESIGN

Retrospective cohort study.

METHODS

This was a population-based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30-day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure-outcome relationship.

RESULTS

The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993-1994 to 17.8% in 2016-2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.73[95CI% 0.58-0.93)], but higher odds of emergency department use (OR 1.67[95%CI 1.56-1.79]).

CONCLUSIONS

Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well-established safety profile.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Post-thyroidectomy bleeding: analysis of risk factors from a national registry

BACKGROUND

Post-thyroidectomy haemorrhage occurs in 1-2 per cent of patients, one-quarter requiring bedside clot evacuation. Owing to the risk of life-threatening haemorrhage, previous British Association of Endocrine and Thyroid Surgeons (BAETS) guidance has been that day-case thyroidectomy could not be endorsed. This study aimed to review the best currently available UK data to evaluate a recent change in this recommendation.

METHODS

The UK Registry of Endocrine and Thyroid Surgery was analysed to determine the incidence of and risk factors for post-thyroidectomy haemorrhage from 2004 to 2018.

RESULTS

Reoperation for bleeding occurred in 1.2 per cent (449 of 39 014) of all thyroidectomies. In multivariable analysis male sex, increasing age, redo surgery, retrosternal goitre and total thyroidectomy were significantly correlated with an increased risk of reoperation for bleeding, and surgeon monthly thyroidectomy rate correlated with a decreased risk. Estimation of variation in bleeding risk from these predictors gave low pseudo-R2 values, suggesting that bleeding is unpredictable. Reoperation for bleeding occurred in 0.9 per cent (217 of 24 700) of hemithyroidectomies, with male sex, increasing age, decreasing surgeon volume and redo surgery being risk factors. The mortality rate following thyroidectomy was 0.1 per cent (23 of 38 740). In a multivariable model including reoperation for bleeding node dissection and age were significant risk factors for mortality.

CONCLUSION

The highest risk for bleeding occurred following total thyroidectomy in men, but overall bleeding was unpredictable. In hemithyroidectomy increasing surgeon thyroidectomy volume reduces bleeding risk. This analysis supports the revised BAETS recommendation to restrict day-case thyroid surgery to hemithyroidectomy performed by high-volume surgeons, with caution in the elderly, men, patients with retrosternal goitres, and those undergoing redo surgery.

Reoperation for Bleeding After Thyroid and Parathyroid Surgery: Incidence, Risk Factors, Prevention, and Management

INTRODUCTION

Bleeding after thyroid and/or parathyroid surgery is a life-threatening emergency. The aim of this study was to determine the rates of reoperation following bleeding, identify risk factors, assess management strategies and outcomes, and develop protocols to reduce risk and improve management of bleeding.

METHODS

A retrospective cohort study of all consecutive patients who underwent thyroid and/or parathyroid surgery over a 7-year period was conducted. A nested case-control design was used to evaluate specific factors and their association with reoperation for bleeding.

RESULTS

Of 1913 patients, 25 (1.3%) underwent reoperation for bleeding. Of the 25 patients who bled, 6 (24%) required reoperation before leaving theatre; 17 (68%) had bleeding within 6 h, 1 (4%) between 6 and 24 h, and 1 (4%) after 24 h. Reoperation for bleeding was not associated with age, gender, or surgeon. Patients who had total thyroidectomy were more likely to have reoperation for bleeding compared to hemithyroidectomy (p = 0.045) or parathyroidectomy (p = 0.001). The following factors were not associated with bleeding: neck dissection, re-do surgery, drain use, blood-thinning medication or clotting disorders, and BMI. Patients who had reoperation for bleeding had longer hospital stay (p = 0.001), but similar rates of RLN palsy, wound infection, and hypoparathyroidism.

CONCLUSION

A higher risk profile for significant post-operative bleeding cannot be determined in patients undergoing thyroid surgery. Based on this experience, we developed protocols to reduce the risk of bleeding (the ITSRED Fred protocol) and for the early detection and management of bleed (the SCOOP protocol) following thyroid and/or parathyroid surgery.

