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Thakkar K, Nwangene NL, Maharjan R, Francis S, Carredo CKC, Dahal R, Khan A. A Comprehensive Management of Neck Hematoma in Post-Thyroidectomy Patient for Papillary Thyroid Cancer: A Case Report. Cureus 2023; 15:e42689. [PMID: 37649935 PMCID: PMC10464918 DOI: 10.7759/cureus.42689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
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.
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Affiliation(s)
- Keval Thakkar
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, USA
- Department of Internal Medicine, Larkin Community Hospital, South Miami, USA
| | | | - Reeju Maharjan
- Department of Neurology, V.N. Karazin Kharkiv National University, Kharkiv, UKR
| | - Sandra Francis
- Department of Medicine, Windsor University School of Medicine, Cayon, KNA
| | | | - Rojaj Dahal
- Department of Internal Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Aadil Khan
- Department of Cardiology, University of Illinois Chicago, Chicago, USA
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2
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Christou N, Di Maria S, Mirallié E, Noullet S, Mathonnet M, Menegaux F. 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). J Visc Surg 2023:S1878-7886(23)00072-3. [PMID: 37211444 DOI: 10.1016/j.jviscsurg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- Niki Christou
- Digestive, Endocrine and General Surgery Department, University Hospital Center of Limoges, Limoges, France.
| | - Sophie Di Maria
- Department of Anesthesia-Resuscitation, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - Eric Mirallié
- Cancer, Digestive and Endocrine Surgery Department, Institut des Maladies de l'Appareil Digestif, University Hospital Center of Nantes, Nantes, France
| | - Séverine Noullet
- Department of General, Visceral and Endocrine Surgery, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - Muriel Mathonnet
- Digestive, Endocrine and General Surgery Department, University Hospital Center of Limoges, Limoges, France
| | - Fabrice Menegaux
- Department of General, Visceral and Endocrine Surgery, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
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3
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Chereau N, Paladino NC, Nomine Criqui C, Tresallet C, Deroide G, Caiazzo R. 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). J Visc Surg 2023:S1878-7886(23)00080-2. [PMID: 37198067 DOI: 10.1016/j.jviscsurg.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
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.
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Affiliation(s)
- Nathalie Chereau
- Department of General, Visceral and Endocrine Surgery, GH Pitié-Salpêtrière, AP-HP, Sorbonne University, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Nunzia Cinzia Paladino
- Department of General, Endocrine and Metabolic Surgery, CHU La Conception, AP-HM, Aix Marseille University, Marseille, France
| | - Claire Nomine Criqui
- Department of Visceral, Metabolic and Oncological Surgery, University of Lorraine, CHRU Nancy, Brabois Hospital, Vandœuvre-lès-Nancy, France
| | - Christophe Tresallet
- Department of Digestive, Bariatric and Endocrine Surgery, HU Paris Seine-Saint-Denis, AP-HP, Avicenne Hospital, Bobigny, France
| | - Gregoire Deroide
- Visceral Surgery Department, Hôpital Franco-Britannique-Fondation Cognacq-Jay, Levallois-Perret, France
| | - Robert Caiazzo
- General and Endocrine Surgery Department, University Hospital Center of Lille, Lille, France
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4
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Menegaux F, Baud G, Chereau N, Christou N, Deguelte S, Frey S, Guérin C, Marciniak C, Paladino NC, Brunaud L, Caiazzo R, Donatini G, Gaujoux S, Goudet P, Hartl D, Lifante JC, Mathonnet M, Mirallié E, Najah H, Sebag F, Trésallet C, Pattou F. SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment. ANNALES D'ENDOCRINOLOGIE 2022; 83:415-422. [PMID: 36309207 DOI: 10.1016/j.ando.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Fabrice Menegaux
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France.
