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

Completion thyroidectomy: A safe option for high-volume surgeons

BACKGROUND

The risk of complication in patients undergoing completion thyroidectomy (cT) is mixed. Several studies report increased risk in comparison to total thyroidectomy (TT) and still others reporting a comparatively decreased risk. We compared the rates of complication in patients at our institution undergoing thyroid lobectomy (TL), (TT), and cT by a single high-volume surgeon.

METHODS

We performed a single-institution retrospective cohort study. Patients undergoing TL, TT, or cT by a high-volume surgeon were included. Rates of complication were collected and compared between the three cohorts.

RESULTS

A total of 310 patients were included. The overall rate of complication was 4.2%. The complication rates in the TL, TT, and cT cohorts were 1%, 7.1%, and 4.5%, respectively (p = 0.10). Transient hypocalcemia was slightly more common in the TT cohort (6.1%) as opposed to the TL (0%) or cT (0.9%) cohort (p = 0.01). The cohorts also had similar rates of recurrent laryngeal nerve signal loss leading to transient dysphonia (TL: 0% vs. TT: 1% vs. cT: 3.6%, p = 0.10).

CONCLUSIONS

While rates of complication tended to predictably decrease as approaches became less extensive, there were no significant differences in complication rates among the three surgical approaches when performed by a high-volume surgeon. Considering the low rates of complication overall, patient counseling and preference should be emphasized to provide appropriate and tailored treatment plans.

Malpractice litigation after thyroid surgery: What factors favor surgeons?

BACKGROUND

Litigation impacts physicians financially, reputationally, and professionally. Although thyroid surgery has favorable patient outcomes, litigation persists. We aimed to characterize malpractice claims after thyroidectomy and investigate which factors favor physicians.

METHODS

We queried the Westlaw legal database using the terms "thyroidectomy" and "medical malpractice" to identify malpractice cases brought against surgeons from 1949 to 2022. We collected and analyzed demographic; clinical; surgical; and legal data, including year, cause for initiating litigation, verdict, state where the lawsuit was brought, and the state's tort reform status.

RESULTS

Of the 68 cases included, medical negligence was the most common cause of action, followed by failure to provide adequate informed consent. The most common inciting surgical event was recurrent laryngeal nerve injury (n = 34, 50%). Surgeons prevailed more often overall (n = 53, 77.9%) and in 11 (91.7%) of the 12 cases treated at academic institutions. The 3 endocrine surgery fellowship-trained surgeons all prevailed in their cases. Of the 15 cases in which patients prevailed, 12 (80%) of which were decided by a jury, the median damages awarded were $569,668 (interquartile range $341,146-$2,594,050). In the 53 cases won by surgeons, 26 were jury decisions (49.1%). Surgeons prevailed in 87.5% of cases brought in the 24 states with tort reform and in 72.7% in the 44 states without tort reform.

CONCLUSION

Non-jury cases and operations done at academic institutions appear to favor decisions for the defendant. Although not statistically significant, all endocrine surgery fellowship-trained defendants won. Where tort reforms are in place, surgeons tend to prevail.

Is transoral endoscopic thyroidectomy safe for total thyroidectomy compared to open thyroidectomy? A propensity-score matched cohort study with papillary thyroid carcinoma

BACKGROUND

Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has become increasingly popular in the treatment of papillary thyroid cancer (PTC). This study aimed to describe the safety and feasibility of total thyroidectomy between the TOETVA and open thyroidectomy (OT) approaches for the treatment of patients with PTC.

METHODS

We retrospectively reviewed 780 consecutive patients suffering from PTC that had undergone total thyroidectomy using TOETVA (n = 107) and OT (n = 673) between April 2016 and December 2021 at our institute. Afterward, a total of 101 matched patients' surgical outcomes were compared using propensity score matching (PSM) analysis.

RESULTS

Before PSM, the patients in the TOETVA group were younger (p < 0.001), had a lower body mass index (p < 0.001) and a greater female population (p < 0.001). After PSM, the TOETVA group was associated with significantly longer operative time (p < 0.001), greater blood loss (p < 0.001), total drainage amount (p < 0.001), higher C-reaction protein level (p < 0.001), better cosmetic satisfaction (p < 0.001) and quality of life (p < 0.001) and lower scar self-consciousness (p < 0.001). There was no statistical difference between the groups in the rate of parathyroid autotransplantation and bilateral lymph node dissection, the positivity of lymph node metastasis, number of dissected lymph nodes and positive lymph nodes, multifocality, postoperative level of blood calcium and parathyroid hormone (PTH), rate of PTH < 15 ng/mL, visual analog scale score, duration of hospital stay, complications, mean thyroid stimulating hormone (TSH)-stimulated Tg level before radioactive iodine, mean Tg level without TSH stimulation, and the proportion of serum Tg level of <1.

