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Nakanishi H, Wang R, Miangul S, Kim GE, Segun-Omosehin OA, Bourdakos NE, Than CA, Johnson BE, Chen H, Gillis A. Clinical outcomes of outpatient thyroidectomy: A systematic review and single-arm meta-analysis. Am J Surg 2024; 236:115694. [PMID: 38443270 DOI: 10.1016/j.amjsurg.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 02/22/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND The aim of this meta-analysis is to investigate the safety of outpatient thyroidectomy based on 24-h and same-day discharge criteria. METHODS CENTRAL, Embase, PubMed, and Scopus were searched. A meta-analysis of selected studies was performed. The review was registered prospectively with PROSPERO (CRD42022361134). RESULTS Thirty-one studies met the eligibility criteria, with a total of 74328 patients undergoing thyroidectomy in an outpatient setting based on 24-h discharge criteria. Overall postoperative complications after outpatient thyroidectomies were 5.7% (95%CI: 0.049-0.065; I2 = 97.3%), consisting of hematoma (0.4%; 95%CI: 0.003-0.005; I2 = 83.4%), recurrent laryngeal nerve injury (0.4%; 95%CI: 0.003-0.006; I2 = 93.5%), and hypocalcemia (1.6%; 95%CI: 0.012-0.019; I2 = 93.7%). The rate of readmission was 1.1% (95%CI: 0.007-0.015; I2 = 95.4%). Results were similar for same-day criteria. CONCLUSIONS Our analysis demonstrated that outpatient thyroidectomy is a safe procedure in the management of thyroid disease for selected patients.
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Affiliation(s)
- Hayato Nakanishi
- St George's University of London, London, SW17 0RE, UK; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Rongzhi Wang
- Department of Surgery, University of Alabama at Birmingham. Birmingham, AL, USA
| | - Shahid Miangul
- St George's University of London, London, SW17 0RE, UK; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Grace E Kim
- Division of Emergency Medicine, NorthShore University Health System, Chicago, IL, USA
| | - Omotayo A Segun-Omosehin
- St George's University of London, London, SW17 0RE, UK; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Natalie E Bourdakos
- St George's University of London, London, SW17 0RE, UK; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Christian A Than
- St George's University of London, London, SW17 0RE, UK; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus; School of Biomedical Sciences, The University of Queensland, St Lucia, 4072, Australia
| | - Benjamin E Johnson
- Division of Surgery, NorthShore University Health System, Chicago, IL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham. Birmingham, AL, USA
| | - Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham. Birmingham, AL, USA.
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Annesi CA, Gillis A, Fazendin JM, Lindeman B, Chen H. Same-day parathyroidectomy for primary hyperparathyroidism -an over 20-year practice. World J Surg 2024. [PMID: 39174347 DOI: 10.1002/wjs.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
INTRODUCTION There has been a shift in recent years toward same-day parathyroidectomies due to the decrease in mutual costs with few significant differences in postoperative morbidity or mortality. We sought to determine if demographics, preoperative patient risk factors, or comorbidities were associated with a patient's likelihood of having same-day or inpatient surgery. MATERIALS AND METHODS A prospective database of parathyroid operations from 2001 to 2022 (n = 2948 patients) was reviewed for surgeries completed for primary hyperparathyroidism. Patients were categorized as same-day or inpatient surgery; demographics, risk factors, and co-morbidities were examined and differences across practice patterns during the 21-year period were studied and also analyzed in a subset of patients from 2013 to 2022. RESULTS In a recent subset of patients from 2013 to 2022, patients having inpatient surgery were more likely to be Black and use anticoagulation or antiplatelet therapy. Multivariable regression confirmed increased odds of aging and black patients requiring inpatient parathyroidectomy. Compared to 2001-2003, there was a significantly increased proportion of patients undergoing same-day surgery; compared to 2010-2012, there was a similar proportion of patients undergoing outpatient surgery between 2013 and 2018, and there was an increased proportion from 2019 through 2022. CONCLUSION Same-day parathyroidectomies have been shown to be safe and has become the typical practice for high-volume parathyroid surgeons over the last decade. Complications such as postoperative hematoma or hypocalcemia were previously shown to be incompletely mitigated by increased LOS or inpatient surgery, although demographics are considered to increase the odds of inpatient parathyroidectomy.
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Affiliation(s)
- Chandler A Annesi
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica M Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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July O'Brien K, Naveed A, Patel S, Gallant JN, Rohde S, Belcher RH. Same-Day Discharge for Pediatric Hemithyroidectomy Patients: Evaluating Safety and Barriers to Discharge. Otolaryngol Head Neck Surg 2024; 171:538-545. [PMID: 38494856 DOI: 10.1002/ohn.726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/04/2024] [Accepted: 02/24/2024] [Indexed: 03/19/2024]
Abstract
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.
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Affiliation(s)
- Kaitlin July O'Brien
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Abdullah Naveed
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Siddharth Patel
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jean-Nicolas Gallant
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan H Belcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Pediatric Otolaryngology-Head and Neck Surgery Division, Monroe Carrell Jr. Hospital at Vanderbilt, Nashville, Tennessee, USA
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Brooks ES, Finn CB, Wirtalla CJ, Kelz RR. Inefficiencies of care in hub and spoke healthcare systems: A multi-state cohort study. Am J Surg 2024; 229:151-155. [PMID: 38160065 DOI: 10.1016/j.amjsurg.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Complex surgical care is often centralized to one high volume (hub) hospital within a system. The benefit of this centralization in common operations is unknown. METHODS Using the Healthcare Cost and Utilization Project's State Inpatient Databases, adult general surgical patients within hospital systems in 13 states (2016-2018) were identified. Risk-adjusted logistic regression estimated the odds of death or serious morbidity (DSM) and prolonged length of stay (LOS) at hubs relative to other system hospitals (spokes). RESULTS We identified 122,895 patients across 43 hub-and-spoke systems. Hubs completed 83.2 % of complex and 59.6 % of common operations. For complex operations, odds of DSM were significantly lower in hubs (OR: 0.80; 95 % CI [0.65, 0.98]). For common operations, odds of DSM were similar between hubs and spokes, while odds of prolonged LOS were greater at hubs (OR 1.19; 95 % CI [1.16,1.24]). CONCLUSIONS While hub hospitals had lower odds of DSM for complex operation, they had higher odds of prolonged length of stay for common operations. This finding shows an opportunity for improved system efficiency.
