Robotic Axillary Thyroidectomy: Multi-Institutional Clinical Experience with the daVinci

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review

PURPOSE

The reported incidence of post surgical hypoparathyroidism (HypoPT) varies greatly. Previous research suggests that the definition of HypoPT is not consistent in the literature. We therefore conducted a systematic review to investigate how HypoPT is defined and whether this definition, as well as the selected threshold for hypocalcemia affects the incidence.

METHODS

Using a predefined search string we identified all articles in PubMed reporting on the incidence of postsurgical HypoPT from 1st January 2010 to January 2017.

RESULTS

We identified 89 articles that employed 20 different definition of HypoPT. The incidence of HypoPT varied from 0.0% to 20.2%. The definitions were not associated with incidence of HypoPT. Use of prophylactic post-operative calcium supplements, however decreased the risk of HypoPT (p = 0.03), and there was a trend towards a lower risk of HypoPT when using a definition of hypocalcemia below lower limit of the reference range (p = 0.09).

CONCLUSION

The large number of definitions of HypoPT, as well as the huge variation in incidence point to a problem suggests that the awareness of HypoPT should be raised. Use of prophylactic post-operative calcium supplements may decrease risk of HypoPT. This, however, may be due to reverse causality as awareness of the risk of HypoPT may promote the use of calcium supplementation.

Relationship of Vitamin D Deficiency and Intraoperative Parathyroid Hormone Elevation in Completion and Total Thyroidectomy

Objective

To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone.

Study Design

Case series with chart review.

Setting

Tertiary academic center.

Subjects and Methods

A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation.

Results

A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03).

Conclusion

Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.

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.

Systematic Review and Meta-Analysis of Unplanned Reoperations, Emergency Department Visits and Hospital Readmission After Thyroidectomy

BACKGROUND

Unplanned reoperation, emergency department (ED) visits, and hospital readmission following thyroid operations usually arise due to complications and are a source of frustration for both surgeons and patients. With the aim of providing insight important for the development of patient quality care improvement initiatives, the primary objective of this review was to evaluate the available literature systematically in order to determine the contemporary rates of reoperation, readmission, and ED visits following thyroid operations. A secondary study objective was to determine if there were any practices that showed promise in reducing the occurrence of these undesirable postoperative events.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses protocols. Twenty-two studies were included in the systematic review. Meta-analysis was performed to obtain the weighted-pooled summary estimates of rates of reoperations, ED visits, and unplanned hospital readmission. Jackknife sensitivity analyses were performed for each data set. Finally, in order to detect the risk of publication bias and the small-study effect, funnel plot analysis was performed.

RESULTS

The pooled rate estimate for reoperation was very low (0.6% [confidence interval (CI) 0.3-1.1%]). This was subject to publication bias because smaller studies tended to report lower rates of reoperation. The pooled rate of ED visits was 8.1% [CI 6.5-9.8%], while the pooled rate of hospital readmission from 19 studies was 2.7% [CI 2.1-3.4%]. Neck hematoma was the most common reason for reoperation, while postoperative hypocalcemia was the most common reason for hospital readmission.

CONCLUSIONS

ED visits and hospital readmission after thyroidectomy are common, and there are several practices that can reduce their occurrence. Routine postoperative calcium and vitamin D supplementation may reduce rates of postoperative hypocalcemia, and avoiding postoperative hypertension may decrease the risk of neck hematoma development and the need for reoperation. Older age, thyroid cancer, dependent functional status, higher ASA score, diabetes, chronic obstructive pulmonary disease, steroid use, hemodialysis, and recent weight loss increase the risk of hospital readmission after thyroid surgery. By further identifying risk factors for reoperation, ED visits, and readmission, this review may assist practitioners in optimizing perioperative care and therefore reducing patient morbidity and mortality after thyroid operations.

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

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

Bidirectional Approach of Video-Assisted Neck Surgery (BAVANS): Endoscopic complete central node dissection with craniocaudal view for treatment of thyroid cancer

INTRODUCTION

Endoscopic thyroidectomy is a well-established surgical technique that is mainly performed for benign thyroid disease. We considered that endoscopic surgery could also be widely indicated for the treatment of thyroid cancer. We herein describe our new bidirectional approach of video-assisted neck surgery (BAVANS) for complete central node dissection in endoscopic thyroid cancer surgery.

