Clinical Review & Education
Clinical Challenges in Otolaryngology
The Pros and Cons of Outpatient Thyroidectomy David L. Steward, MD
HYPOTHESIS Outpatient thyroidectomy is better than inpatient thyroidectomy.
Background In the United States, ambulatory surgery became more common in the 1980s, in part a response to the Omnibus Budget Reconciliation Act. Initial reports of outpatient thyroidectomy emerged in the 1980s, initially as hemithyroidectomy and progressively to total thyroidectomy. The question remains, which is better for the patient following thyroidectomy, recovery in the home or hospital setting? Numerous large database studies have documented a significant increase in thyroidectomy, particularly total thyroidectomy and outpatient thyroidectomy, with estimates of outpatient thyroidectomy accounting for approximately 65% of all cases and highervolume surgeons demonstrating lower complication rates Invited Commentary and greater use of outpatient page 1076 surgery.1-3 A limitation of these database studies is that it is often difficult to distinguish same-day discharge from 23-hour observation cases. However, studies that have been able to do so have documented increasing use and safety of same-day discharge.4 For the sake of discussion, outpatient surgery in this review will refer to discharge on the day of thyroid surgery. A recent statement on outpatient thyroidectomy from the American Thyroid Association highlights many of the issues surrounding this debate.5 The primary reasons cited for the increase in outpatient thyroid surgery include lower cost and patient preference. This trend toward increased use of outpatient thyroidectomy parallels increased use of outpatient surgery in general6 and in part has been facilitated by advances in anesthetic and surgical techniques,7 as well as the ability of the surgeon to select patients who are less likely to experience postoperative complications after discharge.5 Outpatient thyroidectomy is clearly not for every patient, and perhaps not for every surgeon. The pros and cons of outpatient thyroid surgery are presented herein. In the end, the patient and surgeon must decide what is in the patient’s best interest.
Pros The pros of outpatient thyroidectomy include reduced cost, patient preference, and patient safety. The actual cost of medical care can be elusive, but a recent large database study found charges from outpatient vs inpatient thyroidectomy of $7000 vs $22 000.1 In this era of cost-conscious medicine and the Patient Protection and Affordable Care Act, this is an important difference. While not all patients prefer outpatient surgery, the majority would prefer convalescence in their home environment and in the care of loved ones. A survey of patients undergoing outpatient thyroidectomy noted that 95% were satisfied or very satisfied, with only 5% dissatisfied with their experience.8 Social criteria to be considered for same-day surgery include autonomy after discharge; possession of a telephone; suitable living situation; and adequate home support. Thus 1074
some older patients who live alone or young mothers with small children may prefer to stay overnight. Further patient or family insecurity regarding outpatient surgery may factor in a decision for overnight stay. Patientsafetyisparamountwhenconsidering outpatient surgery, and the Institute of Medicine report on medical errors highlights the potential morbidity and mortality David L. Steward, MD fromhospitalization.9 Thus,whileitmayseem counterintuitive, same-day discharge may potentially be safer than an overnight stay in the hospital. Medical comorbidities likely influence the decision regarding safety of hospitalization vs discharge.5,8 Proposed eligibility criteria for safe outpatient thyroidectomy include American Society of Anesthesiologists (ASA) class 1 to 3 and no major medical comorbidities; understanding postoperative instructions and potential complications by patient and available caregiver in a safe outpatient setting; and proximity to skilled medical care facility.5
Cons The primary cons of outpatient thyroidectomy involve management of postoperative complications related to anesthesia and surgery. The primary complications of thyroidectomy that challenge outpatient management include hematoma or bleeding, airway compromise, and hypocalcemia with possible tetany, with the risk of these complications proportional to extent of surgery (hemithyroidectomy less than total thyroidectomy, total thyroidectomy less than total + central neck dissection). Late postoperative hemorrhage and hematoma with potential airway compromise appears to be the greatest potential con of outpatient thyroidectomy. Numerous studies have documented the safety of outpatient thyroidectomy, and the majority of hematomas appear during emergence or within the first 6 hours postoperatively.5,10,11 However, a small number of hematomas occur more than 6 hours after thyroidectomy (0.2% of patients), and the risk is likely greater in coagulopathic patients or those undergoing anticoagulation or antiplatelet therapy.5 Eleven randomized trials and a meta-analysis have failed to demonstrate that routine drain placement prevents hematomas,12 and several studies report increased pain and prolonged hospitalization with their use. However, drain placement in selectedpatientswithlargevascularand/orsubsternalgoiters,thosewith significant intraoperative bleeding, or those with coagulopathy or requiring anticoagulation may require overnight stay.6 Prevention and management of delayed postthyroidectomy hematoma involves a combination of good surgical and anesthetic technique; educated and experienced nursing personnel in recovery and same-day surgery; and patient and family understanding of signs, symptoms, and management plans. Written instructions given to the
