Ambulatory thyroidectomy: Recommendations from the Association Francophone de Chirurgie Endocrinienne (AFCE). Investigating current practices

A Comprehensive Management of Neck Hematoma in Post-Thyroidectomy Patient for Papillary Thyroid Cancer: A Case Report

A post-thyroidectomy hematoma is a rare, potentially fatal surgical complication that may present as hoarseness, dysphagia, and difficulty in breathing, which could progress to complete airway obstruction and, ultimately, death. The treatment for a neck hematoma is emergent surgical drainage. While certain precautions can be taken to prevent this complication, such as the cessation of any anticoagulants prior to surgery, it is still a feared complication of thyroidectomy with an increasing prevalence. In this paper, we discuss a case of a 62-year-old female with papillary thyroid cancer who presents with a postoperative complication of a neck hematoma requiring emergent surgery and conduct a literature review on managing post-thyroidectomy hematomas.

Ambulatory thyroidectomy. Recommendations of the Association francophone de chirurgie endocrinienne (AFCE), with the Société française d'endocrinologie (SFE) and the Société française de médecine nucléaire (SFMN)

Before ambulatory thyroidectomy is proposed, the patient and his family and/or friends will need to be informed by the surgeon of the specificity of this procedure, the normal postoperative effects of a thyroidectomy, and potential complications. Also known as outpatient thyroid surgery, it can only be proposed by an experienced surgeon supported by an adequately trained medical and paramedical team. The healthcare establishment must be in possession of all the resources needed in ambulatory management, with continuity of care guaranteed 24h/24 7d/7 in the event of possible emergency rehospitalization. In all cases, contact the day after the operation between the healthcare facility and the patient is imperative. Ambulatory management can be proposed for lobo-isthmectomy or isthmectomy, possibly involving lymph node dissection. It is also possible for secondary totalization of thyroidectomy (following lobectomy). On the other hand, indications for single-stage total thyroidectomy must be limited and ensure proximity between the patient's home and a healthcare structure with a platform adapted to the pathology necessitating surgical intervention (non-plunging euthyroid goiter). A precise clinical pathway must be set out, including pre-, peri- and postoperative protocols having been formalized for surgery (hemostasis procedures) and for anesthesia (prevention of pain, of vomiting and of hypertension). We recommend at least 6hours of postoperative surveillance in outpatient care. When outpatient treatment is not possible or not recommended, hospitalization stay after thyroidectomy can be limited to 24hours, except in the event of postoperative complications, or a need for effectively dosed anticoagulant treatment.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA). Recommendations of the AFCE (Francophone Association of Endocrine Surgery) with the SFE (French Society of Endocrinology) and the SFMN (French Society of Nuclear Medicine)

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be proposed for selected patients with a thyroid volume<45mL and/or a nodule<4cm (for Bethesda category II, III or IV lesions), or<2cm (for Bethesda category V or VI lesions), with no suspicion of lateral nodal involvement or mediastinal extension who wish to avoid a cervical scar. Such patients should have satisfactory dental status, have been educated on the specific risks of the transoral route and the need for perioperative oral care, and also fully informed regarding the lack of proof of TOETVA effectiveness in terms of quality of life and patient satisfaction. The patient should be made aware of the possibility of postoperative pain in the neck cervical and chin, which may persist for several days to a few weeks after the intervention. Transoral endoscopic thyroidectomy should be performed in centers with expertise in thyroid surgery.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.

Safety and cost-effectiveness of outpatient thyroidectomy: A retrospective observational study

OBJECTIVES

To investigate the safety and cost-effectiveness of outpatient thyroidectomy and provide a systematic postoperative protocol for safe discharge.

METHODS

In this retrospective review, the medical records of all patients who underwent total, hemi, or completion thyroidectomy from July 2017 to April 2019 at 2 tertiary care hospitals were reviewed. Multivariable analysis was performed on the potential predictors of postoperative complications. Healthcare costs were calculated by the type of admission based on the average costs at the 2 centers.

RESULTS

One hundred twenty-two patients were enrolled in this study. The majority of cases were in the outpatient group (n=76, 62.3%). Total thyroidectomy was the most prevalent type of surgery (n=90, 73.7%). There were a total of 20 complications in 18 patients (inpatient=9 versus [vs.] outpatient=9). No cases of cervical hematoma or bilateral vocal cord paralysis were encountered. No significant difference was found between the type of admission (outpatient vs. inpatient) and postsurgical complications (p=0.24). The multivariable regression model retained significance for male gender and American Society of Anesthesiologists Classification III as potential predictors of postoperative complications. Healthcare costs would be reduced by at least 15.5% with the implementation of outpatient surgery.