METHODS

BAVANS involves two different directional pathways to the cervical lesion. Before lymph node dissection, we perform endoscopic thyroidectomy via a conventional gasless precordial or axillary approach. After thyroidectomy, the surgeon repositions by the head of the patient and inserts three ports in front of the upper neck lesion in the submandibular area to approach the paratracheal lesion from an overhead-to-caudal direction.

RESULTS

BAVANS allows for an excellent craniocaudal view and easy access to the peritracheal lymph nodes. Sixteen patients with papillary thyroid cancer underwent BAVANS and progressed satisfactorily after surgery. Of those patients, eight underwent total or near total thyroidectomy, and five patients underwent bilateral central node dissection. The average number of retrieved lymph nodes with unilateral central node dissection was nine, which was higher than that achieved with conventional open surgery. All patients began oral intake within 5 h after surgery. Postoperative Horner syndrome occurred in one patient. No other complications were noted.

CONCLUSIONS

BAVANS is a very effective surgical procedure that many endoscopic surgeons can perform safely and easily. It has both a cosmetic advantage and excellent curability in endoscopic thyroid cancer surgery.

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.

Safety of Outpatient Thyroid and Parathyroid Surgery

Objective

To test our hypothesis that general and thyroid surgery–specific complications, mortality, and postdischarge utilization for patients undergoing outpatient and inpatient thyroid and parathyroid surgery would not differ when outpatient status was defined as discharge within 8 hours of surgery completion.

Study Design

Retrospective observational cohort, 2008 to 2013.

Setting

Kaiser Permanente Northern California and Kaiser Permanente Southern California.

Subjects and Methods

We used a robust set of variables and propensity score methods to match 2362 patients undergoing hemithyroidectomy, total thyroidectomy, or parathyroidectomy surgery as outpatients to 2362 patients undergoing the same procedures as inpatients. Outcomes assessed were 30-day rates of complications, emergency department visits, all-cause hospital readmissions, and mortality.

Results

After matching, no statistically significant differences between inpatients and outpatients were found for complication rates or postdischarge utilization. After matching, there was no statistically significant difference between inpatients and outpatients in hematoma rates, which were 0.55% in both groups. In the matched-pair groups, 2 deaths occurred among inpatients (0.09%) and none occurred among outpatients (0.00%), a difference that was not statistically significant.

Conclusion

Discharge within 8 hours after completion of thyroid and parathyroid surgery is as safe as inpatient surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Day case hemithyroidectomy is safe and feasible: experience in Scotland

Background and aims

We aimed to analyse the safety and feasibility of day case hemithyroidectomy.

Methods and results

We reviewed all hemithyroidectomies led by two surgeons across two sites between 2010 and the end of 2013. Patients were divided into ‘planned inpatient’ or ‘planned day case’.

Results

Day of discharge, conversion to inpatient procedure, intraoperative and postoperative complications and postoperative presentations or readmission to hospital were analysed. Age, gender, American Society of Anaesthesiologists score and indication for surgery were also recorded. One-hundred and eighty hemithyroidectomy cases were analysed, 35 (19.5%) were planned as inpatient procedures. Of the remaining 145 (80.5%) planned day case: 106 (73.1%) were successfully discharged on the same day and 39 (26.9%) were not; 11 (7.6%) were converted to inpatient procedures perioperatively; 8 (5.5%) had additional procedures; 6 (4.1%) had wound infections; 7 (4.8%) presented to ER; 1 (0.7%) of which required readmission to hospital for a reason unrelated to the surgery. None had laryngeal nerve palsy, compressive haematoma or symptomatic hypocalcaemia.

Conclusion

This study showed that hemithyroidectomy by experienced surgeons can be performed safely as a day surgery. No ‘planned day case patients’ in this study developed laryngeal nerve palsy, compressive haematoma or symptomatic hypocalcaemia.

Initial learning curve of single-incision transaxillary robotic hemi- and total thyroidectomy--A single team experience from Europe

INTRODUCTION

The primary advantage of robotic thyroidectomy is to avoid a neck scar. On the other hand, this sophisticated technique implies some potential risks otherwise not associated with conventional thyroidectomy, increased costs, and prolonged operating times. With all these factors being an important issue, we analysed the data of our initial European series in order to understand the nature of the learning curve for this technique.

METHODS

Ten patients underwent transaxillary robotic thyroidectomy for benign disease, performed consistently by the same surgeon with the same team, within a timeframe of 12 months. There were four total thyroidectomies and six hemithyroidectomies. Operating times broken down into creating the working space, docking the robot, and console work (including wound closure), were prospectively recorded and evaluated.