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/08/2015
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Clinical Challenges in Otolaryngology Clinical Review & Education
patient and caregivers preoperatively and postoperatively should include this information. Given the unpredictable nature of hematoma formation, this small but profound risk must be accepted by the surgeon and patient prior to undergoing outpatient thyroidectomy. Transient hypoparathyroidism is the most common complication of total or completion thyroidectomy, affecting approximately 25% of patients, with higher rates associated with concomitant central neck dissection. Patients undergoing first-time hemithyroidectomy are not at significant risk of hypoparathyroidism, making this less of a concern with outpatient surgery. Left untreated, hypoparathyroidism manifests in hypocalcemia and neuromuscular symptoms progressing from mild paresthesias to tetany in the extreme. Hypocalcemic symptoms of untreated or undertreated hypoparathyroidism may not manifest early on postoperative day 1, sometimes manifesting on postoperative day 2 or 3. Thus, overnight observation alone may not rule out potential complications later. Prevention of postthyroidectomy hypocalcemia requires either routine oral calcium and vitamin D supplementation5 or early identificationofhypoparathyroidismusingrapidparathyroidhormone(PTH) testing in recovery with selective oral supplementation with calcium and calcitriol (1,25-OH vitamin D) for the minority of patients with a PTH level lower than 15 to 20 pg/mL (picograms per milliliter to nanograms per liter is a 1-to-1 conversion).5,13 Load dosing with 3-μg calcitriol may improve calcium absorption for patients with low PTH levels.13 Given that vitamin D is fat soluble, it may be dosed daily at 0.5 to 1.0 μg, but calcium requires more frequent dosing, often 1 g administered 3 or 4 times daily. Calcium citrate may be better absorbed than calcium carbonate in patients receiving proton pump inhibitor therapy or in those having undergone prior gastric surgery. Intravenous calcium gluconate has a very short half-life and is reserved for acute treatment of symptomatic hypocalcemia. Anxiety and hyperventilation may exacerbate hypocalcemia due to pH effect on ionized calcium levels and slow deep breathing may temporarily improve symptoms. Preoperative vitamin D supplementation seems reasonable in those with vitamin D deficiency who are considering outpatient thyroidectomy. Written instructions should be given to patient and caregivers preoperatively and postoperatively, including signs, symptoms, and management plans for hypocalcemia. Transient recurrent laryngeal nerve injury may occur in approximately 5% of cases, with higher rates associated with invasive or metastatic thyroid carcinoma. Unilateral injury may cause dysphonia, dysphagia, and mild dyspnea on exertion and may not preclude outpatient management. Dexamethasone administered
ARTICLE INFORMATION Author Affiliation: Department of Otolaryngology– Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
preoperatively may reduce transient laryngeal nerve injury,14 but its postoperative role is uncertain. Bilateral recurrent laryngeal nerve injury is rare but can cause severe dyspnea and stridor, potentially resulting in severe upper airway obstruction, which may require tracheotomy. Patients with bilateral recurrentlaryngealnerveinjurymayhavesurprisinglygoodphonation, andanyaudiblestridorshouldbeevaluatedimmediately.Patientscomplaining of dyspnea and/or dysphagia postoperatively require laryngoscopy to assess vocal cord function prior to discharge. Laryngeal nerve integrity monitoring has not been shown to significantly reduce recurrent laryngeal nerve injury in otherwise uncomplicated cases, but it has been shown to be useful prognostically regarding postoperative vocal cord function. Recurrent laryngeal nerves that initially stimulate well but fail to stimulate at the end of the case are at significant risk for paresis.Ifbothrecurrentnervesfailtostimulateintraoperatively,ahigh level of concern for postoperative respiratory distress should be maintained and extubation should be undertaken cautiously. Complications from anesthesia may be exacerbated by medical comorbidities such as obesity and obstructive sleep apnea, as well as underlying cardiac, pulmonary, or neurologic disorders.5 Other complications include slow emergence, nausea, and vomiting. Outpatient surgery may be relatively contraindicated in these patients.