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Affiliation(s)
- Ezra S Brooks
- Brigham and Women's Hospital, General Surgery Residency Program, 75 Francis St, Boston, MA, 02115, USA.
| | - Caitlin B Finn
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Christopher J Wirtalla
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Rachel R Kelz
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA
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Ahmed LS, Naser F, Mohammed E. Thyroidectomy With or Without Nerve Identification: A Personal Experience and Technique. Cureus 2023; 15:e40312. [PMID: 37448394 PMCID: PMC10337801 DOI: 10.7759/cureus.40312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/10/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Careful and precise dissection of the gland, away from the typical trajectory of the recurrent and external laryngeal nerves, poses a minimal or similar risk of nerve injuries compared to directly visualizing and identifying the nerves. MATERIALS AND METHODS In a randomized controlled study involving 150 patients with various thyroid disorders who underwent different surgical procedures (total, near total, and hemi thyroidectomy), the patients were randomly assigned into two groups using a coin toss. The first group (G1) consisted of 75 patients who underwent thyroidectomy with nerve visual identification, while the second group (G2) comprised 75 patients without the requirement of nerve visualization. The aim was to determine the method with a lower risk of complications. RESULTS The incidence of external laryngeal nerve palsy (ELNP) was found to be higher in G1 patients compared to G2 patients (5.3% vs 2%), while no cases of permanent recurrent laryngeal nerve (RLN) palsy were observed in either group. The frequency of total nerve injury was higher in G1, with 14 patients (10.2%), compared to G2, with eight patients (5.3%). However, there was no significant association between nerve identification and the rate of nerve injury (P value = 0.452). Among the different surgical procedures, total thyroidectomy for toxic goiter was the most common operation associated with transient external laryngeal nerve (TELN) injury and permanent external laryngeal nerve (PELN) injury. CONCLUSION By employing meticulous dissection techniques in proximity to the thyroid capsule, experienced surgeons can effectively reduce the risk of nerve injury, even in the absence of direct nerve visualization.
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Affiliation(s)
- Loay S Ahmed
- Department of General Surgery, Kirkuk College of Medicine, Kirkuk, IRQ
| | - Fakhraddin Naser
- Department of General Surgery, Kirkuk College of Medicine, Kirkuk, IRQ
| | - Emad Mohammed
- Department of Surgery, Azadi Teaching Hospital, Kirkuk, IRQ
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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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Hsu S, Melucci AD, Dave YA, Chennell T, Fazendin J, Suh I, Moalem J. Outpatient endocrine surgery practice patterns are highly variable among US endocrine surgery fellowship programs. Surgery 2023; 173:76-83. [PMID: 36192212 DOI: 10.1016/j.surg.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Todd Chennell
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Insoo Suh
- Department of Surgery, NYU Langone Health, New York, NY
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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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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Risk of hematoma after hemithyroidectomy in an outpatient setting: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2022; 279:3755-3767. [PMID: 35294619 PMCID: PMC9249722 DOI: 10.1007/s00405-022-07312-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/09/2022] [Indexed: 11/30/2022]
Abstract
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.
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Noel CW, Griffiths R, Siu J, Forner D, Urbach D, Freeman J, Goldstein DP, Irish JC, Higgins KM, Devon K, Pasternak JD, Eskander A. A Population-Based Analysis of Outpatient Thyroidectomy: Safe and Under-Utilized. Laryngoscope 2021; 131:2625-2633. [PMID: 34378810 DOI: 10.1002/lary.29816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/23/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought to assess the uptake and safety of outpatient thyroidectomy in Ontario. STUDY DESIGN Retrospective cohort study. METHODS This was a population-based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30-day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure-outcome relationship. RESULTS The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993-1994 to 17.8% in 2016-2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.73[95CI% 0.58-0.93)], but higher odds of emergency department use (OR 1.67[95%CI 1.56-1.79]). CONCLUSIONS Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well-established safety profile. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Griffiths
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Jennifer Siu
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.,Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Urbach
- Women's College Hospital and Departments of Surgery and Health Policy, Management and Evaluation, Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Freeman
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery/Surgical Oncology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Kevin M Higgins
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Surgical Oncology, Sunnybrook Health Sciences Centre and Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Devon
- Section of Endocrine Surgery, Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jesse D Pasternak
- Section of Endocrine Surgery, Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Surgical Oncology, Sunnybrook Health Sciences Centre and Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada
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11
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Wide provider variation in cost for thyroidectomy: Potential benefits of standardizing practice? J Surg Res 2021; 267:9-16. [PMID: 34120017 DOI: 10.1016/j.jss.2021.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 03/30/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE(S) Identifying provider variation in surgical costs could control rising healthcare expenditure and deliver cost-effective care. While these efforts have mostly focused on complex and expensive operations, provider-level variation in costs of thyroidectomy has not been well examined. METHODS We retrospectively evaluated 921 consecutive total thyroidectomies performed by 14 surgeons at our institution between September 2011 and July 2016. Data were extracted from the Change Healthcare Performance Analytics Program. RESULTS Mean patient age was 47.4 ± 0.5 y, 81% were females, 64.7% were Caucasians, and 18.8% were outpatients. The number of thyroidectomies performed by the 14 surgeons ranged from 4 to 597 (mean = 66). The mean costs per provider varied widely from $4,293 to $15,529 (P < 0.001). The mean length of stay was 1d ± .03 with wide variation among providers (0-6 d). Providers whose hospital cost exceeded the institutional mean demonstrated significantly higher anesthesia fees and lab costs (P < 0.001). CONCLUSIONS We found substantial variation in hospital cost among providers for thyroidectomy despite practicing in the same academic institution, with some surgeons spending 3x more for the same operation. Implementing institutional standards of practice could reduce variation and the costs of surgical care.
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12
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Obiarinze R, Fazendin J, Iyer P, Lindeman B, Chen H. Intraoperative parathyroid hormone measurement facilitates outpatient thyroidectomy in children. Am J Surg 2021; 221:683-686. [PMID: 33648715 DOI: 10.1016/j.amjsurg.2021.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We hypothesize that intraoperative parathyroid hormone (ioPTH) measurement after a total thyroidectomy predicts children at risk for hypoparathyroidism and allow for outpatient procedure. METHODS Between 2015 and 2019, we reviewed all patients under the age of 21 undergoing a thyroidectomy (total or lobectomy). Based on the ioPTH concentration, the patients were treated by the following protocol: a) PTH ≥20 pg/mL: no treatment; b) PTH = 10-19 pg/mL: 1000 mg calcium orally TID; c) PTH = 5-9 pg/mL: calcitriol 250 μg orally BID plus 1000 mg calcium orally TID; or d) PTH <5 pg/mL calcitriol 500 μg orally BID plus 1000 mg calcium orally TID. RESULTS Fifty-two patients were included with a median age of 16 (range 6-21 years). Thirty-two patients (62%) had normal PTH (≥10 pg/mL) while 20 (38%) had low PTH levels (<10 pg/mL). Of those patients with low PTH, 60% had normalization of levels within 2 weeks of surgery. CONCLUSIONS Thyroid surgery in children can be performed as an outpatient procedure. The ioPTH measurements and a protocol to treat patients with low PTH assists in safe discharge.
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Affiliation(s)
- Ruth Obiarinze
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
| | - Jessica Fazendin
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Pallavi Iyer
- University of Alabama at Birmingham Department of Pediatrics, CPII M30, 1600 7th Ave S, Birmingham, AL 35233, USA
| | - Brenessa Lindeman
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Herbert Chen
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
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13
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Philteos J, Baran E, Noel CW, Pasternak JD, Higgins KM, Freeman JL, Chiodo A, Eskander A. Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review. Front Endocrinol (Lausanne) 2021; 12:717427. [PMID: 34394008 PMCID: PMC8355596 DOI: 10.3389/fendo.2021.717427] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Justine Philteos
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Elif Baran
- Undergraduate Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Christopher W. Noel
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jesse D. Pasternak
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kevin M. Higgins
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Jeremy L. Freeman
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Albino Chiodo
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Antoine Eskander
- Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- *Correspondence: Antoine Eskander,
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14
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Compton RA, Simmonds JC, Dhingra JK. Total Thyroidectomy as an Ambulatory Procedure in Community Practice. OTO Open 2020; 4:2473974X20957324. [PMID: 33062910 PMCID: PMC7534086 DOI: 10.1177/2473974x20957324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Objective Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice. Study Design Retrospective review and national database analysis. Setting A single community otolaryngology practice. Methods Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings. Results A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study. Conclusions Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.
