The use of drains in thyroid surgery

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.

A clinical comparative study of thyroid surgeries with and without drain

Most of the thyroid surgeries are accompanied by drain placement. The possibility of hematoma or seroma formation postoperatively is of concern to surgeons, as, thyroid is a highly vascular structure and a minor hemorrhage might also turn out to be life threatening, despite actual incidence of it being only 0.3-1%. Thus, drains are placed with an intention to obliterate dead space and clear the collecting blood or serum. Conversely, several studies have indicated chances of clots blocking the drainage tube and resulting in missing out of early detection of a massive bleed. Drains have also been known to add more discomfort to the patient, increase chances of infection, increase post operative pain, scar formation and longer duration of hospital stay. Thus, some surgeons believe in not placing a drain. To compare the outcomes of thyroid surgeries done with drain versus those thyroid surgeries done without drain. 40 patients, of either sex, between 18 and 70 years of age, who underwent thyroid surgeries for various thyroid disorders over a period of 6 months, were randomly allocated to either 'with drain' (group A) or 'without drain' (group B). The surgeon was made aware of drain status only intraoperatively. Patients were assessed for post-operative pain based on Visual Analogue Scale (VAS) at 6 and 24 h post-operatively. Post-operative complications including hematoma, seroma, and wound infection, if any, along with duration of hospitalization, were also documented. Patient was followed up one week post-operatively for wound check and suture removal. Both groups were homogenous according to age, sex, TIRADS, Bethesda, diagnosis and surgery performed. Postoperative pain at 6 and 24 h was significantly higher in group A than in group B [6.15 ± 1.31 vs 3.50 ± 0.88 (p = 0.001) (6 h), 4.45 ± 0.99 vs 1.20 ± 1.10 (p = 0.001) (24 h)]. Mean duration of hospitalization following thyroid surgery was significantly higher among group A than group B [3.80 ± 1.15 vs 2.15 ± 0.36 days (p = 0.001)]. Though not statistically significant, wound pain at 1 week and overall complications were higher in Group A than in Group B (p = 0.182, p = 0.127 respectively). Thyroid surgeries done without drain placement are likely to cause significantly lesser post-operative pain and shorter duration of hospitalization.

Impact of negative pressure wound drainage compared with natural wound drainage after thyroid tumour surgery: A meta-analysis

We conducted a meta-analysis to compare the effectiveness of negative pressure wound drainage to that of spontaneous wound drainage after thyroid tumour surgery. A thorough analysis of the literature up to July 2022 revealed that, of the 1234 patients who used surgery for thyroid tumours, 615 used negative pressure wound drainage and 619 used natural wound drainage. To measure the influence of negative pressure wound drainage in comparison to natural wound drainage following thyroid tumour surgery, mean difference (MD) and odds ratio (OR) with 95% confidence intervals (CIs) were measured using the contentious and dichotomous approaches with a random or fixed-effect model. Subjects who used negative pressure wound drainage had significantly higher averages for drained material (OR, 12.52; 95% CI, 6.78-18.26, P = 0.001), shorter drain placement times (MD, -1.06; 95% CI, 1.57 to -0.55, P = .001), lower rates of infection at the surgical site (OR, 0.17; 95% CI, 0.05-0.60, P = .006), higher rates of wound healing (OR, 5.91; 95% CI, 1.56-22.34, P = .009), and lower rate of wound seroma (OR, 0.21; 95% CI, 0.10-0.42, P < .001) in subjects after thyroid tumour surgery in comparison to subjects who used natural wound drainage after thyroid tumour surgery. Those who used negative pressure wound drainage had significantly higher averages of drained material, shorter drain placement times, lower rates of wound infection at the surgical site, higher rates of wound healing, and lower rates of wound seroma. Care must be used when analysing the results because of the small sample size of 7 of the 13 studies included in the meta-analysis and the lack of studies in several comparisons.

Efficacy and safety of negative pressure versus natural drainage after thyroid surgery: A systematic review and meta-analysis

BACKGROUND

To evaluate whether negative pressure drainage has advantage over natural drainage in effectiveness and safety for patients with thyroid disease after thyroid surgery.

METHOD

We performed intensive literature search and followed the standards described in preferred reporting items for systematic review and meta-analysis (PRISMA) statement to conduct this systematic review. Risk of bias was assessed using the Cochrane Risk of bias tool. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence body.

RESULTS

Total 1195 participants with thyroid disease from 13 studies were included. For patients underwent thyroidectomy without neck dissection, negative pressure drainage group has a lower risk of seroma and wound infection. The duration of tube placement was shorter in negative pressure drainage group, which produced more fluid than natural drainage in the first 24-hour period. The effect of negative pressure drainage on reoperative rates, mortality, and length of hospitalization remains unclear.

CONCLUSIONS

For patients underwent thyroidectomy with neck dissection, the difference between negative and natural pressure drainage groups remains uncertain due to sparse data. The quality of evidence for the above findings is low. The risk of bias for the studies is also serious. Therefore, more randomized or non-randomized controlled trials with larger sample sizes are required.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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