Safety of outpatient thyroidectomy: Review of the American College of Surgeons National Surgical Quality Improvement Program

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

OBJECTIVE

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

STUDY DESIGN

Retrospective cohort.

SETTING

Pediatric tertiary care hospital.

METHODS

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

RESULTS

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

CONCLUSION

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

Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery

BACKGROUND

Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied.

METHODS

This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions.

RESULTS

Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted.

CONCLUSION

Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis

BACKGROUND

Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort.

METHODS

We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort.

RESULTS

Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001).

CONCLUSION

Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.

Emergency department use after outpatient thyroidectomy across three states

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis

BACKGROUND

To address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures.

METHODS

A cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event.

RESULTS

A total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001.

CONCLUSION

Thyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

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

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

The Effects of Chronic Steroid Use on Postoperative Complications Following Thyroidectomy

BACKGROUND

Patients undergoing thyroidectomy are sometimes on chronic steroids for underlying disease. This study examined the postoperative risk profile of thyroidectomy patients on chronic steroids.

METHODS

Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent thyroidectomy were sorted by presence or absence of chronic steroid use. Clinicodemographics, comorbidities, and postoperative complications were recorded and compared between the two. Univariate and multivariate analyses compared the groups and calculated odds ratios (OR).

RESULTS

We identified 42,857 patients. 41,903 (97.8%) patients were not on chronic steroids, while 954 (2.2%) were. Most underwent total thyroidectomy (18,748, 43.75%) or total lobectomy (16,323, 38.09%). Following univariate and multivariate analyses, patients on chronic steroids had increased risk of postoperative bleeding and transfusions (OR = 0.375, p = 0.046, 95% CI 0.223-0.988), open wound infection (OR = 0.226, p < 0.001, 95% CI 0.117-0.437), pulmonary embolism (OR = 0.312, p = 0.034, 95% CI 0.106-0.918), and ventilator use > 48 h (OR = 0.401, p < 0.008, 95% CI 0.205-0.785).

CONCLUSIONS

Chronic steroid use prior to thyroidectomy is an independent risk factor for multiple postoperative complications, namely postoperative bleeding and transfusions, open wound infection, pulmonary embolism, and ventilator use over 48 h. Patients on chronic steroids should be medically optimized before thyroidectomy to reduce the risk of potentially life-threatening complications.

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.

Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery: a systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed at investigating the effectiveness of laryngeal mask airway (LMA) against postoperative pharyngolaryngeal complications after thyroidectomy. MEDLINE, Cochrane Library, google scholar, and EMBASE databases were searched from inception through February, 2021, for randomized controlled trials (RCTs) comparing the incidence of pharyngolaryngeal complications following the use of LMA or endotracheal tube (ETT). Pooled results from seven RCTs involving 600 patients showed an association of LMA with a reduced risk of postoperative sore throat (POST) at 24 h [risk ratio (RR) 0.75, p = 0.006, four trials], but not at 1 h and 48 h after thyroidectomy. POST severity and hoarseness risk were lower in the LMA group than the ETT group at 1 h, 24 h, and 48 h (all p < 0.05). Nevertheless, hoarseness severity was lower in the LMA group only at postsurgical 48 h [standardized mean difference = - 0.35, p = 0.008, three trials]. Moreover, the risk of emergence cough was lower in patients using LMA than those receiving ETT (RR = 0.14, p = 0.002, two trials). The two groups did not differ in the severity of dysphagia at postoperative 1 h, 24 h, and 48 h. This meta-analysis showed that LMA may be associated with fewer pharyngolaryngeal complications compared to ETT without airway impacts. The limited number of included studies warrants further research to support our findings.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

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.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery

OBJECTIVES/HYPOTHESIS

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS).

STUDY DESIGN

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP).

METHODS

All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission.

RESULTS

A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P = .009), obese (54.8% vs. 43.8%, P = .003), and have hypertension (35.0% vs. 25.0%, P = .002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P = .041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P = .002), male gender (OR: 1.415, P = .025), obesity (OR: 1.527, P = .008), and ASA III-IV (OR 1.501, P = .018).