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Affiliation(s)
- Rebecca A Compton
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Jonathan C Simmonds
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Jagdish K Dhingra
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA.,ENT Specialists, Inc, Brockton, Massachusetts, USA
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15
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Moeller EA, Walker T, F Khan Z, P Parreco J, L Buicko J. Socioeconomic Characteristics of Patients Undergoing Ambulatory Parathyroidectomy and a Comparison of Institutional Charges. Am Surg 2020; 88:668-673. [PMID: 32988223 DOI: 10.1177/0003134820951479] [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: 11/16/2022]
Abstract
BACKGROUND Parathyroidectomy is frequently performed as ambulatory surgery. This study seeks to characterize the socioeconomic factors that may impact the patient selection for outpatient parathyroidectomy. METHODS The 2016 Florida State Inpatient Database (SID) and the 2016 Florida State Ambulatory Surgery Database (SASD) were queried for all patients undergoing parathyroidectomy using the International Classification of Diseases 10 (ICD-10) procedure codes. Univariable comparison and multivariate logistic regression were performed for outpatient versus inpatient parathyroidectomy using all relevant patient and hospital characteristics from the database. RESULTS Seven hundred and sixteen patients underwent parathyroidectomy in Florida in 2016; 322 parathyroidectomies were performed in the ambulatory setting (45.0%). After multivariate logistic regression, patients over age 65 and parathyroidectomies performed at high-volume centers were more likely to be performed at an outpatient center. Those patients who were black, Hispanic, had a Charlson Comorbidity Index ≥3, Medicare, Medicaid, and Self-pay were associated with a decreased likelihood of having an outpatient procedure. DISCUSSION Access to ambulatory parathyroidectomy is more common in patients with private insurance, white ethnicity, and fewer comorbidities.
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Affiliation(s)
- Ellie A Moeller
- 7824 Department of Surgery, University of Miami Leonard M. Miller School of Medicine, FL, USA
| | - Tamar Walker
- 7824 Department of Surgery, University of Miami Leonard M. Miller School of Medicine, FL, USA
| | - Zahra F Khan
- 7824 Department of Surgery, University of Miami Leonard M. Miller School of Medicine, FL, USA
| | - Joshua P Parreco
- 7824 Department of Surgery, University of Miami Leonard M. Miller School of Medicine, FL, USA
| | - Jessica L Buicko
- 7824 Department of Surgery, University of Miami Leonard M. Miller School of Medicine, FL, USA
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16
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Sekar S, Belavendra A, Jacob PM. Early Discharge and Selective Calcium Supplementation after Thyroidectomy Based on Post-Operative Day 1 Parathormone and Calcium Level: A Prospective Study. Indian J Endocrinol Metab 2020; 24:319-324. [PMID: 33088754 PMCID: PMC7540830 DOI: 10.4103/ijem.ijem_172_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/28/2020] [Accepted: 06/25/2020] [Indexed: 11/13/2022] Open
Abstract
AIM This study aimed to evaluate a protocol using post thyroidectomy parathyroid hormone (PTH) levels on the day after surgery to facilitate early discharge of patients. METHODS This prospective observational study was done in Christian Medical College, India over 1 year with 125 consecutive patients who had serum PTH and calcium values measured in the morning following thyroidectomy/first postoperative day (D1). Patients with no symptoms and signs of hypocalcemia and with serum calcium ≥8 mg/dL and PTH ≥6 pg/ml according to the protocol were discharged without supplements on D1. Patients were followed up and tested for a week after surgery in the outpatient clinic to assess hypocalcemia and readmission rates. RESULTS Seventy five patients (60%) could be discharged early on D1without calcium supplementation; only one patient had mild hypocalcemia symptoms managed with oral calcium supplements during outpatient follow-up within 1 week and none who followed the protocol required readmission. Temporary biochemical hypocalcemia was encountered in 36 patients (28.8%) including symptomatic hypocalcemia in 13 patients (10.4%). Among the 36 patients with hypocalcemia, 26 patients (72.2%) had a PTH level <6 pg/ml. Three patients required intravenous calcium infusion to correct hypocalcemia. Sensitivity, specificity and positive predictive value, and ROC of PTH 6 pg/ml in predicting hypocalcemia were 70.5%, 94.5% and 83.3%, 0.86, respectively. The low PTH could also guide early supplementation of calcium and all the severe hypocalcemia patients had PTH lower than the cut off of 6 pg/ml. CONCLUSION A PTH and calcium-based protocol can be effectively used for early discharge of thyroidectomy patients the day after surgery without calcium supplementation. The compliance of the patient for early discharge was good.
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Affiliation(s)
- Suganya Sekar
- Department of Endocrine and Breast Surgery, Velammal Medical College and Research Centre, Madurai, Tamil Nadu, India
| | - Antonisamy Belavendra
- Department of Biostatistics and, Christian Medical College, Vellore, Tamil Nadu, India
| | - Paul M. Jacob
- Department of Endocrine Surgery, Christian Medical College, Vellore, Tamil Nadu, India
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17
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Asban A, Anue A, Xie R, Chen H. Increasing Use of Thyroidectomy as Definitive Treatment for Hyperthyroidism. J Surg Res 2020; 246:435-441. [DOI: 10.1016/j.jss.2019.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/02/2019] [Accepted: 09/13/2019] [Indexed: 01/21/2023]
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18
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Postoperative Bleeding after Thyroid Surgery: Care Instructions. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:329-336. [PMID: 32377106 PMCID: PMC7192296 DOI: 10.14744/semb.2019.95914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 11/20/2022]
Abstract
Prospective studies on the incidence, etiology, and prognosis of well-characterized patients with bleeding after thyroid surgery are lacking. Bleeding after thyroid surgery cannot be predicted or prevented even if risk factors are known in every single procedure, which enhances the im-portance of the following issues: (a) meticulous hemostasis and surgical technique; (b) coopera-tion with the anesthesiologist, i.e., controlling the Valsalva maneuver, adequate blood pressure at the end of the operation as well as at extubation phase and (c) in case of bleeding, a prompt management to guarantee a better outcome. This requires an intensive postoperative clinical monitoring of patients, ideally, in a recovery room with trained staff for at least 4-6 h. Early recognition of postoperative bleeding with immediate intervention is the key to the management of this complication.
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19
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Saadi R, Brandt A, Kim Y, Cottrill E, Saunders B, Schaefer E, Goldenberg D. Degree of technical difficulty of thyroidectomy for autoimmune thyroid disease. Head Neck 2019; 42:262-268. [PMID: 31651072 DOI: 10.1002/hed.25991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/16/2019] [Accepted: 10/09/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Our goal was to elucidate the differences in degree of technical difficulty of thyroidectomy in patients with autoimmune thyroid diseases. METHODS Charts of adult patients who had undergone thyroidectomy were reviewed. Patients with Hashimoto's Thyroiditis (HT) or Graves' Disease (GD) were individually compared to a control group of patients with early stage malignancy or goiter. RESULTS The HT (n = 65) group was significantly more likely to have friable (P = .001) and fibrotic (P < .001) thyroids, longer operative times (P = .02), and a 22-modifier (P = .005). The GD (n = 169) group was significantly more likely to have friable (P < .001), vascular (P < .001), fibrotic (P = .038), and heavy (P = .002) thyroids, longer operative times (P = .03), increased length of stay (P = .01) and a 22-modifier (P = .01). CONCLUSION Our experience at an institution with a high-volume thyroid practice demonstrates that patients with autoimmune thyroid disease have consistent qualitative changes of the thyroid and significantly increased operative times and surgical difficulty.