CONCLUSION

Outpatient thyroidectomy is as safe as inpatient thyroidectomy given the proper selection of cases. We project cost containment of over $711 thousand per 1,000 cases for outpatient thyroid surgeries.

Medicolegal Analysis of 81 Malpractice Claims Against Bariatric Surgeons in France

BACKGROUND

Medicolegal expertise concerning bariatric surgery has greatly evolved, both quantitatively and qualitatively, but unfortunately, the jurisprudence is poor on the subject.

OBJECTIVES

The aim of this article is to propose a global and practical approach to medical liability in bariatric surgery.

SETTING

University Hospital, France METHODS: This is a retrospective study which deals with an analysis of cases of surgical malpractice litigation between 2009 and 2011. Only the malpractice claims taken to the High Court and the Regional Commission of Reconciliation and Compensation have been taken into account in this study.

RESULTS

During this period, there were 426 cases of visceral and digestive surgical malpractice litigation, 81 of which involved bariatric surgery (19%). Fistula was the most common complication leading to a malpractice claim (43.67%). The period of time between the allegations and the procedure was 2 years on average, with a range of 1 to 6 years. There were seven fistulas reported with gastric bypass GB (18.5%) and 31 with sleeve gastrectomy SG (81.5%) leading to malpractice claims. In the majority of cases, only the surgeon was implicated. Sometimes the anaesthetist or the surgical staff were implicated separately or "in solidum" with the surgeon. Every surgical technique was examined.

CONCLUSION

Patients do not spontaneously differentiate between recovery from a complication and the result of an alleged error. Attention must be paid to the implications and discourteous remarks. Surgical complications are often unpredictable events and are not synonymous with medical mistakes.

What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort

CONTEXT

The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment.

OBJECTIVES

To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls.

DESIGN

A large observational study based on medical reimbursements, 2009-2011.

SETTING

Data from the Sniiram (National Health Insurance Information System).

PATIENTS

Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head-neck cancer).

MAIN OUTCOME MEASURES

Medical investigations during, prior and after thyroidectomy.

RESULTS

A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4-12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%).

CONCLUSIONS

This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Ambulatory thyroidectomy: an anesthesiologist's perspective

Thyroidectomy has been performed on an inpatient basis because of concerns regarding postoperative complications. These include cervical hematoma, bilateral recurrent laryngeal nerve injury and symptomatic hypocalcemia. We have reviewed the current available evidence and aimed to collate published data to generate incidence of the important complications. We performed a literature search of Medline, EMBASE and the Cochrane database of randomized trials. One hundred sixty papers were included. Twenty-one papers fulfilled inclusion criteria. Thirty thousand four hundred fifty-three day-case thyroid procedures were included. Ten papers were prospective and 11 retrospective. The incidences of complications were permanent vocal cord paralysis 7/30259 (0.02%), temporary hypocalcemia 129/4444 (2.9%), permanent hypocalcemia 405/29203 (1.39%), cervical hematoma 145/30288 (0.48%) and readmission rate 105/29609 (0.35%). Analysis of cervical hematoma data demonstrated that in only 3/14 cases the hematoma presented as an inpatient, and in the remaining 11/14, it occurred late, with a range of 2–9 days. There is a paucity of data relating to anesthetic techniques associated with ambulatory thyroidectomy. Cost comparison between outpatient and inpatient thyroidectomy was reported in three papers. Cost difference ranged from $676 to $2474 with a mean saving of $1301 with ambulatory thyroidectomy. There is a body of evidence that suggests that ambulatory thyroidectomy in the hands of experienced operating teams within an appropriate setting can be performed with acceptable risk profile. In most circumstances, this will be limited to hemithyroidectomies to reduce or avoid the potential for additional morbidity. We have found little evidence to support the use of one anesthetic technique over another. The rates of hospital admission and readmission related to anesthetic factors appear to be low and predominantly related to pain and postoperative nausea and vomiting. A balanced anesthetic technique incorporating appropriate analgesic and antiemetic regimens is essential to avoid unnecessary hospital admission/readmission.

Early discharge after total thyroidectomy: a retrospective feasibility study

AIM

The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study.

PATIENTS AND METHODS

Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis.

RESULTS

As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge.

CONCLUSION

On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.

Clinical Pathway for Thyroidectomy

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Ambulatory thyroid surgery: do the risks overcome the benefits?

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