CONCLUSIONS

Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Adverse effects of chronic steroid use following thyroidectomy

BACKGROUND

Prior to thyroid surgery, a subset of patients chronically uses steroids to manage medical conditions such as Grave's disease, auto-immune conditions, or organ transplantation. Existing literature describes adverse effects of prolonged steroid use on surgical outcomes, however there remains a paucity of data investigating the specific effects of steroid use on postoperative outcomes after thyroidectomy. This study aims to identify complication risks steroid users are predisposed to after thyroidectomy.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify and isolate all patients who had undergone thyroidectomy procedures by Current Procedure Terminology codes from 2005 through 2018. Univariate analysis was performed to compare steroid uses and non-steroid users. Coarsened exact matching was utilized to homogenize the two cohorts based on demographics and preoperative comorbidities.

RESULTS

A total of 153,595 thyroidectomies were initially included. After Coarsened exact matching, 116,861 patients were categorized as non-steroid users, and 2,965 as steroid users. The steroid cohort demonstrated significantly higher rates of any complication (P < 0.001) as well as overall surgical, cardiopulmonary, and renal complications. Individual complications such as superficial surgical site infections (P = 0.013), pulmonary embolism (P = 0.016), deep vein thrombosis (P = 0.011), progressive renal insufficiency (P = 0.006), and unplanned readmission (P = 0.026) were also increased.

CONCLUSIONS

Patients with chronic steroid use undergoing thyroidectomy are at an increased risk for surgical, cardiopulmonary, and renal complications. Further research on preoperative steroid management is necessary for optimizing outcomes in this population.

[Outpatient Surgery in German ENT]

Currently there is an intense discussion ongoing to enhance and expand outpatient surgery in the ENT in Germany, which is the intention by several politicians. The goal is to achieve a frequency of outpatient surgery comparable to an international level.To achieve this goal, acceptance of outpatient interventions by both, surgeons and patients is required, particularly in regard of equal quality standards and patient safety requirements.In the following review the organization, outcome, quality management and strategies for different ENT outpatient surgery worldwide is analyzed. Basically, outpatient surgery is organized in different ways: office-based-procedures in local anesthesia, procedures in ambulatory surgery center settings as standalone facilities or in connection with and adjacent to a hospital with possible inpatient treatment. Contact and resident times of the patients in the outpatient surgery centers differ between some hours through 23 hours. A deliberated and careful selection of patients which are suitable for outpatient procedures is required and should address comorbidities, medications, social circumstances, health literacy of the patient and its relatives, and distance from home to the hospital. A careful and strict quality management is mandatory which comprises the entire process from patient selection through patient entry, surgery, discharge and postoperative care in a multidisciplinary setting.Zur besseren Lesbarkeit des Textes wird bei geschlechterbezogenen Bezeichnungen die männliche Form benutzt. Es sind jedoch in gleicher Rangfolge auch das jeweilige weibliche Geschlecht oder andere Geschlechtsausprägungen gemeint.

Ambulatory Surgery vs Overnight Observation for Total Thyroidectomy: Cost Analysis and Outcomes

Objective

To compare financial impact between patients undergoing ambulatory (same-day discharge) vs overnight admission after total thyroidectomy while showing associated surgical outcomes.

Study Design

Retrospective review.

Setting

University of Alabama at Birmingham Medical Center from October 2011 and July 2017.

Methods

Patients undergoing total thyroidectomy without concurrent procedures were selected for review. Demographics, comorbidities, admission status, postoperative outcomes including minor and major complications, charges, and costs were collected. Admission status was categorized as inpatient (admission to hospital ≥1 night) or outpatient (discharged from the postoperative recovery unit). Costs were obtained from all related hospital, clinic, and emergency department visits at the University of Alabama at Birmingham within 30 days of the original surgery. After statistical analysis, outcomes and costs were compared between inpatient and outpatient total thyroidectomy patients.

Results

Of 870 total thyroidectomy patients included for analysis, 367 (42.2%) met outpatient criteria. A total of 169 patients (19.4%) had a complication, and only hypocalcemia occurred significantly more in the inpatient group (14.3% vs 9.26%; P < .05). No complications occurred more frequently in the outpatient population. There were no mortalities. There was a statistically significant difference between the total cost of inpatient and outpatient thyroidectomies, with outpatient surgery costing on average $2367.27 less per patient (P < .0001).