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Affiliation(s)
- Robert Saadi
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Alyssa Brandt
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Yesul Kim
- Department of Dermatology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Elizabeth Cottrill
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Brian Saunders
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Eric Schaefer
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - David Goldenberg
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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20
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Dombrowsky A, Weiss D, Bushman N, Chen H, Balentine CJ. Can imaging studies be omitted in patients with sporadic primary hyperparathyroidism? J Surg Res 2018; 231:257-262. [DOI: 10.1016/j.jss.2018.05.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/30/2018] [Accepted: 05/23/2018] [Indexed: 11/28/2022]
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Voss S, San-Marina S, Oldenburg MS, Ekbom D, Madden BJ, Charlesworth MC, Janus JR. Histone Variants as Stem Cell Biomarkers for Long-Term Injection Medialization Laryngoplasty. Laryngoscope 2018; 128:E402-E408. [DOI: 10.1002/lary.27429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 06/04/2018] [Accepted: 06/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Stephen Voss
- Department of Otorhinolaryngology; Medical Genome Facility-Proteomics, Mayo Clinic; Rochester Minnesota
| | - Serban San-Marina
- Department of Otorhinolaryngology; Medical Genome Facility-Proteomics, Mayo Clinic; Rochester Minnesota
| | - Michael S. Oldenburg
- Otolaryngology-Head and Neck Surgery, Prevea Health Services; Green Bay Wisconsin U.S.A
| | - Dale Ekbom
- Department of Otorhinolaryngology; Medical Genome Facility-Proteomics, Mayo Clinic; Rochester Minnesota
| | | | | | - Jeffrey R. Janus
- Department of Otorhinolaryngology; Medical Genome Facility-Proteomics, Mayo Clinic; Rochester Minnesota
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22
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Reinhart HA, Snyder SK, Stafford SV, Wagner VE, Graham CW, Bortz MD, Wang X. Same day discharge after thyroidectomy is safe and effective. Surgery 2018; 164:887-894. [PMID: 30093278 DOI: 10.1016/j.surg.2018.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/30/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. METHODS This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. RESULTS A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. CONCLUSION Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.
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Affiliation(s)
- Henry A Reinhart
- Department of Surgery, UT Rio Grande Valley School of Medicine, Edinburg, TX.
| | - Samuel K Snyder
- Department of Surgery, UT Rio Grande Valley School of Medicine, Edinburg, TX
| | | | | | | | - Michael D Bortz
- Department of Surgery, Baylor Scott & White Health, Temple, TX
| | - Xiaohui Wang
- School of Mathematical and Statistical Sciences, UT Rio Grande Valley, Edinburg, TX
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To admit or not to admit? Experience with outpatient thyroidectomy for Graves' disease in a high-volume tertiary care center. Am J Surg 2018; 216:985-989. [PMID: 30007745 DOI: 10.1016/j.amjsurg.2018.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Outpatient thyroidectomy is increasingly performed. Thyroidectomy for Graves' disease, however, has greater risk of periprocedural complications, limiting use of same-day procedures. We sought to demonstrate that these patients may be managed with ambulatory surgery. METHODS The experience of one endocrine surgeon with thyroidectomy for Graves' was examined from January 2016-November 2017. Forty-one patients met criteria. Patient demographics, perioperative parameters, and postoperative outcomes including emergency department utilization and readmission were recorded. RESULTS Mean age was 31.5 ± 17.0 years, with 80% females. Mode ASA score was 3, and median operative time was 77 minutes (43-132). Complications included transient hypocalcaemia in 12%, and temporary laryngeal nerve palsy in 9.7%, with no permanent complications. Two patients were admitted immediately postoperatively for non-medical reasons. Thirty-day emergency rdepartment visits were noted in 9.7%, with subsequent readmission of 7%. CONCLUSIONS Outpatient total thyroidectomy is safe and effective with acceptable morbidity in the Graves' patient.
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Yang Y, Huang K, Huang Y, Peng L. Assessment of the safety and feasibility of 24-hour hospitalization after thyroidectomy. Can J Physiol Pharmacol 2018; 96:893-897. [PMID: 29842796 DOI: 10.1139/cjpp-2018-0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study assessed the safety and feasibility of 24-hour hospitalization after thyroid surgery. A randomized controlled trial study was performed for 432 patients scheduled for thyroidectomy in Guangdong General Hospital between January 2014 and January 2016. Group A cases (n = 216) were 24-hour hospital stay and group B cases (n = 216) were inpatient. Preoperative patient characteristics and operative characteristics as well surgical complications were evaluated. Two hundred and fourteen patients (99%) of group A were discharged after a 24-hour postoperative observation except 1 patient hospitalized 2 days for persistent nausea after surgery, and 1 patient who was hospitalized for 2 days for fear of the complication after the operation. The complication rates were similar between the 2 groups (9/216, 11/216; P > 0.05) and no one was readmitted for operation. The overall complication rate of 24-hour hospital stay procedure was low, and there were no differences in the rate of complications between these 2 groups. Thyroid surgery with 24-hour hospital stay is feasible and safe by experienced surgeon in a setting of appropriate facility and management protocol.
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Affiliation(s)
- Youcheng Yang
- a Southern Medical University, Guangzhou, Guangdong, China.,b Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, China
| | - Kan Huang
- b Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, China
| | - Yijie Huang
- b Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, China
| | - Lin Peng
- a Southern Medical University, Guangzhou, Guangdong, China.,b Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, China
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Jang S, Mandabach M, Aburjania Z, Balentine CJ, Chen H. Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice? Surgery 2017; 163:638-642. [PMID: 29224707 DOI: 10.1016/j.surg.2017.10.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/23/2017] [Accepted: 10/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution. METHODS We retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2. RESULTS The median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196-5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0-1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality. CONCLUSION We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care.
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Affiliation(s)
- Samuel Jang
- Howard Hughes Medical Institute, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Meagan Mandabach
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Zviadi Aburjania
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | | | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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Lee DJ, Chin CJ, Hong CJ, Perera S, Witterick IJ. Outpatient versus inpatient thyroidectomy: A systematic review and meta-analysis. Head Neck 2017; 40:192-202. [PMID: 29120517 DOI: 10.1002/hed.24934] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/08/2017] [Accepted: 07/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Outpatient thyroidectomy has gained popularity due to improved resource utilization. METHODS We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, CINAHL, Web of Science, and the Cochrane library. We included all studies examining the outcomes of outpatient thyroidectomy as compared with those of inpatient thyroidectomy. Risk of bias was assessed using the Newcastle-Ottawa scale. Postoperative complications (hematoma, hypocalcemia, and recurrent laryngeal nerve injury) and readmission/reintervention rates were compared. RESULTS After screening 1665 records, 10 nonrandomized observational studies were included. There were fewer complication rates in the outpatient group than the inpatient group (relative risk [RR] 0.56; 95% confidence interval [CI] 0.37-0.83). There was no difference in readmission/reintervention rates (RR 0.60; 95% CI 0.33-1.09). CONCLUSION The results suggest outpatient thyroidectomy may be as safe as inpatient thyroidectomy in appropriately selected patients. The results are limited by high risk of bias. Well-designed prospective studies are necessary to further assess the safety of outpatient thyroidectomy.