A Review of Parathyroid Surgery for Primary Hyperparathyroidism from the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS)

BACKGROUND

The United Kingdom Registry of Endocrine and Thyroid Surgeons is a national database holding details on > 28,000 parathyroidectomies.

METHODS

An extract (2004-2017) of the database was analysed to investigate the reported efficacy, safety and use of intra-operative surgical adjuncts in targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) for adult, first-time primary hyperparathyroidism (PHPT).

RESULTS

50.9% of 21,738 cases underwent tPTx. Excellent short-term (median follow-up 35 days) post-operative normocalcaemia rates were reported overall (tPTx 96.6%, BNE 94.5%, p < 0.05) and in image-positive cases (tPTx 96.7%, BNE 96%, p < 0.05). Intra-operative PTH improved overall normocalcaemia rates (tPTx 97.8% vs 96.3%, BNE 95% vs 94.4%: both p < 0.05). Intra-operative nerve monitoring reduced vocal cord (VC) dysfunction in image-positive tPTx, but not in BNE (97.8% vs 93.2%, p < 0.05). Complications were higher following BNE (7.4% vs 3.8%, p < 0.05), especially hypocalcaemia (5.3% vs 2%, p < 0.05). There was no difference in rates of subjective dysphonia following tPTx or BNE (2.4% vs 2.3%, p > 0.05), nor any difference in VC dysfunction when formally examined (4.9% vs 4.1%, p > 0.05).

CONCLUSIONS

In image-positive, first time, adult PHPT cases, tPTx is as safe and effective as BNE, with both achieving excellent short-term results with minimal complications.

Risk Score of Neck Hematoma: How to Select Patients for Ambulatory Thyroid Surgery?

BACKGROUND

The risk of postoperative compressive hematoma is the major limitation for a wide development of ambulatory thyroidectomy (AT). The aim of this study was to establish a risk score of hematoma on the basis of preoperative criteria.

METHODS

All patients who underwent thyroidectomy between 2002 and 2017 were reviewed in a high-volume endocrine surgery center. Multivariate analysis of risk factors associated with hematoma was performed in lobectomy and total thyroidectomy (TT). We assigned the risk factors identified by multivariate analysis weighted points proportional to the regression coefficient values. A simple sum of all accumulated points for each patient calculated the total score.

RESULTS

For lobectomy [31 hematoma among 3912 patients (0.8%)], the weighted points of Vit K antagonist (VKA) were 3 (OR 9.86), and 1 in male gender (OR 2.4). For TT [162 hematoma among 13,903 patients (1.2%)], the weighted points of VKA were 4 (OR 12.18), 1 in male gender (OR 1.89), and 1 for diabetes (OR 1.86). Other factors weighted 0 in both groups. A total score >1 was linked to a risk of hematoma > 1.3% for lobectomy or TT. AT should not be proposed to any patient under VKA, and in case of TT, to male patients with diabetes. Prospectively, patients had AT from May 2018 to February 2020, 529 patients underwent ambulatory TL (483) or TT (46) and only one patient experienced neck hematoma.

CONCLUSION

We established a simple and reproducible predictive score of early discharge for lobectomy and TT that could be useful for patients' management.

High-risk surgical procedures and semi-emergent surgical procedures for ambulatory surgery

PURPOSE OF REVIEW

This review evaluates more complex surgical procedures to see whether they might be suitable for ambulatory surgery. Operations that have shown an increasing daycase rate in England include thyroidectomy, joint arthroplasty, spinal surgery and hysterectomy, and these procedures are evaluated. Similarly, there have been recent developments in the management of nonelective ambulatory surgery with more timely throughput and home discharge for suitable patients.

RECENT FINDINGS

Caveats on patient selection with the development of focussed educational programmes about the proposed operation have assisted with the development of shorter discharge times. Strict antiemetic guidelines, multimodal analgesic protocols and postoperative multidisciplinary follow-up are core components of the pathway for effective ambulatory management. Communication after discharge should include phone calls from the Ambulatory Unit and easy access to the medical staff who conducted their operation.