Conclusion

Outpatient total thyroidectomy can lead to cost reduction in highly selected patients who have few comorbidities while remaining safe for the patient.

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

BACKGROUND

Outpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines.

METHODS

This is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines.

RESULTS

In total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed.

CONCLUSION

The salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.

Outcomes of pediatric thyroidectomy: a cross-sectional evaluation

Introduction

Pediatric thyroidectomy is performed by a variety of surgical specialties. Thyroidectomy can result in a number of complications. Previous studies cite that the most common complications in children are pain and transient hypocalcemia. The purposes of this report are to assess the adverse events of thyroidectomies performed in the pediatric population and to assess the relationship between surgical specialties and postoperative thyroidectomy complications.

Methods

We conducted a cross-sectional analysis of cases from January 1, 2014 through November 1, 2015 using the National Surgical Quality Improvement Program database for patients undergoing excision of cyst or adenoma of the thyroid, unilateral thyroid lobectomy, or total thyroidectomy.

Results

Of the 344 patients who underwent thyroidectomy, 10 (2.9%) experienced at least one complication. The most common complications were readmission, surgical site infections, and wound disruption. There was a statistically significant association between complication incidence and surgical specialty (p=0.006). Pediatric otolaryngology had a statistically significantly higher number of complications than pediatric surgery (p<0.008).

Conclusion

Overall, the incidence of adverse events following pediatric thyroidectomy was low.

Postoperative Complications After Thyroidectomy: Time Course and Incidence Before Discharge

BACKGROUND

Although complication rates after thyroidectomy are well described in the literature, the timing of these events is less understood. This study delineates the timeline and risk factors for early adverse events after thyroidectomy.

MATERIALS AND METHODS

This study included a retrospective review of 161,534 patients who underwent thyroidectomy between 2005 and 2018 using the American College of Surgeons National Surgical Quality Improvement Program database. Time to specific complications was analyzed for all patients undergoing thyroidectomy, with further stratification of hemithyroidectomy and total thyroidectomy cohorts. Univariate analyses were conducted to analyze demographics, preoperative comorbidities, and complications. A multivariate logistic regression model was generated to identify significant risk factors for 7-day postoperative complications.

RESULTS

The overall complication rate was 3.28%. A majority of complications arose before discharge including the following: blood transfusion (96%), hematoma formation (68%), pneumonia (53%), and cardiac arrest (67%). Approximately 37% of unplanned reoperations occurred before discharge in the hemithyroidectomy versus 63% in the total thyroidectomy cohort. Greater than 65% of mortalities occurred after discharge in both groups. Complications generally occurring within 7 d for the entire cohort included the following: pneumonia (3; 2-8 [median postoperative day; interquartile range]), pulmonary embolism (6; 2-12), cardiac arrest (1; 0-5), myocardial infarction (2; 1-6), blood transfusions (0; 0-1), and hematoma formation (0; 0-2). Superficial surgical site infection (9; 6-16) occurred later. Patients who underwent outpatient surgery had a decreased risk of complications (odds ratio 0.41) in the 7-day postoperative period.

CONCLUSIONS

Although early complications after thyroidectomy are rare, they have a distinct time course, many of which occur after discharge. However, in selected patients undergoing outpatient thyroidectomy, overall risk of complications is decreased. Understanding timing helps establish better preoperative communication and education to improve postoperative expectations for the provider and patient.

Short-Term Morbidity and Predictors of Adverse Events Following Esthesioneuroblastoma Surgery

INTRODUCTION

The short-term adverse events and predictors of morbidity in surgical resection of esthesioneuroblastoma (ENB) are largely unknown, and investigating these variables can help direct planning for at-risk patients.

METHODS

The 2005-2017 National Surgical Quality Improvement Program database was queried to identify patients with a diagnosis of ENB undergoing skull base surgery for tumor resection. Information regarding demographics, patient morbidity score, pre-operative and intra-operative data, and post-operative outcomes were extracted. Cox proportional hazard analysis was utilized to assess complication and readmission/reoperation rates.