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Affiliation(s)
- Daniel J Lee
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Christopher J Chin
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada.,Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Dalhousie Medicine New Brunswick, St. John, New Brunswick, Canada
| | - Chris J Hong
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada
| | - Stefan Perera
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ian J Witterick
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
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McLaughlin EJ, Brant JA, Bur AM, Fischer JP, Chen J, Cannady SB, Chalian AA, Newman JG. Safety of outpatient thyroidectomy: Review of the American College of Surgeons National Surgical Quality Improvement Program. Laryngoscope 2017; 128:1249-1254. [PMID: 28988415 DOI: 10.1002/lary.26934] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/14/2017] [Accepted: 08/29/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate national trends in admission status after thyroidectomy in the United States and to evaluate the factors associated with 30-day unplanned readmission and reoperation. STUDY DESIGN Retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) METHODS: The ACS-NSQIP database was queried for patients who underwent a partial or total thyroidectomy between 2005 and 2014. Outpatient surgery was defined as discharge on the day of surgery. Patient demographic information, unplanned hospital readmission, and reoperation were reviewed. Risk factors were identified using logistic regression modeling. RESULTS A total of 76,604 cases met inclusion criteria as described above. There were 1,473 (1.9%) patients who underwent reoperation and 477 unplanned 30-day readmissions (1.4%) for procedures performed since 2012. There was a significant positive trend in the percentage of thyroidectomy (partial and total) patients who underwent outpatient procedures by year of operation (P < .001). Outpatient procedures were not more likely to have unplanned readmissions or reoperations. Independent patient risk factors for unplanned readmission and reoperation included current dialysis, chronic steroid use, unintentional weight loss, American Society of Anesthesiologists class 3 to 4, and active bleeding disorders. CONCLUSIONS Over the past decade there has been a clear trend toward increasing outpatient thyroid surgery. Thyroidectomy performed as an outpatient was not found to be an independent risk factor for readmission or reoperation. Patients with serious medical comorbidities and active bleeding disorders are at increased risk of unplanned readmission or reoperation and should have their surgery performed on an inpatient basis. LEVEL OF EVIDENCE 2c. Laryngoscope, 128:1249-1254, 2018.
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Affiliation(s)
- Eamon J McLaughlin
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason A Brant
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Andres M Bur
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - John P Fischer
- Division of Plastic and Reconstructive Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jinbo Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Khadra H, Mohamed S, Hauch A, Carter J, Hu T, Kandil E. Safety of same-day thyroidectomy: meta-analysis and systematic review. Gland Surg 2017; 6:292-301. [PMID: 28861367 DOI: 10.21037/gs.2017.01.05] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Performance of thyroid surgery as a same day surgery procedure has been a controversial topic. This study aimed to compare the safety and efficacy of outpatient thyroid surgery with inpatient thyroid surgery by meta-analysis of current literature. METHODS Articles were identified from the following keyword searches: outpatient thyroidectomy/thyroid surgery, same day thyroidectomy/thyroid surgery. Outcomes included perioperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, and readmissions. Data were extracted following review of appropriate studies by authors and random effects models were used. RESULTS 34 potentially relevant publications were identified and 14 studies fulfilled the predetermined inclusion criteria, totaling 10,478 patients, 4,565 of whom were discharged the same day following thyroid surgery. There was no difference in malignancy rate between the two groups (95% CI, 0.84-2.31; P=0.196). Inpatient group were 2.23 times (95% CI, 1.36-3.36; P=0.001) more likely to develop transient RLN injury and 2.32 times (95% CI, 1.06-5.06; P=0.034) more likely to have documented transient hypocalcemia compared to outpatients. Inpatient groups were 2.10 times (95% CI, 1.33-3.33; P=0.002) more likely to have documented other complications. The two groups also had similar readmission rates (95% CI, 0.71-1.41; P=1.000). CONCLUSIONS Our meta-analysis suggests that discharging selective patients the same day after a thyroid surgery is as safe, feasible, and efficacious as admitting them for observation. Admitting patients after thyroid surgery is associated with higher reported risk of complications.
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Affiliation(s)
- Helmi Khadra
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Salah Mohamed
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Adam Hauch
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - John Carter
- Department of Otolaryngology, Head and Neck Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tian Hu
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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Greenleaf EK, Goyal N, Hollenbeak CS, Boltz MM. Resource utilization associated with cervical hematoma after thyroid and parathyroid surgery. J Surg Res 2017; 218:67-77. [PMID: 28985879 DOI: 10.1016/j.jss.2017.04.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/06/2017] [Accepted: 04/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative cervical hematoma (PCH) after thyroid and parathyroid surgery is a well-known complication. This study used data from the Nationwide Inpatient Sample to identify risk factors, estimate mortality, length of stay (LOS), and total costs attributable to PCH in patients undergoing procedures for thyroid and parathyroid diseases. METHODS Patients aged >18 y who underwent thyroid or parathyroid surgery between 2001 and 2011 were identified and stratified by the occurrence of PCH. Univariate analyses of patient demographics, clinical and hospital characteristics were performed. Multivariable logistic regression was used to determine risk factors for hematoma formation. LOS and costs were fit to linear regression models to determine the effect of PCH after adjusting for patient and hospital characteristics. RESULTS Of patients who underwent thyroid or parathyroid surgery, 619 patients (0.8%) had a PCH. Predisposing factors included nonelective admission (emergent: OR = 2.01, P < 0.0001; urgent: OR = 1.47, P = 0.003), diagnosis of Graves' disease (OR = 1.90, P < 0.0001), or other benign pathology (OR = 1.43, P = 0.011) and having ≥2 comorbidities (2-3 comorbidities, OR = 1.24; P = 0.036 and ≥ 4 comorbidities, OR = 2.28; P < 0.0001). After adjusting for those characteristics, the total excess LOS and costs attributable to PCH were 2.1 d (P < 0.0001) and $7316 (P < 0.0001), respectively. In addition, after risk adjustment, odds of mortality more than tripled (P < 0.0001) in the setting of PCH. CONCLUSIONS Because risk for PCH is largely driven by preoperative patient risk factors, five clinicians have an opportunity to stratify patients accordingly and thereby minimize the resource utilization and health care spending among those with lowest risk.
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Affiliation(s)
- Erin K Greenleaf
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Neerav Goyal
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Christopher S Hollenbeak
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Melissa M Boltz
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
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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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Frank E, Park J, Simental A, Vuong C, Lee S, Filho PA, Kwon D, Liu Y. Six-Year Experience of Outpatient Total and Completion Thyroidectomy at a Single Academic Institution. Am Surg 2017. [DOI: 10.1177/000313481708300426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Outpatient thyroidectomy has become slowly accepted with various published reports predominantly examining partial or subtotal thyroidectomy. Concerns regarding the safety of outpatient total and completion thyroidectomy remain, especially with regard to vocal fold paralysis, hypocalcemia, and catastrophic hematoma. We aimed to evaluate the safety of outpatient thyroid surgery in a large cohort by retrospectively comparing outcomes in those who underwent outpatient (n = 251) versus inpatient (n = 291) completion or total thyroidectomy between February 2009 and February 2015. Outpatient completion and total thyroidectomy had lower rates of temporary hypocalcemia (6% vs 24.4%; P < 0.001) and no significant difference in rates of return to emergency department (1.2% vs 1.4%), hematoma formation (0.8% vs 0.7%), temporary (2% vs 4.1%) or permanent (0.4% vs 0.7%) vocal fold paralysis, or permanent hypocalcemia (0.4% vs 0%) compared with the inpatient group. Outpatients requiring calcium replacement had shorter duration of postoperative calcium supplementation (44.4 ± 59.3 days vs 63.3 ± 94.4 days; P < 0.001). Our data demonstrate similar safety in outpatient and inpatient total and completion thyroidectomy.
