Perioperative practices in thyroid surgery: An international survey

Discrepancies in Thyroidectomy Outcomes Between General Surgeons and Otolaryngologists

Thyroidectomy is a common operation, performed by general surgeons and otolaryngologists. Few studies compare complication rates between these two specialties. We hypothesized that there would be no difference in the incidence of postoperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, or hematoma based on the surgical specialty performing the thyroidectomy. The 2016-2017 National Surgical Quality Improvement Program Targeted Thyroidectomy database was queried for patients who underwent thyroidectomy for both benign and malignant thyroid diseases. Thyroidectomies performed by general surgeons were compared to those performed by otolaryngologists. Multivariate logistic regression was used to identify risk factors associated with RLN injury, hematoma, and hypocalcemia. From 11,595 patients, 6313 (54.4%) were performed by general surgeons and 5282 (45.6%) by otolaryngologists. Goiter (43.7%) and nodule/neoplasm (40.8%) were the most common indications for the general surgery and otolaryngology cohorts respectively. General surgeons used an energy vessel sealant device more frequently (77.7% vs. 51.5%, p < 0.001), whereas RLN monitoring (67.4% vs. 58.3%, p < 0.001) and drain placement (44.3% vs. 14.8%, p < 0.001) were utilized more often by otolaryngology. After controlling for covariates, thyroidectomy by general surgeons had an increased associated risk of RLN injury (OR = 1.26, CI = 1.07-1.48, p = 0.006) and post-operative hypocalcemia (OR = 1.17, CI = 1.00-1.37, p = 0.046). Thyroidectomy volume is relatively equally distributed among general surgeons and otolaryngologists. Operation by a general surgeon is associated with an increased risk for RLN injury and postoperative hypocalcemia. This discrepancy may be explained by case volume, training, and/or completion of an endocrine surgery fellowship; however, this discrepancy still merits ongoing attention.

Preoperative prophylactic active vitamin D to streamline total thyroidectomy

Background

Hypocalcaemia is a common complication after total thyroidectomy (TT). Treatment consists of calcium and active vitamin D supplementation. Low levels of vitamin D before surgery have been shown to be a risk factor for postoperative hypocalcaemia, yet studies examining routine preoperative vitamin D supplementation have shown conflicting results. This retrospective cohort study aims to investigate the potential benefit of preoperative active vitamin D supplementation on hypocalcaemia and its symptoms after TT.

Methods

This study included patients undergoing TT at Uppsala University Hospital from January 2013 to December 2020, resulting in a total of 401 patients after exclusion. Routine preoperative alfacalcidol treatment was initiated for all TT patients in January 2017 resulting in two groups for comparison: one group (pre-January 2017) that was prescribed preoperative alfacalcidol and one that was not. Propensity score matching was used to reduce bias. The primary outcome was early postoperative hypocalcaemia (serum calcium, S-Ca less than 2.10 mmol/l); secondary outcomes were symptoms of hypocalcaemia and length of stay.

Results

After propensity score matching, there were 108 patients in each group. There were 2 cases with postoperative day one S-Ca less than 2.10 in the treated group and 10 cases in the non-treated group (P < 0.001). No patients in the treated group had a S-Ca below 2.00 mmol/l. Preoperative alfacalcidol was associated with higher mean serum calcium level day one (2.33 versus 2.27, P = 0.022), and reduced duration of hospital stay (P < 0.001). There was also a trend toward fewer symptoms of hypocalcaemia (18.9 per cent versus 30.5 per cent, P = 0.099).

Conclusions

Prophylactic preoperative alfacalcidol was associated with reduced biochemical hypocalcaemia and duration of hospital stay following TT. Also, with this protocol, it is suggested that routine day 1 postoperative S-Ca measurement is not required.

Appropriate selection of candidates for outpatient thyroidectomy

PURPOSE OF REVIEW

Although traditionally an inpatient procedure, outpatient thyroidectomy has gained traction as a viable and well tolerated alternative for selected patients, with an added benefit of cost savings.

RECENT FINDINGS

Research on outpatient thyroidectomy has focused on establishing its noninferiority in outcomes compared to the standard inpatient or overnight observation. Numerous studies have found comparable low rates of postoperative complications and no increase in readmission. Selection criteria have been well established by professional societies and research studies support the selection bias benefitting appropriately selected patients. The primary benefit of outpatient thyroidectomy reported is a decrease in cost, though additional theoretical benefits such as decreased exposure to nosocomial infections.

SUMMARY

Outpatient thyroidectomy is a well tolerated approach in appropriately selected candidates, with cost reduction benefits. Adherence to societal guidelines for patient selection is paramount.

ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols are evidenced-based multidisciplinary programs implemented in the perioperative setting to improve postoperative recovery and attenuate the surgical stress response. However, evidence on their effectiveness in thyroid and parathyroid surgery remains sparse. Therefore, our goal was to investigate the clinical benefits and cost-effectiveness of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy.