RESULTS

A total of 95 patients undergoing skull base surgery for resection of ENB were included. Mean age, BMI, operation time, and post-operative length of stay (LOS) of the cohort were 53.6 ± 16.2 years, 29.1 ± 6.5, 392.0 ± 204.6 minutes, and 5.8 ± 4.6 days, respectively. In total, 31 patients (32.6%) experienced at least one 30-day adverse event, which included blood transfusion intra-operatively or within 72 hours from the operation (22.1%), readmission (10.7%), intubation >48 hours (7.4%), reintubation (4.2%), organ or space infection (4.2%), reoperation (4.0%), superficial or deep surgical site infection (2.1%), sepsis (2.1%), pulmonary embolism (1.1%), and myocardial infarction (1.1%). Patients who experienced at least one adverse event had significantly higher operation time (486.8 ± 230.4 vs. 347.5 ± 176.2 minutes, p = 0.002), LOS (9.2 ± 5.6 days vs. 4.2 ± 3.0, p < 0.001), and lower hematocrit (37.3 ± 5.9 vs. 41.2 ± 3.8, p < 0.001) and albumin levels (3.8 ± 0.6 vs. 4.2 ± 0.3, p = 0.009). Patients with a higher American Society of Anesthesiologists (ASA) score (HR = 2.39; p = 0.047) or longer operation time (HR = 1.004; p = 0.001) had a significantly higher risk for experiencing adverse events. Obesity was not associated with different intra- or post-operative outcomes, but older patients had shorter operations (p = 0.002) and LOS (p = 0.0014).

CONCLUSION

Longer operation time and lower pre-operative hematocrit and albumin levels may all increase complication rates in ENB resection. Patients with high ASA score or more advanced age may have different short-term outcomes.

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.

A National Comparison of Postoperative Outcomes in Completion Thyroidectomy and Total Thyroidectomy

OBJECTIVE

To characterize and assess the non-thyroid-specific postoperative complications of completion thyroidectomy as compared with total thyroidectomy.

STUDY DESIGN

Retrospective analysis: 2005 to 2017.

SETTING

National Surgical Quality Improvement Program database.

SUBJECTS AND METHODS

Patients aged >18 years receiving a completion or total thyroidectomy were eligible for inclusion. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded.

RESULTS

A total of 70,638 patients were analyzed, representing 64,763 total thyroidectomies and 5875 completion thyroidectomies. The 30-day mortality rate was 0.1% for both procedures (P > .05). Overall, 1.7% and 1.4% of patients undergoing total and completion thyroidectomies experienced at least 1 complication (P > .05), while 1.2% and 0.9% had a postoperative medical complication (P = .0186), respectively. On multivariable analysis, patients undergoing total thyroidectomies were significantly more likely to return to the operating room (odds ratio [OR], 1.36; 95% CI, 1.04-1.80; P = .027) and to be readmitted (OR, 1.45; 95% CI, 1.16-1.81; P = .001). Adjusted analysis also demonstrated that patients undergoing total thyroidectomies were more likely to be inpatients (OR, 1.17; 95% CI, 1.11-1.24; P < .001), be treated by nonotolaryngologists (OR, 1.36; 95% CI, 1.29-1.45; P < .001), and smoke (OR, 1.22; 95% CI, 1.13-1.33; P < .001).

CONCLUSION

National data suggest that total and completion thyroidectomies are relatively safe procedures but that completion thyroidectomies are associated with lower rates of postoperative complications. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.

Racial disparities in comorbid conditions among patients undergoing thyroidectomy for Graves' disease: An ACS-NSQIP analysis

BACKGROUND

Studies indicate that racial disparities exist in the presentation and outcomes of patients undergoing thyroidectomy for cancer and benign disease. We examined the relationship between race, pre-operative characteristics and outcomes in patients undergoing thyroidectomy for GD.

METHODS

Patients were identified from the 2013-2016 American College of Surgeons NSQIP database using ICD-9/10 codes consistent with diffuse toxic goiter.