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Affiliation(s)
- Ethan Frank
- Loma Linda University School of Medicine, Loma Linda, California
| | - Joshua Park
- Loma Linda University School of Medicine, Loma Linda, California
| | - Alfred Simental
- Loma Linda University School of Medicine, Loma Linda, California
| | | | - Steve Lee
- Loma Linda University School of Medicine, Loma Linda, California
| | | | - Daniel Kwon
- Loma Linda University School of Medicine, Loma Linda, California
| | - Yuan Liu
- Loma Linda University School of Medicine, Loma Linda, California
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Arer IM, Kus M, Akkapulu N, Aytac HO, Yabanoglu H, Caliskan K, Tarim MA. Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study. Int J Surg 2016; 38:9-14. [PMID: 28039060 DOI: 10.1016/j.ijsu.2016.12.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/08/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia. METHODS A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia. RESULTS Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers. CONCLUSION Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.
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Affiliation(s)
- Ilker Murat Arer
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Murat Kus
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Nezih Akkapulu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Huseyin Ozgur Aytac
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Hakan Yabanoglu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Kenan Caliskan
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Mehmet Akin Tarim
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
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Sveinsdottir H, Borgthorsdottir T, Asgeirsdottir MT, Albertsdottir K, Asmundsdottir LB. Recovery After Same-Day Surgery in Patients Receiving General Anesthesia: A Cohort Study Using the Quality of Recovery-40 Questionnaire. J Perianesth Nurs 2016; 31:475-484. [DOI: 10.1016/j.jopan.2015.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/08/2015] [Accepted: 07/20/2015] [Indexed: 10/21/2022]
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Farooq MS, Nouraei R, Kaddour H, Saharay M. Patterns, timing and consequences of post-thyroidectomy haemorrhage. Ann R Coll Surg Engl 2016; 99:60-62. [PMID: 27551897 DOI: 10.1308/rcsann.2016.0270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Post-thyroidectomy bleeding is a low frequency but potentially life threatening event that is very difficult to predict. Given the increasing drive towards thyroidectomy with same day discharge, this study was conducted with the aim of identifying patterns, timing and consequences of post-thyroidectomy bleeding to assess the feasibility of day-case thyroidectomy. METHODS All patients who underwent a thyroidectomy between 2008 and 2015 at our institution were identified. Patterns, timing and consequences in all those who developed post-thyroidectomy bleeding were studied. RESULTS Of the 805 patients included in the study, 14 required re-exploration for bleeding; 7 (50%) of these within 8 hours of surgery, 6 (43%) between 18 and 30 hours, and 1 (7%) at 49 hours. Just under half (43%) of those with post-thyroidectomy bleeding had thyrotoxicosis. CONCLUSIONS A significant number of postoperative haemorrhages occurred beyond the immediate postoperative period. Same day discharge after thyroidectomy cannot therefore be recommended as a routine practice.
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Affiliation(s)
- M S Farooq
- Barking, Havering and Redbridge University Hospitals NHS Trust , UK
| | - R Nouraei
- University College London Hospitals NHS Foundation Trust , UK
| | - H Kaddour
- Barking, Havering and Redbridge University Hospitals NHS Trust , UK
| | - M Saharay
- Barking, Havering and Redbridge University Hospitals NHS Trust , UK
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Oltmann SC, Alhefdhi AY, Rajaei MH, Schneider DF, Sippel RS, Chen H. Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures. Ann Surg Oncol 2016; 23:2874-82. [PMID: 27138383 DOI: 10.1245/s10434-016-5241-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates. METHODS Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable. RESULTS A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH. CONCLUSIONS POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Amal Y Alhefdhi
- Department of Surgery, The King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Christakis IA, Potylchansky E, Silva AM, Nates JP, Prieto PA, Graham PH, Grubbs EG, Lee JE, Perrier ND. Cervical hematoma following an endocrine surgical procedure: The MD Anderson experience. Surgery 2016; 160:377-83. [PMID: 27063343 DOI: 10.1016/j.surg.2016.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/08/2016] [Accepted: 02/15/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Airway compromise from postoperative neck hematoma remains the most feared complication after cervical endocrine operative procedures. Events are rare and potentially lethal, and clear multidisciplinary guidelines for management of these patients are lacking. The aim of our study was to review the experience of a tertiary cancer center in this scenario. METHODS Data prospectively collected over a 10-year period, between 2005 and 2014, were retrospectively analyzed. We included all adult patients who had had a neck operation and needed reoperation for postoperative neck hematoma after an endocrine procedure. We excluded pediatric patients and cases with incomplete records. RESULTS The inclusion criteria were met for 21 patients (21/2,930; 0.7%). The median age at operation was 56.2 years (SD: 16.7). The M:F ratio was 1:2. All 21 patients presented with a neck swelling at the time of reoperation. Eight of 21 patients (38%) underwent emergency bedside clot evacuation. Presentation was within 6 hours for two thirds (14/21) of the patients; the remaining one third of the patients had the hematoma develop during the evening/night (from 1700-0500). The mean estimated hematoma size was 98 cc (SD: 58). A source of bleeding was identified in 12 of 21 cases (57%). A total of 15.8% of patients had an airway classified as difficult/awkward under the American Society of Anesthesiologists classification for their wound re-exploration. CONCLUSION Postoperation, increased vigilance is needed for the first 6 hours to detect patients with neck swelling. Emergency drainage by the bedside was performed in 38% of patients. A difficult airway was uncommon in our series.
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Affiliation(s)
- Ioannis A Christakis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elena Potylchansky
- Department of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Angelica M Silva
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph P Nates
- Department of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter A Prieto
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Meltzer C, Klau M, Gurushanthaiah D, Tsai J, Meng D, Radler L, Sundang A. Safety of Outpatient Thyroid and Parathyroid Surgery. Otolaryngol Head Neck Surg 2016; 154:789-96. [DOI: 10.1177/0194599816636842] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/11/2016] [Indexed: 12/15/2022]
Abstract
Objective To test our hypothesis that general and thyroid surgery–specific complications, mortality, and postdischarge utilization for patients undergoing outpatient and inpatient thyroid and parathyroid surgery would not differ when outpatient status was defined as discharge within 8 hours of surgery completion. Study Design Retrospective observational cohort, 2008 to 2013. Setting Kaiser Permanente Northern California and Kaiser Permanente Southern California. Subjects and Methods We used a robust set of variables and propensity score methods to match 2362 patients undergoing hemithyroidectomy, total thyroidectomy, or parathyroidectomy surgery as outpatients to 2362 patients undergoing the same procedures as inpatients. Outcomes assessed were 30-day rates of complications, emergency department visits, all-cause hospital readmissions, and mortality. Results After matching, no statistically significant differences between inpatients and outpatients were found for complication rates or postdischarge utilization. After matching, there was no statistically significant difference between inpatients and outpatients in hematoma rates, which were 0.55% in both groups. In the matched-pair groups, 2 deaths occurred among inpatients (0.09%) and none occurred among outpatients (0.00%), a difference that was not statistically significant. Conclusion Discharge within 8 hours after completion of thyroid and parathyroid surgery is as safe as inpatient surgery.