RESULTS

By the end of the initial learning curve comprising ten patients, the total operating time for a robotic hemithyroidectomy and for a total thyroidectomy has decreased by 49% to 190 min, and by 31% to 229 min, respectively. Intraoperative complications were successfully managed without conversion to open access surgery.

CONCLUSION

The learning curve for transaxillary robotic thyroidectomy is rather steep; reasonable progress in terms of operating times can be achieved within the first ten cases. Consistency in the team and careful patient selection are paramount factors for success.

Ambulatory Thyroidectomy

Objective

Determine rates and reasons for revisits after ambulatory adult thyroidectomy.

Study Design

Cross-sectional analysis of multistate ambulatory surgery and hospital databases.

Setting

Ambulatory surgery data from the State Ambulatory Surgery Databases of California, Florida, Iowa, and New York for calendar years 2010 and 2011.

Subjects and Methods

Ambulatory thyroidectomy cases were linked to state ambulatory, emergency, and inpatient databases for revisit encounters occurring within 30 days. The numbers of revisits, mortality, and associated diagnoses were analyzed.

Results

A total of 25,634 cases of ambulatory thyroid surgery were identified: 44.2% total thyroidectomy (TT) and 55.8% partial thyroidectomy (PT). Common indications for surgery included goiter/cyst (39.5%), benign/uncertain neoplasm (24.2%), and malignant neoplasm (24.0%). The 30-day revisit rate was 7.2% (n = 1858; 61.8% emergency department, 22.4% inpatient admission, and 15.8% ambulatory surgery center). The most common diagnosis at revisit was hypocalcemia (20.8% of revisits), followed by wound hematoma/seroma/bleeding (7.1%). Higher rates of revisit, hypocalcemia, and hematoma/seroma/bleeding were seen in patients undergoing TT ( P < .016 for all). Sixteen patients had bleeding less than 24 hours after the index procedure (0.1% overall, 0.9% of revisits). Most hypocalcemia and hematoma/bleeding occurred over the first postoperative week. Three deaths occurred within 30 days of the index procedure.

Conclusion

In carefully selected patients, ambulatory thyroidectomy demonstrates a good postoperative morbidity and mortality profile. Common reasons for revisits included hypocalcemia and bleeding/seroma/hematoma, which occurred with relatively high frequencies as late as a week after surgery. Quality improvement measures should be targeted at lowering revisit rates and safely managing complications.

Thyroid surgery as a 23-hour stay procedure

INTRODUCTION

The main barriers to short stay thyroidectomy are haemorrhage, bilateral recurrent laryngeal nerve palsy causing respiratory compromise and hypocalcaemia. This study assessed the safety and effectiveness of thyroidectomy as a 23-hour stay procedure.

METHODS

All patients undergoing total or completion thyroidectomy were prescribed calcium and vitamin D3 supplements following surgery. Retrospective analysis identified patients admitted for longer than 23 hours and any readmissions.

RESULTS

A total of 164 patients were admitted for 23-hour stay thyroid surgery over a 25-month period between 2008 and 2010. Four patients (2%) required admission for longer than 23 hours. No patients required emergency intervention for postoperative haemorrhage or airway compromise. Biochemical hypocalcaemia (despite calcium supplements) was detected in one patient when measured at the outpatient clinic two weeks following surgery. Twelve patients (7.3%) attended the accident and emergency department following discharge; four required admission for intravenous antibiotics for wound infection and one for biochemical hypocalcaemia.

CONCLUSIONS

This single centre UK experience demonstrates that thyroidectomy can be carried out both safely and effectively as a 23-hour stay procedure. Prophylactic prescription of calcium and vitamin D3 reduces hypocalcaemia, and thereby also prolonged admission and readmission due to hypocalcaemia. Supplements are an acceptable, cost effective method of reducing hypocalcaemia and shortening postoperative length of stay.

Hypocalcaemia following total thyroidectomy: early post-operative parathyroid hormone assay as a risk stratification and management tool

Objective:

To develop a practical, efficient and predictive algorithm to manage potential or actual post-operative hypocalcaemia after complete thyroidectomy, using a single post-operative parathyroid hormone assay.