| | - Gregory Baud
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Nathalie Chereau
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Niki Christou
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Limoges, France
| | - Sophie Deguelte
- Service de Chirurgie Digestive et Endocrinienne, Hôpital Robert-Debré, Université de Champagne Ardennes, Reims, France
| | - Samuel Frey
- Service de Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Université de Nantes, Nantes, France
| | - Carole Guérin
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Camille Marciniak
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Nunzia Cinzia Paladino
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Laurent Brunaud
- Département de Chirurgie Viscérale, Métabolique et Cancérologique, Université de Lorraine, CHRU Nancy, Hôpital Brabois Adultes, Vandœuvre les Nancy, France
| | - Robert Caiazzo
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Gianluca Donatini
- Service de Chirurgie Viscérale et Endocrinienne, CHU-Poitiers, Poitiers Université, Poitiers, France
| | - Sebastien Gaujoux
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Pierre Goudet
- Département de Chirurgie Générale et Endocrinienne, CHU de Dijon, Université de Bourgogne, Dijon, France
| | - Dana Hartl
- Département d'Anesthésie, de Chirurgie et de Radiologie Interventionnelle, Unité de Chirurgie Thyroïdienne, Institut Gustave Roussy, Villejuif, France
| | - Jean-Christophe Lifante
- Service de Chirurgie Endocrinienne, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Muriel Mathonnet
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Limoges, France
| | - Eric Mirallié
- Service de Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Université de Nantes, Nantes, France
| | - Haythem Najah
- Service de Chirurgie Digestive et Endocrinienne, Hôpital Haut Lévêque, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frederic Sebag
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Christophe Trésallet
- Service de Chirurgie Digestive, Bariatrique et Endocrinienne, HU Paris Seine-Saint-Denis, AP-HP, Hôpital Avicenne, Bobigny, France
| | - Francois Pattou
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
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Embury-Young Y, Keshtkar F, Porter G. Should Thyroid Lobectomy Be Performed as a Day-Case Procedure? A Single-Centre Retrospective Audit. Cureus 2022; 14:e31435. [DOI: 10.7759/cureus.31435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/14/2022] Open
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AlEssa M, Al-Angari SS, Jomah M, AlOqaili A, Mujammami M, Al-Hakami HA, Al-Dhahri SF. Safety and cost-effectiveness of outpatient thyroidectomy: A retrospective observational study. Saudi Med J 2021; 42:189-195. [PMID: 33563738 PMCID: PMC7989291 DOI: 10.15537/smj.2021.2.25686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/30/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed AlEssa
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Samiah S. Al-Angari
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Mohammed Jomah
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Aqeel AlOqaili
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Muhammad Mujammami
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Hadi A. Al-Hakami
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
| | - Saleh F. Al-Dhahri
- From the Department of Otolaryngology - Head & Neck Surgery (AlEssa, Al-Angari, Jomah, Al-Dhahri), College of Medicine; from the Division of Endocrinology and Metabolism, Department of Medicine (Mujammami), King Saud University; from the Department of Otolaryngology - Head & Neck Surgery (AlEssa), King Abdulaziz Medical City, National Guard Health Affairs; from the Division of Otolaryngology - Head & Neck Surgery, Department of Surgery (AlOqaili), King Abdullah bin Abdulaziz University Hospital; from the Department of Otolaryngology - Head & Neck Surgery (Al-Dhahri), King Fahad Medical City, Riyadh; and from the Department of Otolaryngology - Head & Neck Surgery (Al-Hakami), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.
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Abstract
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.
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8
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Benhami A, Chuffart E, Christou N, Liva-Yonnet S, Mathonnet M. Ambulatory surgery under local anesthesia for parathyroid adenoma: Feasibility and outcome. J Visc Surg 2018; 155:253-258. [DOI: 10.1016/j.jviscsurg.2017.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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9
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Brunaud L, Zarnegar R, Mirallie E. At last a step forward toward ambulatory care for endocrine surgery in France? J Visc Surg 2018; 155:251-252. [PMID: 30001992 DOI: 10.1016/j.jviscsurg.2018.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- L Brunaud
- Unité Inserm U954, service de chirurgie digestive, hépatobiliaire, pancréatique, endocrinienne et cancérologique, université de Lorraine, centre hospitalier régional universitaire (CHRU) de Nancy-Brabois, rue du Morvan, 54511 Vandoeuvre-Les-Nancy, France.