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Affiliation(s)
| | - Marc Klau
- Southern California Permanente Medical Group, Anaheim, California, USA
| | | | - Joanne Tsai
- Health Information Technology and Transformation Analytics, Kaiser Permanente, Oakland, California, USA
| | - Di Meng
- Health Information Technology and Transformation Analytics, Kaiser Permanente, Oakland, California, USA
| | - Linda Radler
- The Permanente Federation, Oakland, California, USA
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Brekke A, Elfenbein DM, Madkhali T, Schaefer SC, Shumway C, Chen H, Schneider DF, Sippel RS, Balentine C. When patients call their surgeon's office: an opportunity to improve the quality of surgical care and prevent readmissions. Am J Surg 2015; 211:599-604. [PMID: 26762830 DOI: 10.1016/j.amjsurg.2015.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 11/07/2015] [Accepted: 11/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about care coordination and communication with outpatient endocrine surgery patients. This study evaluated phone calls between office nurses and surgical patients to identify common issues addressed and their effect on patient care. METHODS Qualitative analysis of preoperative and postoperative phone conversations between office nurses and endocrine surgery patients. RESULTS We identified 183 thyroidectomy patients with 38% contacting our office before surgery and 54% within 30 days after surgery. Common reasons for preoperative calls included questions about preoperative evaluation (21%), medications (18%), and insurance and/or work paperwork (12%). Postoperatively, common topics included medications (23%), laboratory results (23%), and concerns about wounds (12%). Nursing staff prevented unnecessary readmission in 7 patients (4%) whereas appropriately referring 16 (9%) for early evaluation. CONCLUSIONS Patients frequently contact their surgeons before and after endocrine surgery cases. Our findings suggest several areas for improving communication with patients.
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Affiliation(s)
- Andrew Brekke
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Dawn M Elfenbein
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Tariq Madkhali
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Sarah C Schaefer
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Cindy Shumway
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - David F Schneider
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Courtney Balentine
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375.
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Abstract
Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma. Despite this concern, outpatient thyroidectomy is becoming increasingly common, especially among high-volume endocrine surgeons. Multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. This article reviews the data on safety and outcomes for outpatient thyroidectomy and discusses several techniques used to minimize risk to patients.
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Affiliation(s)
- Courtney J Balentine
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, K3/704 Clinical Science Center, Madison, WI 53792-7375, USA
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, K3/704 Clinical Science Center, Madison, WI 53792-7375, USA.
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Kwak HY, Dionigi G, Liu X, Sun H, Woo SU, Son GS, Lee JB, Bae JW, Kim HY. Predictive factors for longer operative times for thyroidectomy. Asian J Surg 2015; 40:139-144. [PMID: 26321156 DOI: 10.1016/j.asjsur.2015.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/OBJECTIVE Conventional open thyroidectomy is considered as a safe surgery nowadays. However, surgeons sometimes encounter unexpected difficulty when performing thyroidectomies. The aim of this paper was to identify the predictors of a difficult thyroidectomy for the management of patients with papillary thyroid carcinoma. METHODS A database of patients who underwent open conventional thyroidectomy with cervical lymph node dissection after diagnosed papillary thyroid carcinoma between July 2008 and June 2013 was examined. In addition, the patients were subgrouped by difficult thyroidectomy (DT) and nondifficult thyroidectomy to determine the predictors of DT according to operation time. Clinicopathologic characteristics, surgical outcomes, and postoperative morbidities were investigated. RESULTS No between-group differences in clinicopathologic factors and postoperative complications, except for male sex (p < 0.001) and tumor size (p = 0.039), were noted. Male sex [odds ratio (OR) 4.158, 95% confidence interval (CI) 2.020-8.559, p = 0.043] and age < 45 years (OR 2.239, 95% CI 1.304-3.843, p = 0.003) were independent factors associated with DT in a multivariate logistic regression model. Elevated antithyroglobulin antibody (OR 1.004, 95% CI 1.000-1.008, p = 0.030) was a variable which is statistically significant, but not clinically significant. DISCUSSION Young age and male sex might be regarded as predictors of DT. Expecting DT before surgery might help surgeons, especially beginners, prevent troublesome situations.
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Affiliation(s)
- Hee Yong Kwak
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Gianlorenzo Dionigi
- 1st Division of Surgery, Department of Surgical Sciences, Endocrine Surgery Research Center, University of Insubria, Varese, Italy
| | - Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Sang Uk Woo
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Gil Soo Son
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Bok Lee
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jeoung Won Bae
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hoon Yub Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea.
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Schneider DF, Mazeh H, Oltmann SC, Chen H, Sippel RS. Novel thyroidectomy difficulty scale correlates with operative times. World J Surg 2015; 38:1984-9. [PMID: 24615607 DOI: 10.1007/s00268-014-2489-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate a new thyroidectomy difficulty scale (TDS) for its inter-rater agreement, correspondence with operative times, and correlation with complications. METHODS We developed a four item, 20-point TDS. Following cases where two board-certified surgeons participated, each surgeon completed a TDS, blinded to the other's responses. Paired sets of TDS scores were compared. The relationship between operative time and TDS scores was analyzed with linear regression. Multiple regression evaluated the association of TDS scores and other clinical data with operative times. RESULTS A total of 119 patients were scored using TDS. In this cohort, 22.7% suffered from hyperthyroidism, 37.8% experienced compressive symptoms, and 58.8% had cancer. The median total TDS score was 8, and both surgeons' total scores exhibited a high degree of correlation. Overall, 87.4% of the two raters' total scores were within one point of each other. Patients with hyperthyroidism received higher median scores than euthyroid patients (10 vs. 8, p < 0.01). Similarly, patients who suffered a complication had higher scores than those without complications (10 vs. 8, p = 0.04). TDS scores demonstrated a linear relation with operative times (R2 = 0.36, p < 0.01). Cases with a score of ≥14 took 41.0% longer compared to cases with scores of ≤5 (p < 0.01). In the multiple regression analysis, TDS scores independently predicted the operative time (p < 0.01). CONCLUSION The TDS is an accurate tool whose scores correlate with more difficult thyroidectomies as measured by complications and operative times.