Methods:

This paper reports a prospective study of 59 patients who underwent total or completion thyroidectomy over a period of 24 months. Parathyroid hormone levels were checked post-operatively on the day of surgery, and all patients were evaluated for hypocalcaemia both clinically and biochemically with serial corrected calcium measurements.

Results:

No patient with an early post-operative parathyroid hormone level of 23 ng/l or more (i.e. approximately twice the lower limit of the normal range) developed hypocalcaemia. All the patients who initially had post-operative hypocalcaemia but had an early parathyroid hormone level of 8 ng/l or more (i.e. approximately two-thirds of the lower limit of the normal range) had complete resolution of their hypocalcaemia within three months.

Conclusion:

Early post-operative parathyroid hormone measurement can reliably predict patients at risk of post-thyroidectomy hypocalcaemia, and predict those patients expected to recover from temporary hypocalcaemia. A suggested post-operative management algorithm is presented.

Costs of outpatient thyroid surgery from the University HealthSystem Consortium (UHC) database

OBJECTIVE

To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers.

STUDY DESIGN

Cross-sectional analysis of a national database.

SETTING

The University HealthSystem Consortium (UHC) data collected from discharge summaries.

SUBJECTS AND METHODS

Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy.

RESULTS

During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P < .0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation.

CONCLUSION

Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.

Barriers to Same-Day Discharge of Patients Undergoing Total and Completion Thyroidectomy

Objective

Describe barriers to same-day surgery for patients undergoing total and completion thyroidectomy.

Study Design

Case series with chart review.

Setting

Academic health sciences center.

Subjects and Methods

The subjects were patients who underwent total thyroidectomy or completion thyroidectomy and remained in hospital overnight or longer. A review was performed on patients who were operated on by a single surgeon from July 2005 through June 2013.

Results

Two hundred and sixty-eight cases were planned for same-day surgery. One hundred patients were not discharged on the same day (37%). Patients observed overnight or admitted to hospital had significantly lower postoperative calcium levels, 8.4 mg/dL ( P < .0001), and lower intraoperative parathyroid hormone (PTH), mean 6.0 pg/mL ( P < .0001). Those significantly more likely to require overnight observation were male patients ( P = .0117), black patients ( P = .0045), those with completion thyroidectomy ( P = .0039), and those with a complication of surgery ( P = .003).

Conclusion

Intraoperative PTH less than 10 pg/mL was the most frequent factor (25.7%) precluding same-day discharge, followed by admission for social/financial/transportation reasons (22.6%), large dead space from goiter (15.5%), multiple comorbidities (13.4%), multiple surgical reasons (5.2%), airway observation (5.2%), pain management (3.1%), and intractable nausea due to general anesthetic (2.1%). Hypocalcemia and postoperative bleeding still remain obstacles to outpatient thyroid surgery; however, the use of rapid PTH testing, modern hemostatic techniques, appropriate calcium prophylaxis, and experienced clinical decision making can effectively stratify which patients require overnight observation.

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.

Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006

BACKGROUND

Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time.

METHODS

Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures.

RESULTS

The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006.

CONCLUSIONS

From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.

Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-NSQIP database

STUDY DESIGN

Propensity score-adjusted prospective cohort study.

OBJECTIVE

To compare the incidence of complications in patients undergoing single-level lumbar discectomy between the inpatient and outpatient settings, to determine baseline 30-day complication rates for lumbar discectomy, and to identify independent risk factors for complications.

SUMMARY OF BACKGROUND DATA

Lumbar discectomy is the most common spinal procedure performed and can be done on an outpatient basis. Lower costs, greater patient satisfaction, and equivalent safety have been reported with outpatient surgery.

METHODS

Patients undergoing lumbar discectomy between 2005 and 2010 were selected from The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patient selection was based on a single primary current procedural terminology code. To ensure comparable inpatient and outpatient cohorts, patients with multilevel procedures were excluded. Thirty-day postoperative complications and preoperative patient characteristics were identified and compared. Propensity score matching and multivariate logistic regression analysis were used to adjust for selection bias and identify predictors of 30-day morbidity.

RESULTS

Of the 4310 lumbar discectomy cases, 2658 (61.7%) underwent an inpatient hospital stay after surgery, whereas 1652 (38.3%) patients had outpatient surgery. Unadjusted overall complication rates (6.5% vs. 3.5%, P < 0. 0001) were higher in those undergoing inpatient surgery. After propensity score matching, overall complication rate was still higher with the inpatient cohort (5.4% vs. 3.5%, P = 0.0068). Adjusted comparison using multivariate logistic regression also demonstrated a significantly higher rate of complication for inpatients (odds ratio, 1.521; 95% confidence interval, 1.048-2.206). Age, diabetes, presence of preoperative wound infection, blood transfusion, operative time, and an inpatient hospital stay were all independent risk factors of short-term complication after lumbar discectomy.