SUMMARY

There should be no reason why more complex surgical operations could not be included in a day surgery armamentarium. Similarly, the evidence for more effective use of timely emergency care with shortened length of stay is increasing.

Thyroidectomy in a Surgical Volunteerism Mission: Analysis of 464 Consecutive Cases

Although surgical volunteer missions (SVMs) have become a popular approach for reducing the burden of surgical disease worldwide, the outcomes of specific procedures in the context of a mission are underreported. The aim of this study was to evaluate outcomes and efficiency of thyroid surgery within a surgical mission. This was a retrospective analysis of medical records of all patients who underwent thyroid surgery within a SVM from 2006 to 2019. Postoperative complication rate was the safety endpoint, whereas length of hospital stay (LOS) was the efficiency endpoint. Serious complications were defined as Clavien-Dindo class 3-5 complications. Expected safety and efficiency outcomes were calculated using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical risk calculator and compared to their observed counterparts. A total of 464 thyroidectomies were performed during the study period. Mean age of the patients was 40.3 ± 10.8 years, and male-to-female ratio was 72 : 392. Expected overall (p=0.127) and serious complication rates (p=0.738) were not significantly different from their observed counterparts. Expected LOS was found to be significantly shorter as compared to its observed counterpart (0.6 ± 0.2 vs. 2.5 ± 1.0 days; p < 0.001). This study found thyroid surgery performed within a surgical mission to be safe. NSQIP surgical risk calculator underestimates the LOS following thyroidectomy in surgical missions.

Postoperative Bleeding after Thyroid Surgery: Care Instructions

Prospective studies on the incidence, etiology, and prognosis of well-characterized patients with bleeding after thyroid surgery are lacking. Bleeding after thyroid surgery cannot be predicted or prevented even if risk factors are known in every single procedure, which enhances the im-portance of the following issues: (a) meticulous hemostasis and surgical technique; (b) coopera-tion with the anesthesiologist, i.e., controlling the Valsalva maneuver, adequate blood pressure at the end of the operation as well as at extubation phase and (c) in case of bleeding, a prompt management to guarantee a better outcome. This requires an intensive postoperative clinical monitoring of patients, ideally, in a recovery room with trained staff for at least 4-6 h. Early recognition of postoperative bleeding with immediate intervention is the key to the management of this complication.

Surgical management of cytologically indeterminate thyroid nodules

Nodules in the thyroid are frequent. Preoperative investigations including fine-needle cytology and ultrasound cannot in all patients rule out malignancy. Thus, surgical excision for histopathologic examination is often needed. In this narrative review, we examine aspects of the surgical management of indeterminate thyroid nodules, using a comprehensive review of the available literature. The authors manually searched PubMed for relevant literature, including recently published guidelines. Hemithyroidectomy without lymph node dissection remains the recommended management in indeterminate thyroid nodules, i.e., the complete removal of one lobe of the thyroid, for indeterminate thyroid nodules, defined as nodules with fine-needle cytology fulfilling the criteria of Bethesda III or IV categories. At surgery, it is important to preserve the recurrent and superior laryngeal nerves, and intraoperative neuromonitoring is a useful adjunct. Recent data also suggest that parathyroid autofluorescent techniques are promising tools for parathyroid preservation. There is still lack of specific preoperative investigations to rule in or out central lymph node metastasis. Intraoperative frozen section of lymph nodes can be valuable, but prophylactic or diagnostic central lymph node dissection is not routinely recommended. Outcomes after thyroid surgery are better with high-volume surgeons and institutions. Surgery is probably best performed by high-volume surgeons in institutions with on-site expert pathologists and with technical adjuncts available for nerve and parathyroid preservation. Day-care surgery may be an option for selected patients.

Current practice in the surgical management of parathyroid disorders: a United Kingdom survey

PURPOSE

Surgery for primary hyperparathyroidism is undertaken by many specialties but predominantly endocrine and ear, nose and throat (ENT) surgeons. There is currently no consensus on the peri-operative management of primary hyperparathyroidism. We sought to determine current surgical practice and identify any inter-specialty variation in the United Kingdom (UK).