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Affiliation(s)
- David F Schneider
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, K3/738, Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792, USA,
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Molinari AS, Treiguer A, Gava VG, Rojas JLB, Evangelista PE, Gonçalves I, Golbert A. Thyroid surgery performed on an overnight basis: a 17 years of experience. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015. [PMID: 26222232 DOI: 10.1590/2359-3997000000071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aimed to evaluate the results of thyroid surgeries with hospitalization periods shorter than 18 hours performed in a surgical endocrinology service, correlating these results with type of procedure, the definitive diagnosis and complications associated with the procedure. SUBJECTS AND METHODS The procedures performed, complications associated, hospitalization period, and relationships among these variables were assessed in consecutive patients subjected to different types of thyroid surgeries from January 1997 to March 2014 by the same group of surgeons. Data were analyzed by frequency, and the associations between the hospitalization period and other variables were analyzed using the Pearson chi-square test and Fisher's exact test, using a multiple comparisons test with Bonferroni correction. RESULTS Among the 3,411 surgeries performed, 799 of them were malignant neoplasia, 2,505 were benign tumors and 107 were Graves' disease. The following procedures were performed: total thyroidectomy (1597 patients); total thyroidectomy with neck exploration (369 patients); lobectomy plus isthmectomy (1084 patients); total thyroidectomy complementation (145 patients); total thyroidectomy with neck dissection (84 patients); modified radical total thyroidectomy (13 patients); nodulectomy (11 patients); unresectable (9 patients); central neck dissection (48 patients); lateral neck dissection (38 patients); and others (13 patients). The following surgical complications, characteristic of the procedure: hemorrhage in 41 (1.2%) patients, hypoparathyroidism in 10 (0.3%) patients and recurrent laryngeal nerve (RLN) injury in 23 (0.7%) patients. Hospitalization shorter than 18 hours was observed in 97% of patients. CONCLUSION Thyroid surgery can be safely performed in virtually all patients on an overnight basis in specialized services.
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Liu J, Li Z, Liu S, Wang X, Xu Z, Tang P. Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution study based on 5156 cases from the past 2 years. Head Neck 2015; 38:216-9. [PMID: 25225123 DOI: 10.1002/hed.23868] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The occurrence of and risk factors for postoperative cervical hematoma remain unclear. METHODS We conducted a retrospective analysis of 5156 patients treated at a single institution. RESULTS The occurrence of postoperative cervical hematoma was 0.85% (44 of 5156 patients). The multivariate analysis showed that male sex, benign pathology, hypertension, and previous thyroid surgery are individual risk factors with odds ratios of 1.906, 2.004, 7.962, and 4.407, respectively. The majority (88.7%) of hematomas occurred within 12 hours after surgery. Obvious bleeding points were detected in 28 cases (73.6%) during reexploration, surface of the strap muscle, superior thyroid vessel, and end of the recurrent laryngeal nerve were the most frequent bleeding sources. CONCLUSION Hematoma often occurs within 12 hours after thyroid surgery. Hypertension, previous thyroid surgery, male sex, and benign pathology may increase the risk of hematoma.
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Affiliation(s)
- Jie Liu
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
| | - Zhengjiang Li
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
| | - Shaoyan Liu
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
| | - Xiaolei Wang
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
| | - Zhengang Xu
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
| | - Pingzhang Tang
- Department of Head and Neck Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science (CAMS), Beijing, China
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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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Lorenz K, Sekulla C, Kern J, Dralle H. Management von Nachblutungen nach Schilddrüsenoperationen. Chirurg 2014; 86:17-23. [DOI: 10.1007/s00104-014-2818-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Oltmann SC, Brekke AV, Schneider DF, Schaefer SC, Chen H, Sippel RS. Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study. Ann Surg Oncol 2014; 22:952-8. [PMID: 25212835 DOI: 10.1245/s10434-014-4077-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypocalcemia occurs after total thyroidectomy (TT) for Graves disease via parathyroid injury and/or from increased bone turnover. Current management is to supplement calcium after surgery. This study evaluates the impact of preoperative calcium supplementation on hypocalcemia after Graves TT. METHODS A prospective study of patients with Graves disease undergoing TT was performed. Patients with Graves disease managed over a 9-month period took 1 g of calcium carbonate (CC) three times a day for 2 weeks before TT. Those managed the previous year without supplementation served as historic controls. Age-, gender-, and thyroid weight-matched, non-Graves TT patients were procedure controls. Patient demographics, postoperative laboratory values, complaints, and medications were reviewed. Parathyroid hormone (PTH)-based postoperative protocols dictated postoperative CC and calcitriol use. RESULTS Forty-five patients with Graves disease were treated with CC before TT, and 38 patients with Graves disease were not. Forty control subjects without Graves disease were identified. Age, gender, and thyroid weight were comparable. Preoperative calcium and PTH levels were equivalent. PTH values immediately after surgery, at postoperative day 1, and at 2-week follow-up were equivalent. Postoperative use of scheduled CC (p = 0.10) and calcitriol (p = 0.60) was similar. Postoperatively, patients with untreated Graves disease had lower serum calcium levels than pretreated patients with Graves disease or control subjects without Graves disease (8.3 mg/dL vs. 8.6 vs. 8.6, p = 0.05). Complaints of numbness and tingling were more common in nontreated Graves disease (26%) than in pretreated Graves disease (9%) or in control subjects without Graves disease (10%, p < 0.05). CONCLUSIONS Calcium supplementation before TT for Graves disease significantly reduced biochemical and symptomatic postoperative hypocalcemia. Preoperative calcium supplementation is a simple treatment that can reduce symptoms of hypocalcemia after Graves TT.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, WI, USA
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Changing Trends in Thyroid and Parathyroid Surgery over the Decade: Is Same-day Discharge Feasible in the United Kingdom? World J Surg 2014; 38:2825-30. [DOI: 10.1007/s00268-014-2673-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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48
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Khavanin N, Mlodinow A, Kim JYS, Ver Halen JP, Antony AK, Samant S. Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients. Ann Surg Oncol 2014; 22:429-36. [PMID: 24841353 DOI: 10.1245/s10434-014-3785-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.
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Affiliation(s)
- Nima Khavanin
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Predictors of 30-day readmission after outpatient thyroidectomy: an analysis of the 2011 NSQIP data set. Am J Otolaryngol 2014; 35:332-9. [PMID: 24602456 DOI: 10.1016/j.amjoto.2014.01.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 01/26/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE With enhancements in patient safety and improvements in anesthesia administration, outpatient thyroidectomy is now frequently undertaken as an outpatient procedure, with several peer-reviewed reports of safe implementation totaling over 4500 procedures since 2006. However, robust statistical analyses of predictors for readmission are lacking. METHODS The 2011 NSQIP data set was queried to identify all patients undergoing thyroidectomy on an outpatient basis. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify the predictors of these events. RESULTS In total 5121 patients were identified to have undergone an outpatient thyroidectomy in 2011. Overall 30-day morbidity was rare with only 47 patients (0.92%) experiencing any perioperative morbidity. One hundred eleven (2.17%) patients were readmitted within 30 days of the operation. A history of COPD was the only preoperative comorbid medical condition that significantly increased a patient's risk for readmission (OR 3.73 95% CI 1.57-8.85, p=0.003). Patients with a surgical complication were more than 7 times as likely to be readmitted (OR 2.08-25.28, p=0.002), and those with a medical complication were over 19 times as likely to be readmitted (OR 7.32-50.78, p<0.001). CONCLUSIONS Readmission after outpatient thyroidectomy is infrequent, and compares well with other outpatient procedures. The main identified risks include preoperative COPD and any of the generic postoperative complications tracked in NSQIP. As procedures continue to transition into outpatient settings and financial penalties associated with readmission become a reality, these findings will serve to optimize outpatient surgery utilization.
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Chirurgie ambulatoire : évolution des techniques et de la prise en charge chirurgicale. Vers une chirurgie d’excellence. Presse Med 2014; 43:278-82. [DOI: 10.1016/j.lpm.2013.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 11/05/2013] [Indexed: 11/21/2022] Open
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