Outpatient Thyroid Surgery is Safe and Desirable

Newswise — Thyroidectomy (removal of the thyroid) has traditionally required multi-day hospitalization. At a minimum, many surgeons advocate overnight observation following this special surgical procedure. While the thyroid is a relatively superficial organ and mortality related are extremely low, its close proximity to other structures has inspired caution out of concern for possible complications, such as laryngeal nerve damage, hemorrhage, and trauma to the upper airway. Although the thyroidectomy can now be performed with minimally invasive approaches, short operative time, and without the need for surgical drains, physicians have continued to guard against complications with inpatient hospital stays.

Some surgeons have actively advocated moving the thyroidectomy from a primarily inpatient surgery toward an outpatient procedure. Despite their efforts, a consensus regarding optimal postoperative management of thyroidectomy patients has not been reached. A new study may shed some light on optimizing practices.

A new study examines a novel approach of careful patient selection coupled with prophylactic calcium supplementation to minimize hospital stays and enable same-day discharge. The authors of "Outpatient Thyroid Surgery is Safe and Desirable" are David J. Terris MD, Brent Moister, Melanie W. Seybt MD, and Christine G. Gourin MD, from the Department of Otolaryngology- Head and Neck Surgery, and Edward Chin MD, from the Department of Medicine (Section of Endocrinology), all at the Medical College of Georgia, Augusta, GA. Their findings are being presented at the 110th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 17-20, 2006, at the Metro Toronto Convention Centre, Toronto, Canada.

MethodologyThis prospective, non-randomized study of consecutive patients undergoing thyroidectomy between December 2004 and October 2005 was performed at the Medical College of Georgia Health System and Augusta Veterans Administration Hospital. Patients were segregated into two groups on the basis of admission status (outpatient or inpatient). Patients undergoing 23-hour observation with an overnight stay were considered inpatients, while outpatients were discharged directly from the ambulatory recovery unit. Demographic and clinical data were collected; outcome data were compiled including estimated blood loss (EBL), duration of surgery (time from skin incision to closure), time to discharge (time from skin closure to hospital discharge), need for admission, and hospital charges. Hospital charges were queried to include total billed charges over the dates of service related to thyroidectomy.

A number of surgical techniques were used, including a Kocher incision, minimally invasive thyroid surgery with access to the thyroid compartment, and endoscopic thyroidectomy. Laryngeal nerve monitoring was employed as required. Vocal cord mobility was assessed and documented preoperatively and again in the post-anesthesia care unit or on the ward using flexible fiberoptic laryngoscopy. Following surgery, outpatients were assessed and discharged once ambulatory, tolerating a diet, and managing their pain with oral medications. Patients were seen for follow-up within one to two weeks after surgery and subsequently as clinically indicated.

All patients who underwent total or completion thyroidectomy were placed on a prophylactic calcium supplementation regimen consisting of a three-week taper of oral calcium carbonate (600mg TID for the first week, 600mg BID for the second week, and 600mg Qday for the third week). Postoperative ionized calcium levels were measured following convalescence to determine the presence of permanent hypocalcemia. Inpatient stays were for medically infirm patients with significant co-existing conditions, patients who underwent concomitant procedures requiring admission, and patients who expressed a preference for admission. Patients with large lesions incurring a potential for significant postoperative dead space were not considered suitable for outpatient management. All other patients were considered for management on an outpatient basis.

ResultsNinety-one patients underwent thyroid surgery. Fifteen patients were male, seventy-six patients were female; the mean age was 46.3 ± 14.7 years. Fifty-two (57 percent) were managed on an outpatient basis. Thirty-nine were considered inpatients (twenty-six of these remained in the hospital overnight for a 23-hour observation period; 13 were admitted for a mean of 3.4 ± 2.8 days). The mean age of the outpatients (44.8 ± 13.3 years) was not statistically different from the mean age of the inpatients (48.5 ± 16.3 years). The gender ratio was also similar (85 percent female among outpatient, 82 percent female among inpatients).

Fifty-two patients had a thryroid procedure performed on an outpatient basis, 26 patients were observed under a 23-hour status, and 13 were admitted. There were two complications in the outpatient group and one in the inpatient group. Costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288. The procedures consisted of 42 hemithyroidectomies (surgical removal of one lobe of the thyroid gland), 38 total thyroidectomies, and 11 completion thyroidectomies. Operative time was lower in the outpatient group (102 ± 32 vs. 144 ± 51 minutes).

Despite the trend toward outpatient surgery, surgeons who perform thyroid and parathyroid surgery have been reluctant to adopt this approach primarily out of concern for bleeding and transient hypocalcemia. However, the advent of new ultrasonic technology, used in this study, has improved the ability to achieve and maintain a bloodless field. This technology has led to a conclusion by many that surgical drains, a soft plastic tube that drains fluid out and sources of infection of the area, offer no benefit to the patient, and if anything, result in a higher rate of infection and bleeding.

A second major deterrent to performing thyroid (and parathyroid) surgery on an ambulatory basis is the fear of life-threatening hypocalcemia, or low blood calcium level. Ten years ago, researchers described a regimen of oral calcium administration following parathyroidectomy, supporting outpatient status in nearly all cases performed at a major hospital. Researchers for this current study provided oral calcium supplementation in patients undergoing total or completion thyroidectomy to accomplish outpatient thyroid surgery safely. This method has proven uniformly successful with the study subjects, with none displaying any signs of calcium deficiency in the blood.

ConclusionsDespite cost-savings achieved with outpatient surgery, the real benefits of pursuing ambulatory thyroidectomy were not financial. The peripheral benefits of outpatient surgery include the advantages of convalescence in the home environment (which is appealing to many individuals) and minimizing exposure to the organisms which populate most medical centers. On the other hand, patients for whom inpatient hospitalization should still be considered include medically infirm individuals, those undergoing concomitant procedures that would normally require admission, or those with known blood disease.

This study suggests that for carefully selected patients who prefer convalescence at home, and are not weak due to age and disease, outpatient thyroid surgery is safe and cost-effective, even when a total or completion thyroidectomy has been performed.