Bottom Line Overall, outpatient thyroidectomy is increasingly used and cost advantageous and appears safe and well tolerated in selected patients. Patient satisfaction is high, and the risk of symptomatic hypocalcemia, delayed hematoma, and airway compromise are low with contemporary techniques in the hands of experienced surgeons and high-volume centers. Outpatient thyroidectomy, especially following total or completion, is clearly not for every patient or surgeon, and hospital administrators and third-party payers should defer to the patient and surgeon regarding this option. Education of perianesthesia nurses, patients, and other caregivers regarding recognition and management of postthyroidectomy complications is critical. Patients should be given both verbal and written instructions preoperatively and postoperatively and must have continuous access to a physician. Despite all precautions, complications are inevitable, and both patient and surgeon must accept the low risk of potentially life-threatening complication occurring in the outpatient setting. Surgeons interested in starting to perform outpatient thyroidectomy may want to begin with straightforward hemithyroidectomy in patients residing locally and establishing a record of success before advancing to more challenging cases.
Published Online: October 9, 2014. doi:10.1001/jamaoto.2014.2353. Conflict of Interest Disclosures: None reported.
Corresponding Author: David L. Steward, MD, Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0528 ([email protected]).
REFERENCES
Section Editor: Marion Boyd Gillespie, MD, MSc.
2. Stack BC Jr, Moore E, Spencer H, Medvedev S, Bodenner DL. Outpatient thyroid surgery data from the University Health System (UHC) Consortium. Otolaryngol Head Neck Surg. 2013;148(5):740-745.
Submitted for Publication: October 25, 2013; final revision received March 26, 2014; accepted April 16, 2014.
jamaotolaryngology.com
1. Sun GH, DeMonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006. Thyroid. 2013;23(6):727-733.
3. Loyo M, Tufano RP, Gourin CG. National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope. 2013;123(8): 2056-2063. 4. Snyder SK, Hamid KS, Roberson CR, et al. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg. 2010;210(5): 575-584. 5. Terris DJ, Snyder S, Carneiro-Pla D, et al; American Thyroid Association Surgical Affairs Committee Writing Task Force. American Thyroid Association statement on outpatient thyroidectomy. Thyroid. 2013;23(10):1193-1202.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/08/2015
1075
Clinical Review & Education Clinical Challenges in Otolaryngology
6. Houlton JJ, Steward DL. Ambulatory endocrine surgery. In: Terris DJ, Miccoli P, eds. Minimally Invasive and Robotic Thyroid and Parathyroid Surgery. New York, NY: Springer; 2014:21-29. 7. Hopkins B, Steward D. Outpatient thyroid surgery and the advances making it possible. Curr Opin Otolaryngol Head Neck Surg. 2009;17(2):95-99. 8. Materazzi G, Dionigi G, Berti P, et al. One-day thyroid surgery: retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period. Eur Surg Res. 2007;39(3):182-188.
9. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press; 1999. 10. Leyre P, Desurmont T, Lacoste L, et al. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg. 2008;393(5):733-737. 11. Burkey SH, van Heerden JA, Thompson GB, Grant CS, Schleck CD, Farley DR. Reexploration for symptomatic hematomas after cervical exploration. Surgery. 2001;130(6):914-920.
12. Sanabria A, Carvalho AL, Silver CE, et al. Routine drainage after thyroid surgery—a meta analysis. J Surg Oncol. 2007;96(3):273-280. 13. Houlton JJ, Pechter W, Steward DL. PACU PTH facilitates safe outpatient total thyroidectomy. Otolaryngol Head Neck Surg. 2011;144(1):43-47. 14. Schietroma M, Cecilia EM, Carlei F, et al. Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial. JAMA Otolaryngol Head Neck Surg. 2013;139(5):471-478.