RESULTS

AA patients were more likely to have an ASA classification of ≥3 (41% vs 30%, p < 0.001), a higher rate of CHF (2.1% vs 0.5%, p = 0.01), hypertension (46% vs 32%, p < 0.001) and dyspnea (10% vs 5%, p < 0.001) compared to Non-Hispanic Caucasians (NH-C) patients. Complications were higher in patients with ASA≥3 and CHF but not affected by race.

CONCLUSIONS

Analysis of a national database of thyroidectomy for GD revealed a higher burden of preoperative comorbidities in AA patients compared to other races, although race was not an independent predictor of outcomes.

Outpatient thyroidectomy in the pediatric population

Preoperative optimization and patient education have allowed for the transition of thyroid surgery to the outpatient setting over the last few decades. Performing these operations in the outpatient setting has proven to be cost-effective and safe in the adult population. The purpose of this study is to evaluate the safety and efficacy of outpatient thyroid surgery in the pediatric population. A retrospective review from December 2015 to February 2019 of patients under the age of 18 years of age undergoing thyroidectomy performed by two endocrine surgeons at a large academic was performed. There were 55 consecutive operations performed in 51 patients for thyroid pathology, two were excluded as they were inpatient procedures. Cases were reviewed for complications, unplanned same-day admission, 30-day admission, unplanned reoperation, and death. Mean age was 15 ± 0.3 years (range 9-18 years), 79% of the patients were female. Operations were performed for Graves' disease (n = 29), thyroid cancer (n = 9), thyroid nodule (n = 6), multinodular goiter (n = 4), Hashimoto's disease (n = 3), and toxic adenoma (n = 2). Operations performed included: total thyroidectomy (n = 36), thyroid lobectomy (n = 13), total thyroidectomy with lymph node dissection (n = 2), and lateral neck dissection (n = 2). All patients were discharged home within 6 h after completion of the operation. Five (9.4%) patients had transient hypoparathyroidism, with parathyroid hormone levels <10 pg/mL immediately postoperatively. One patient (1.9%) developed a postoperative hematoma on postoperative day six and required reoperation and readmission. Two patients (3.8%) had permanent hypoparathyroidism and one had transient hoarseness (1.9%). There were otherwise no readmissions or ED visits. In conclusion, outpatient thyroid surgery is safe and effective for pediatric patients.

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.

Outpatient versus inpatient parotidectomy: Comparison of postoperative complication rates

OBJECTIVES

Parotidectomies have become a common outpatient procedure, but their impact on postoperative complications as compared to inpatient procedures has not been evaluated in a multi-institutional study.

STUDY DESIGN

The aim of this retrospective analysis was to evaluate the differences in outcomes using a standardized cohort of patients undergoing outpatient or inpatient parotidectomies.

METHODS

The National Surgical Quality Improvement Program database was queried for parotidectomies between 2005 and 2014. Univariate analyses were conducted to compare the outpatient and inpatient cohorts. A propensity-matching algorithm was used to ensure equal distribution of demographics and preoperative comorbidities.

RESULTS

Among the 4,368 parotidectomies examined, 2,915 (66.7%) were outpatient and 1,453 (33.3%) were inpatient. In the unmatched analysis, the inpatient group had higher rates of smokers (P = < 0.001), hypertension (P = 0.003), and disseminated cancer (P = 0.014). The outpatient group had higher rates of patients under age 40 years (P = 0.015), females (P = 0.016), and American Society of Anesthesiology class 1 and 2 (P = < 0.001). The total work relative value units (RVUs) were 17.01 ± 3.44 for the inpatient cohort and 16.19 ± 3.70 for the outpatient cohort (P = < 0.001). Following propensity matching, 1,352 cases were selected for each cohort, with no significant differences in comorbidities. Total work RVU after matching was 16.90 ± 3.47 for the inpatient group and 16.75 ± 3.44 for the outpatient group (P = .235). The matched inpatient cohort had increased rates of surgical complications (3.1% vs. 1.8%, P = 0.033), pneumonia (0.5% vs. 0.0%, P = 0.016), and overall complications (4.5% vs. 2.6%, P = 0.009).

CONCLUSION

Outpatient parotidectomies are associated with similar as well as decreased complication rates as compared to inpatient parotidectomies.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:655-661, 2019.