CONCLUSION

After adjusting for confounders using propensity score matching and multivariate logistic regression analysis, patients undergoing outpatient lumbar discectomy had lower overall complication rates than those treated as inpatients. Surgeons should consider outpatient surgery for lumbar discectomy in appropriate candidates.

Thyroidectomy outcomes: a national perspective

OBJECTIVES

Describe trends and outcomes of patients undergoing thyroidectomy.

STUDY DESIGN AND SETTING

Retrospective search of national inpatient database.

SUBJECTS AND METHODS

The Nationwide Inpatient Sample 2009 was searched using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for thyroidectomy. Data extraction included patient demographics, hospital characteristics, and associated diagnoses. Subgroup analysis was performed on mortalities; bivariate and multivariate analysis was used to examine predictors of complications.

RESULTS

In the United States, 59,478 patients were admitted and underwent thyroidectomy in 2009. Their mean (SD) age was 53.0 (16.4) years. Mean (SD) length of stay was 3.0 (6.9) days, and mean (SD) total charges was $39,236 ($73,679). Total thyroidectomy was performed in 53.6% of patients; 33.2% underwent unilateral lobectomy. Most common thyroid disorders included nontoxic nodular goiter (36.0%) and malignant neoplasm (30.3%). There were 363 (0.61%) mortalities, with a mean (SD) age of 65.5 (15.2) years, length of stay of 13.9 (15.2) days, and total charges of $218,855 ($191,977). Of all patients, 6.18% had hypocalcemia and 0.77% had hypoparathyroidism; the incidence of vocal cord paresis was 0.85% unilaterally and 0.34% bilaterally. Multivariate analysis revealed predictors of complications following thyroid surgery were female sex (P = .0001), total thyroidectomy procedure (P < .0001), hospital location and teaching status (P = .0060), hospital bed size (P = .0054), type of thyroid disorder, and underlying patient comorbidities.

CONCLUSION

Reporting of normative data for thyroidectomy facilitates comparison. Hospitalizations for patients undergoing thyroidectomy require significant resource utilization. Predictors of complications include female sex, type of thyroid disorder and procedure, hospital location and teaching status, hospital bed size, and patient comorbidities.

Calcium management after thyroidectomy: a simple and cost-effective method

OBJECTIVE

Hypocalcemia is one of the principal complications of total or completion thyroidectomy. A number of different protocols for managing this potential complication have been published. Our simple postoperative regimen is described and the safety and cost-effectiveness assessed.

STUDY DESIGN

Case series with planned data collection.

SETTING

Academic medical center.

SUBJECTS AND METHODS

All patients undergoing total or completion thyroidectomy from January 2008 through June 2010 were evaluated. Data collected included age; gender; procedure performed; levels of ionized calcium, parathyroid hormone, and vitamin D; complications; and need for readmission. Standard descriptive statistics were used to summarize these data.

RESULTS

In total, 526 patients had thyroid surgery during the 30-month study period. Of these, 307 underwent completion or total thyroidectomy and were prescribed a 3-week tapering course of calcium carbonate postoperatively. Twenty-three patients (7.5%) experienced symptoms of hypocalcemia that were managed on an outpatient basis with additional doses of oral calcium. Two patients (0.7%) required readmission. The cost of a 3-week regimen of calcium carbonate is approximately $15. This is considerably less expensive than either the cost of overnight admission or published laboratory protocols that are designed to predict the risk of hypocalcemia.

CONCLUSIONS

Prophylactic calcium supplementation without routine laboratory assessment proved to be a safe and cost-effective method of preventing and managing postoperative hypocalcemia following total or completion thyroidectomy.

Robotic endocrine surgery: technical details and review of the literature

Over the last decade, robotic technology has been used in multiple general surgical procedures. Endocrine surgeons have embraced this technology and subsequently transformed neck operations into more cosmetically acceptable procedures and improved ergonomics. Technical details of various robotic endocrine surgical procedures have recently been described. The aim of this review is to illustrate these technical details and analyze the current data to propose an evidence-based approach to robotic endocrine surgery.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.