CONCLUSION

TOETVA is a safe and feasible technique for better cosmetic effects and similar surgical outcomes compared to conventional open surgery for the studied patients that required total thyroidectomy.

Examining National Guideline Changes Association With Hemithyroidectomy Rates by Surgeon Volume

INTRODUCTION

The 2015 American Thyroid Association (ATA) guidelines established that hemithyroidectomy (HT) is an appropriate treatment for patients with low-risk thyroid cancer. HT rates increased since the ATA guidelines were released; however, the relationship between surgeon volume and the initial extent of surgery has not been established.

METHODS

A statewide database was used to identify patients with thyroid cancer who underwent initial thyroidectomy from 2013 to 2020. High-volume thyroid surgeons were defined as those who performed >25 thyroid procedures per year. A mixed-effect logistic model was used to compare low- and high-volume surgeons' initial extent of surgery pre-2015 and post-2015 ATA guidelines. Descriptive statistics were used to describe other surgical outcomes.

RESULTS

The analysis included 3199 patients with thyroid cancer who underwent initial thyroidectomy. Twenty-four surgeons (6%) were considered high-volume; they performed 48% (n = 1349) of the operations. After the 2015 ATA guidelines were released, the rate of HT increased significantly for low- (23% to 28%, P = 0.042) but not high-volume (19% to 23%, P = 0.149) surgeons. Low-volume surgeons had significantly higher rates of readmission (P = 0.008), re-operation (P = 0.030), complications (P < 0.001), and emergency room visits (P = 0.002) throughout the entire study period.

CONCLUSIONS

The publication of the 2015 ATA guidelines was associated with a significant increase in HT rates, primarily in low-volume thyroid surgeons. While low-volume surgeons began performing more HTs, they continued to have higher rates of readmission, reoperations, complications, and emergency room visits than high-volume surgeons.

Readmission Rates Following Major Head and Neck Surgery With Concurrent Tracheostomy

OBJECTIVES

To determine the influence of major head and neck procedures on readmission and complication rates following tracheostomy.

METHODS

A retrospective cohort study using the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology codes were used to identify tracheostomy patients and to define the underlying head and neck procedure. Patients under the age of 18 and with unknown pre-operative variables were excluded. Univariate and multivariable analyses were performed.

RESULTS

A total of 3240 tracheostomy patients undergoing major head and neck surgery were identified in NSQIP. The 30-day mortality rate was 104 (3.2%) and 258 (9.0%) patients were readmitted. 637 (19.7%) patients had an unplanned return to the operating room. There were 1606 (49.6%) non-tracheostomy specific complications, which included 850 (26.2%) medical and 1142 (35.2%) surgical complications. On multivariable analysis, we found that the underlying procedures did not impact the risk of readmission (P > .05 for all). The underlying procedure was also not associated with unplanned return to the operating room except for thyroidectomies, which had a lower risk than free tissue graft reconstruction (OR = 0.53 (95%CI 0.31, 0.88), P = .018).

CONCLUSION

While almost 1 in every 2 patients had a complication following major head and neck surgery that included creation of a tracheostomy, the rate of readmission is comparatively low and is not associated with the underlying procedure. These findings should reassure head and neck surgeons that properly managed tracheostomies do not constitute a disproportionate risk of readmission.

Management of Patients with Cervicofacial Edema and Paresthesia during Perioperative Period of Transoral Endoscopic Thyroidectomy

Objective

To analyze the clinical intervention effect of transoral endoscopic thyroidectomy on the neck and face during perioperative period.

Method

From January 2019 to January 2020, 60 patients included in this study were randomly divided into observation group and control group according to the ratio of 1 : 1, with 30 cases in each group. Both groups underwent rapid surgical intervention during the perioperative period. The patients in the observation group received neck and face management. The degree of jaw swelling, the degree of facial microexpression completion, and the changes in jaw and neck sensation were compared between the two groups.

Results

There was no significant difference in neck and face swelling, pain, facial microexpression, and feeling between the two groups before operation. Patients with facial I/II swelling degree in the observation group were significantly more than in the control group, and the patients with III swelling degree were less than in the control group. There was significant difference for facial swelling between the two groups in the three intervention periods after the operation, and the difference was statistically significant (P < 0.05). The scores of facial microexpression in the observation group were higher than those in the control group during the three postoperative intervention periods, with statistical significance (P < 0.05). There was no significant difference in the pain score of the first day after surgery between the two groups (P = 0.298). In the other two postoperative intervention periods, the pain score of the observation group was lower than that of the control group, with a statistically significant difference, and the difference was statistically significant (P < 0.05). The threshold of chin and neck sensory pressure in the two groups was statistically significant (P < 0.05) except that the "cheek in area 4" (P = 0.290).