METHODS

An online survey was disseminated to members of the British Association of Endocrine & Thyroid Surgeons (BAETS) in the UK.

RESULTS

78 surgeons responded (40 Endocrine, 37 ENT and 1 maxillofacial). 90% of surgeons used ultrasound and sestamibi for pre-operative localisation. Intraoperative frozen section (31%) and parathyroid hormone monitoring (41%) were the most common adjuncts used intraoperatively. 68% of surgeons did not use any wound drains. Nearly two-thirds of surgeons (64%) discharged patients from the clinic within 3 months, There were some significant differences (p < 0.05) in particular areas of practice between endocrine and ENT surgeons (%, p): use of single-photon emission computed tomography (SPECT) (Endocrine 25% vs. ENT 5%), preoperative laryngeal assessment (endocrine 58% vs. ENT 95%), intraoperative laryngeal nerve monitoring (endocrine 35% vs. ENT 68%), use of monopolar diathermy (endocrine 58% vs. ENT 22%), bipolar diathermy (endocrine 60% vs. 89%) and surgical ties (endocrine 48% vs. ENT 19%).

CONCLUSION

Our study demonstrates some similarities as well as some notable differences in practice between endocrine and ENT surgeons, and therefore, highlights the need for national consensus with respect to some key areas in parathyroid surgery.

Same day discharge after thyroidectomy is safe and effective

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely.

METHODS

This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits.

RESULTS

A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke.

CONCLUSION

Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

To admit or not to admit? Experience with outpatient thyroidectomy for Graves' disease in a high-volume tertiary care center

BACKGROUND

Outpatient thyroidectomy is increasingly performed. Thyroidectomy for Graves' disease, however, has greater risk of periprocedural complications, limiting use of same-day procedures. We sought to demonstrate that these patients may be managed with ambulatory surgery.

METHODS

The experience of one endocrine surgeon with thyroidectomy for Graves' was examined from January 2016-November 2017. Forty-one patients met criteria. Patient demographics, perioperative parameters, and postoperative outcomes including emergency department utilization and readmission were recorded.

RESULTS

Mean age was 31.5 ± 17.0 years, with 80% females. Mode ASA score was 3, and median operative time was 77 minutes (43-132). Complications included transient hypocalcaemia in 12%, and temporary laryngeal nerve palsy in 9.7%, with no permanent complications. Two patients were admitted immediately postoperatively for non-medical reasons. Thirty-day emergency rdepartment visits were noted in 9.7%, with subsequent readmission of 7%.

CONCLUSIONS

Outpatient total thyroidectomy is safe and effective with acceptable morbidity in the Graves' patient.

Assessment of the safety and feasibility of 24-hour hospitalization after thyroidectomy

This study assessed the safety and feasibility of 24-hour hospitalization after thyroid surgery. A randomized controlled trial study was performed for 432 patients scheduled for thyroidectomy in Guangdong General Hospital between January 2014 and January 2016. Group A cases (n = 216) were 24-hour hospital stay and group B cases (n = 216) were inpatient. Preoperative patient characteristics and operative characteristics as well surgical complications were evaluated. Two hundred and fourteen patients (99%) of group A were discharged after a 24-hour postoperative observation except 1 patient hospitalized 2 days for persistent nausea after surgery, and 1 patient who was hospitalized for 2 days for fear of the complication after the operation. The complication rates were similar between the 2 groups (9/216, 11/216; P > 0.05) and no one was readmitted for operation. The overall complication rate of 24-hour hospital stay procedure was low, and there were no differences in the rate of complications between these 2 groups. Thyroid surgery with 24-hour hospital stay is feasible and safe by experienced surgeon in a setting of appropriate facility and management protocol.

Litigation in thyroid surgery in England

Thyroid surgery has the potential for significant life-changing postoperative complications. Since 1995, the NHS Litigation Authority has handled litigation claims in England. This article reviews all thyroid surgery litigation claims between 1995 and 2012 and looks at potential strategies to minimize future claims.