DATA SOURCE

A systematic review of Medline, Scopus, Embase, and gray literature was performed to identify studies of ERAS or clinical care protocols for thyroidectomy and parathyroidectomy.

REVIEW METHODS

Two reviewers screened studies using predetermined inclusion criteria. Our primary outcomes included hospital length of stay and hospital costs. Readmission and postoperative complication rates composed our secondary outcomes. Meta-analysis was performed to compare outcomes for patients enrolled in the ERAS protocol versus standard of care.

RESULTS

A total of 450 articles were identified; 7 (1.6%) met inclusion criteria with a total of 3082 patients. Perioperative components in ERAS protocols varied across the studies. Nevertheless, patients enrolled in ERAS protocols had reduced hospital length of stay (mean difference, -0.64 days [95% CI, -0.92 to -0.37]) and hospital costs (in US dollars; mean difference, -307.70 [95% CI, -346.49 to -268.90]), without an increase in readmission (odds ratio, 0.75 [95% CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95% CI, 0.82-1.57]).

CONCLUSION

There is growing literature supporting the role of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. These protocols significantly reduce hospital length of stay and costs without increasing complications or readmission rates.

Analyzing the ATA statement on outpatient thyroidectomy using the NSQIP database

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgeon-performed ultrasound in a head and neck surgical oncology clinic: saving time and improving patient care

INTRODUCTION

Surgeon-performed ultrasound (SUS) for head and neck masses is increasingly being performed by head and neck surgeons. This is the first study assessing its impact in a head and neck surgical oncology clinic, examining the effect on various parameters.

METHODS

Retrospective analysis was conducted on a database, analysing and comparing all new patients reviewed 6 months prior to (pre-SUS group) and 6 months following (post-SUS group) the introduction of SUS to the outpatient head and neck surgical oncology clinic. The numbers of radiology imaging investigations (ordered through a medical imaging department), fine-needle aspirations (FNAs) performed, clinical appointments and time to definitive treatment decision were analysed and compared.

RESULTS

A total of 365 patients were included: 169 in the pre-SUS group and 196 in the post-SUS group. There was a statistically significant difference in the number of total radiological imaging investigations performed (1.60 vs. 0.70, p < 0.00001), radiologist-performed FNAs (0.24 vs. 0.10, p = 0.0234), time for definitive treatment decision being made (16.4 days vs. 11.6 days, p = 0.04338), and number of clinical encounters (3.03 vs. 2.29, p < 0.00001). No statistically significant difference was observed in the number of head and neck surgical oncology clinic appointments (1.70 vs. 1.66, p = 0.6672).

CONCLUSION

Surgeon-performed ultrasound reduces the number of radiological imaging investigations and FNAs performed, reduces time for definitive treatment decision being made, and reduces the number of clinical encounters for patients. This supports its use in head and neck cancer setting and has important implications for both patients and the health-care system.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Preventative and management strategies of hypocalcemia after thyroidectomy among surgeons: An international survey study

OBJECTIVE

To determine international surgeon practice patterns for transient postoperative hypocalcemia in patients undergoing total thyroidectomy.

METHODS

All member surgeons of the American Thyroid Association and the International Association of Thyroid Surgeons were contacted via email to complete a 20-question survey which included both questions about demographic information and preventing and managing postoperative hypocalcemia after thyroidectomy. Univariate analysis was performed to determine whether providers check preoperative vitamin D levels, postoperative calcium trends and/or PTH to assess for postoperative hypocalcemia.

RESULTS

A total of 332 surgeons responded to the survey with 72.26% in practice for >10 years and 82.18% performing >50 total thyroidectomies per year. 13.29% of surgeon's surveyed reported that they routinely check preoperative vitamin D levels. Surgeon case volume, type of practice (academic vs non-academic practice), and geographic location in the US were significant predictors of whether surgeons check preoperative Vitamin D levels. International surgeons were significantly more likely to check both postoperative serum Ca and PTH compared to US based surgeons (p < .01). There was no significance difference in practice patterns based on whether the surgeon was a General Surgeon or an Otolaryngologist.

CONCLUSIONS

Using a questionnaire distributed to both General Surgeons and Otolaryngologists, we demonstrated that there is significant variation in practice patterns between surgeons practicing in the United States and surgeons practicing in other countries, and practice often differs from recommended guidelines.

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

INTRODUCTION

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results.

METHODS

Over 46 months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfth months post-operatively until VCP recovered.

RESULTS

In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125 days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027).

CONCLUSION

The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

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.

Thyroid Disease Around the World

Thyroid disease is one of the most common pathologies in the world, with two of the most clinically important subgroups being iodine deficiency and thyroid goiter, and thyroid cancer. This review looks at the current state of thyroid disease in the world and evaluates the future direction in terms of thyroid disease treatment and prevention. Several of the most impactful epidemiologic studies are presented and analyzed, as well as a brief overview of the current socioeconomic burden of disease.