Conclusion

The results showed that these interventions, such as the elevation of bed after operation, 24-hour intermittent cryotherapy, ice cubes in mouth, and the "meter" functional training, have good clinical effects on the symptoms of facial swelling and abnormal sensation of neck and face. It can accelerate the speed of edema dissipation, improve the patients' postoperative comfort, and improve the satisfaction and quality of life of patients with the effect of surgery and beauty.

Prevalence of Postoperatively Detected High-risk Features in 2- to 4-cm Papillary Thyroid Cancers

CONTEXT

The 2015 American Thyroid Association guidelines proposed thyroid lobectomy as an acceptable option for 1- to 4-cm papillary thyroid cancers (PTC) without extrathyroidal extension (ETE) or lymph node (LN) metastasis. However, high-risk features are often detected postoperatively, even in tumors that are considered low risk on preoperative workup. A continued evaluation is necessary to determine the optimal treatment strategies.

OBJECTIVE

We examined the frequency of preoperatively and postoperatively detected high-risk features in 2- to 4-cm PTCs to assess the appropriate surgical extent.

METHODS

All patients who underwent a thyroid surgery between 2015 and 2020 with a final diagnosis of 2- to 4-cm PTC were selected. Demographics, preoperative findings, perioperative course, and surgical pathology were retrospectively analyzed.

RESULTS

Of the entire study cohort (N = 424), 244 (57.5%) patients had at least 1 of the following high-risk features: gross ETE (18.6%), distant metastasis (1.2%), >3 LN involvement with extranodal extension (24.8%), any LN > 3 cm (0.5%), positive margin (13.2%), TERT mutation (2.6%), vascular invasion (10.8%), cN1 disease (28.5%), and > 5 LN involvement (30.4%). Two hundred patients had neither ETE nor LN metastasis on preoperative imaging, but 62/200 (31.0%) were found to have at least 1 of the aforementioned high-risk features on final pathology. Preoperative imaging had sensitivities of 75.9% and 44.4% for detecting gross ETE and LN metastasis, respectively.

CONCLUSION

A significant portion of patients with 2- to 4-cm PTCs, including those who preoperatively met the criteria for lobectomy, were found to have high-risk features on final pathology. Careful patient selection and appropriate counseling are necessary when considering lobectomy for tumors greater than 2 cm.

Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study

Simple Summary

The increasing use of high-quality imaging techniques together with improved access to healthcare has led to an increase in the detection of thyroid nodules. Fine-needle aspiration cytology (FNAC) is currently considered the most accurate examination for the assessment of thyroid nodular disease. However, in about 25% of cases, FNAC leads to the diagnosis of an indeterminate thyroid nodule, which represents a problem because malignancy, although relatively low (up to 30%), cannot be excluded with certainty. According to the 2015 American Thyroid Association guidelines, patients with thyroid nodular disease with an indeterminate cytology can undergo, based on established factors, a total thyroidectomy or a hemithyroidectomy. However, if an intermediate or high-risk differentiated thyroid carcinoma is detected after the hemithyroidectomy, through histological examination, the above-mentioned guidelines recommend performing a completion thyroidectomy. The main aim of this study was to assess the rate of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology.

Abstract

There is still controversy as to whether patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology have a comparable, increased or decreased risk of complications compared to those submitted to primary thyroid surgery. The main aim of this study was to investigate this topic. Patients undergoing a thyroidectomy for thyroid nodular disease with an indeterminate cytology in four high-volume thyroid surgery centres in Italy, between January 2017 and December 2020, were retrospectively analysed. Based on the surgical procedure performed, four groups were identified: the TT Group (total thyroidectomy), HT Group (hemithyroidectomy), CT Group (completion thyroidectomy) and HT + CT Group (hemithyroidectomy with subsequent completion thyroidectomy). A total of 751 patients were included. As for the initial surgery, 506 (67.38%) patients underwent a total thyroidectomy and 245 (32.62%) a hemithyroidectomy. Among all patients submitted to a hemithyroidectomy, 66 (26.94%) were subsequently submitted to a completion thyroidectomy. No statistically significant difference was found in terms of complications comparing both the TT Group with the HT + CT Group and the HT Group with the CT Group. The risk of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology was comparable to that of patients submitted to primary thyroid surgery (both a total thyroidectomy and hemithyroidectomy).