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.

Risk factors for postoperative complications in total thyroidectomy: A retrospective, risk-adjusted analysis from the National Surgical Quality Improvement Program

Thyroid cancer incidence is increasing, and with it, an increase in total thyroidectomy. There are limited studies comparing outcomes in total thyroidectomy performed in the inpatient versus outpatient setting.The objective of this study was to perform a comparative analysis of risk factors and outcomes of postoperative morbidity and mortality in total thyroidectomy performed as an inpatient versus outpatient surgery.Retrospective cohort study of data from the 2005 to 2014 multi-institutional, risk-adjusted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. A multivariate regression model with corresponding odds ratios and 95% confidence intervals was used to determine 30-day morbidity and mortality after total thyroidectomies, and also risk factors of postoperative outcomes.From 2005 to 2014, 40,025 total thyroidectomies were performed (48.5% inpatient, 51.5% outpatient). The 30-day complication rate for all total thyroidectomies was 7.74%. Multivariate logistic regression analysis was performed to control for potential confounding variables. Preoperative factors that affected complications rates for inpatient thyroidectomies included: age ≥70, non-Caucasian race, dependent functional status, history of congestive heart failure, smoking history, bleeding disorder, wound infection, and preoperative sepsis (P < 0.05). In addition, preoperative factors affecting complications in thyroidectomy performed as an outpatient surgery included malignant thyroid pathology (P  0.05).We identified a subset of preoperative conditions that affect risk of complications after total thyroidectomy. Recommendations for patient selection for outpatient total thyroidectomies should be modified to account for pre-existing conditions that increase the risk of postoperative morbidity.

Patterns, timing and consequences of post-thyroidectomy haemorrhage

INTRODUCTION Post-thyroidectomy bleeding is a low frequency but potentially life threatening event that is very difficult to predict. Given the increasing drive towards thyroidectomy with same day discharge, this study was conducted with the aim of identifying patterns, timing and consequences of post-thyroidectomy bleeding to assess the feasibility of day-case thyroidectomy. METHODS All patients who underwent a thyroidectomy between 2008 and 2015 at our institution were identified. Patterns, timing and consequences in all those who developed post-thyroidectomy bleeding were studied. RESULTS Of the 805 patients included in the study, 14 required re-exploration for bleeding; 7 (50%) of these within 8 hours of surgery, 6 (43%) between 18 and 30 hours, and 1 (7%) at 49 hours. Just under half (43%) of those with post-thyroidectomy bleeding had thyrotoxicosis. CONCLUSIONS A significant number of postoperative haemorrhages occurred beyond the immediate postoperative period. Same day discharge after thyroidectomy cannot therefore be recommended as a routine practice.

Cervical hematoma following an endocrine surgical procedure: The MD Anderson experience

BACKGROUND

Airway compromise from postoperative neck hematoma remains the most feared complication after cervical endocrine operative procedures. Events are rare and potentially lethal, and clear multidisciplinary guidelines for management of these patients are lacking. The aim of our study was to review the experience of a tertiary cancer center in this scenario.

METHODS

Data prospectively collected over a 10-year period, between 2005 and 2014, were retrospectively analyzed. We included all adult patients who had had a neck operation and needed reoperation for postoperative neck hematoma after an endocrine procedure. We excluded pediatric patients and cases with incomplete records.

RESULTS

The inclusion criteria were met for 21 patients (21/2,930; 0.7%). The median age at operation was 56.2 years (SD: 16.7). The M:F ratio was 1:2. All 21 patients presented with a neck swelling at the time of reoperation. Eight of 21 patients (38%) underwent emergency bedside clot evacuation. Presentation was within 6 hours for two thirds (14/21) of the patients; the remaining one third of the patients had the hematoma develop during the evening/night (from 1700-0500). The mean estimated hematoma size was 98 cc (SD: 58). A source of bleeding was identified in 12 of 21 cases (57%). A total of 15.8% of patients had an airway classified as difficult/awkward under the American Society of Anesthesiologists classification for their wound re-exploration.