| | - R Zarnegar
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, USA
| | - E Mirallie
- Centre hospitalier universitaire (CHU) de Nantes-Hôtel Dieu, clinique de chirurgie digestive et endocrinienne (CCDE), institut des maladies de l'appareil digestif (IMAD), place Alexis-Ricordeau, 44093 Nantes, France
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10
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Mathonnet M, Cuerq A, Tresallet C, Thalabard JC, Fery-Lemonnier E, Russ G, Leenhardt L, Bigorgne C, Tuppin P, Millat B, Fagot-Campagna A. What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort. BMJ Open 2017; 7:e013589. [PMID: 28389487 PMCID: PMC5558818 DOI: 10.1136/bmjopen-2016-013589] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Anne Cuerq
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Christophe Tresallet
- Department of General, Visceral and Endocrine Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | | | | | - Gilles Russ
- Department of Thyroid Diseases and Endocrine Tumors, Pitié Salpêtrière Hospital, University Paris VI, Institut E3M, Paris, France
| | - Laurence Leenhardt
- Department of Thyroid Diseases and Endocrine Tumors, Pitié Salpêtrière Hospital, University Paris VI, Institut E3M, Paris, France
| | - Claude Bigorgne
- Department of Pathology, La Pitié Salpétrière Hospital, Paris, France
| | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | | | - Anne Fagot-Campagna
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
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11
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Abstract
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.
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Affiliation(s)
| | - Sankalap Tandon
- Department of Otolaryngology, Head & Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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12
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Tartaglia F, Giuliani A, Sorrenti S, Tromba L, Carbotta S, Maturo A, Carbotta G, De Anna L, Merola R, Livadoti G, Pelle F, Ulisse S. Early discharge after total thyroidectomy: a retrospective feasibility study. G Chir 2017; 37:250-256. [PMID: 28350971 DOI: 10.11138/gchir/2016.37.6.250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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13
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Ayala MA, Yencha MW. Outpatient Thyroid Surgery in a Low-Surgical Volume Hospital. World J Surg 2015; 39:2253-8. [DOI: 10.1007/s00268-015-3097-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Villar del Moral JM, Soria Aledo V, Colina Alonso A, Flores Pastor B, Gutiérrez Rodríguez MT, Ortega Serrano J, Parra Hidalgo P, Ros López S. Clinical Pathway for Thyroidectomy. Cir Esp 2015; 93:283-99. [PMID: 25732107 DOI: 10.1016/j.ciresp.2014.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/17/2014] [Accepted: 11/29/2014] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Jesús María Villar del Moral
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - Víctor Soria Aledo
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Morales Meseguer, Murcia, España
| | - Alberto Colina Alonso
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - Benito Flores Pastor
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Morales Meseguer, Murcia, España
| | - María Teresa Gutiérrez Rodríguez
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario de Basurto, Bilbao, España
| | - Joaquín Ortega Serrano
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Clínico Universitario de Valencia, Valencia, España
| | - Pedro Parra Hidalgo
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Consejería de Sanidad de la Región de Murcia, Murcia, España
| | - Susana Ros López
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Arnau de Vilanova, Lérida, España
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15
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Doran HE, Palazzo F. Ambulatory thyroid surgery: do the risks overcome the benefits? Presse Med 2014; 43:291-6. [PMID: 24485830 DOI: 10.1016/j.lpm.2014.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/06/2014] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Helen E Doran
- Salford Royal Foundation Trust, department surgery, Stott Lane, M6 8HD, Salford, United Kingdom.
| | - Fausto Palazzo
- Hammersmith hospital, department endocrine and thyroid surgery, Imperial college, W12 0HS, London, United Kingdom
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