CONCLUSION

Postoperation, increased vigilance is needed for the first 6 hours to detect patients with neck swelling. Emergency drainage by the bedside was performed in 38% of patients. A difficult airway was uncommon in our series.

[Surgical assessment of complications after thyroid gland operations]

BACKGROUND

The extent, magnitude and technical equipment used for thyroid surgery has changed considerably in Germany during the last decade. The number of thyroidectomies due to benign goiter have decreased while the extent of thyroidectomy, nowadays preferentially total thyroidectomy, has increased. Due to an increased awareness of surgical complications the number of malpractice claims is increasing.

OBJECTIVES

In contrast to surgical databases the frequency of complications in malpractice claims reflects the individual impact of complications on the quality of life. In contrast to surgical databases unilateral and bilateral vocal fold palsy are therefore at the forefront of malpractice claims. As guidelines are often not applicable for the individual surgical expert review, the question arises which are the relevant criteria for the professional expert witness assessing the severity of the individual complication.

RESULTS

While in surgical databases major complications after thyroidectomy, such as vocal fold palsy, hypoparathyroidism, hemorrhage and infections are equally frequent (1-3 %), in malpractice claims vocal fold palsy is significantly more frequent (50 %) compared to hypoparathyroidism (15 %), hemorrhage and infections (about 5 % each). To avoid bilateral nerve palsy intraoperative nerve monitoring has become of utmost importance for surgical strategy and malpractice suits alike. For surgical expert review documentation of individual risk-oriented indications, the surgical approach and postoperative management are highly important.

CONCLUSION

Guidelines only define the treatment corridors of good clinical practice. Surgical expert reviews in malpractice suits concerning quality of care and causality between surgical management, complications and sequelae of complications are therefore highly dependent on the grounds and documentation of risk-oriented indications for thyroidectomy, intraoperative and postoperative surgical management.

[Avoidance and management of hypoparathyroidism after thyroid gland surgery]

Postoperative hypoparathyroidism after bilateral thyroid gland surgery or after interventions for recurrence is defined as intact parathyroid hormone levels (iPTH) < 15 pg/ml with simultaneous normal, below normal and markedly decreased serum calcium levels. After bilateral thyroid surgery and after reoperations a single iPTH measurement performed 12-24 h postoperatively can be used to predict parathyroid metabolism. Patients with an iPTH level ≥ 15 pg/ml may be discharged safely, patients with an iPTH < 10 pg/ml must be substituted with calcium and vitamin D and patients with an iPTH between 10 and 15 pg/ml (grey zone) may be discharged if a second measurement 48 h after surgery documents an iPTH ≥ 15 pg/ml. This procedure increases the length of hospital stay. Patients in the (grey zone) must be substituted. The iPTH level and its course determine the necessity, dose and length of calcium and vitamin D substitution.

Enhanced recovery programmes in head and neck surgery: systematic review

Objective:

To review the literature on enhanced recovery programmes in head and neck surgery.

Method:

A systematic review was performed in May 2013.

Results:

Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed.

Conclusion:

Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.

[Total thyroidectomy with lymph node dissection of the central compartment for node-positive, capsular invasive papillary thyroid cancer: video contribution]

The aim of radical oncological surgery for nodal metastasized papillary thyroid cancer is, as for other oncological interventions in visceral surgery, the anatomy-related implementation of the concept of en bloc (no touch) resection of the organ bearing the primary tumor together with the first lymph node station, while the structures of the aerodigestive tract, the recurrent laryngeal nerves and parathyroid glands are preserved. The surgical technique is demonstrated in detail with the help of a video of the operation and which is available on-line, the advantages and disadvantages of the technique are discussed.

Perioperative care in elderly patients undergoing thyroid surgery

The features of western world population are rapidly changing. The increment geriatric population obliges clinicians to implement specific recommendations and guidelines to manage these patients. In the field of thyroid surgery, when indications are represented by benign conditions, surgeons and endocrinologists tent to avoid surgery for the increased perioperative risks in the over 70 year old population. We reviewed our experience in thyroid surgery in geriatric patients within the environment of a "week surgery unit". This unit was conceived to offer a highly specialized setting for thyroid patients needing short stay after surgery. Results showed that the surgical outcomes were comparable to the ones from third surgery in young patients. The week surgery approach is the best and safest formula to offer to the geriatric population needing thyroid surgery.

Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients

BACKGROUND

With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking.

METHODS

The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts.

RESULTS

In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication.

CONCLUSIONS

Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.

Predictors of 30-day readmission after outpatient thyroidectomy: an analysis of the 2011 NSQIP data set

PURPOSE

With enhancements in patient safety and improvements in anesthesia administration, outpatient thyroidectomy is now frequently undertaken as an outpatient procedure, with several peer-reviewed reports of safe implementation totaling over 4500 procedures since 2006. However, robust statistical analyses of predictors for readmission are lacking.

METHODS

The 2011 NSQIP data set was queried to identify all patients undergoing thyroidectomy on an outpatient basis. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify the predictors of these events.

RESULTS

In total 5121 patients were identified to have undergone an outpatient thyroidectomy in 2011. Overall 30-day morbidity was rare with only 47 patients (0.92%) experiencing any perioperative morbidity. One hundred eleven (2.17%) patients were readmitted within 30 days of the operation. A history of COPD was the only preoperative comorbid medical condition that significantly increased a patient's risk for readmission (OR 3.73 95% CI 1.57-8.85, p=0.003). Patients with a surgical complication were more than 7 times as likely to be readmitted (OR 2.08-25.28, p=0.002), and those with a medical complication were over 19 times as likely to be readmitted (OR 7.32-50.78, p<0.001).

CONCLUSIONS

Readmission after outpatient thyroidectomy is infrequent, and compares well with other outpatient procedures. The main identified risks include preoperative COPD and any of the generic postoperative complications tracked in NSQIP. As procedures continue to transition into outpatient settings and financial penalties associated with readmission become a reality, these findings will serve to optimize outpatient surgery utilization.

Ambulatory thyroid surgery: do the risks overcome the benefits?

With appropriate selection, ambulatory thyroid surgery is feasible. Thyroid surgery is unique amongst ambulatory procedures in that it is associated with a small but unpredictable risk of rapid onset compromising cervical haematoma that may require immediate treatment. Reports of "safety" are frequently from series which are too small to give complete assurance. Postoperative haemorrhage is the only issue that makes day case surgery questionable because other risks (hypocalcaemia, nerve injury) can be mitigated. Studies suggest 20-60% bleed will occur after 6 hours but the clinical severity of later bleeds is unclear. The reliability of more specific data from complications occurring at home is liable to under-reporting. The need for a tracheostomy is considerably higher when there is a delay in the recognition of symptoms (as it could be at home) and re-intervention; this underlies the increased morbidity with laryngeal and supraglottic oedema that may accompany a delay in the treatment of post-thyroidectomy bleeds. The estimated cost savings from ambulatory thyroid surgery may be an over-estimate given that true costs may be reduced by optimisation of ward staffing.

American Thyroid Association statement on outpatient thyroidectomy

BACKGROUND

The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for outpatient thyroidectomy and to explore preoperative, intraoperative, and postoperative factors that should be considered in order to optimize the safe and efficient performance of ambulatory surgery.

SUMMARY

A series of criteria was developed that may represent relative contraindications to outpatient thyroidectomy, and these fell into the following broad categories: clinical, social, and procedural issues. Intraoperative factors that bear consideration are enumerated, and include choice of anesthesia, use of nerve monitoring, hemostasis, management of the parathyroid glands, wound closure, and extubation. Importantly, postoperative factors are described at length, including suggested discharge criteria and recognition of complications, especially bleeding, airway distress, and hypocalcemia.

CONCLUSIONS

Outpatient thyroidectomy may be undertaken safely in a carefully selected patient population provided that certain precautionary measures are taken to maximize communication and minimize the likelihood of complications.