Invited Commentary CLINICAL CHALLENGES IN OTOLARYNGOLOGY
Advantages and Disadvantages of Outpatient Thyroid Surgery Ralph P. Tufano, MD, MBA
Outpatient thyroidectomy, defined as a discharge from medical care the same day of surgery, is gaining favor by physicians and other clinicians and third-party payers as an option for many surgical patients w ith thyroid disease beRelated article page 1074 cause it enables significant cost savings in health care expenditures. However, quality and patient safety remain the principal objectives in the delivery of health care and should never be compromised. In recent years, there has been an increasing emphasis on outpatient thyroidectomy, with an ever-growing number of published studies reporting on it since 2006. In this issue, Steward1 expertly reviews the eligibility criteria for outpatient thyroidectomy, in addition to the perioperative factors that should be considered in order to optimize the safe and efficient performance of outpatient thyroid surgery. Traditionally, thyroidectomy has entailed at a minimum, an overnight stay and often up to 3 days of inpatient observation to ensure that no substantial complications occurred outside of the hospital. The longer hospital stay had been justified because of the inherent risk of delayed complications, such as postoperative hemorrhage with airway obstruction and parathyroid gland dysfunction with subsequent life-threatening hypocalcemia. Postoperative hemorrhage can acutely compromise the airway, necessitating an emergency procedure to decompress the central neck hematoma. This, of course, is more likely to be a catastrophic problem if it occurs outside of a health care facility. Perioperative anesthesia preparation with antiemetic medication and the evolution of hemostatic aids and energy devices, together with a meticulous technique, have helped reduce the incidence of neck hematomas, especially more than 6 hours postoperatively. The risk of postoperative hypocalcemia can now be assessed more reliably in the early postoperative period using established predictors of hypocalcemia such as postoperative intact parathyroid hormone measurement and serum calcium trends. Mild postoperative hypocalcemia typically can be managed with patient education, along with oral calcium and vita1076
min D supplementation. The routine use of postoperative oral calcium and/or vitamin D supplementation has been advocated by some surgeons to minimize the incidence of hypocalcemia for all patients and to shorten the hospital stay.2 However, not every surgeon and patient is comfortable with the routine administration of calcium and/or vitamin D supplements.
Pros The concept of short stay and outpatient thyroidectomy was born in the 1990s, owing to a few high-volume thyroid surgeons observing a very low rate of substantial complications necessitating inpatient management. In particular, patients with minimal comorbidities usually convalesced quickly, with a rapid return to their baseline daily function.3,4 In more recent years, the practice of outpatient thyroidectomy has increased substantially with similar satisfactory results, in part owing to patient preference, surgeon comfort, and the relative strain of the inpatient stay on the US health care system.5,6 The potential advantages associated with outpatient thyroidectomy include decreased risk of nosocomial infections; decreased exposure to medical errors and/or iatrogenic complications; patient recovery in a quiet and comfortable familiar setting with support from family and friends; conservation of critical hospital resources; and decreased health care expenses.
Cons The cons of outpatient thyroidectomy are significant. The majority of thyroid surgical procedures in the United States is performed by low-volume thyroid surgeons.6 They may not be familiar or experienced with the latest techniques and algorithms to minimize outpatient surgical complications. Patients often present with multiple comorbidities, making it difficult for surgeons to know when to even consider outpatient thyroidectomy. A framework for the safe implementation of outpatient thyroidectomy has been outlined to help guide patients, surgeons, and society as a whole as to when to consider outpatient thyroidectomy.2 Nonetheless, individual surgeon and patient/caregiver comfort with outpatient thyroidec-
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/08/2015
jamaotolaryngology.com
Clinical Challenges in Otolaryngology
The Pros and Cons of Outpatient Thyroidectomy David L. Steward, MD
HYPOTHESIS Outpatient thyroidectomy is better than inpatient thyroidectomy.
Background In the United States, ambulatory surgery became more common in the 1980s, in part a response to the Omnibus Budget Reconciliation Act. Initial reports of outpatient thyroidectomy emerged in the 1980s, initially as hemithyroidectomy and progressively to total thyroidectomy. The question remains, which is better for the patient following thyroidectomy, recovery in the home or hospital setting? Numerous large database studies have documented a significant increase in thyroidectomy, particularly total thyroidectomy and outpatient thyroidectomy, with estimates of outpatient thyroidectomy accounting for approximately 65% of all cases and highervolume surgeons demonstrating lower complication rates Invited Commentary and greater use of outpatient page 1076 surgery.1-3 A limitation of these database studies is that it is often difficult to distinguish same-day discharge from 23-hour observation cases. However, studies that have been able to do so have documented increasing use and safety of same-day discharge.4 For the sake of discussion, outpatient surgery in this review will refer to discharge on the day of thyroid surgery. A recent statement on outpatient thyroidectomy from the American Thyroid Association highlights many of the issues surrounding this debate.5 The primary reasons cited for the increase in outpatient thyroid surgery include lower cost and patient preference. This trend toward increased use of outpatient thyroidectomy parallels increased use of outpatient surgery in general6 and in part has been facilitated by advances in anesthetic and surgical techniques,7 as well as the ability of the surgeon to select patients who are less likely to experience postoperative complications after discharge.5 Outpatient thyroidectomy is clearly not for every patient, and perhaps not for every surgeon. The pros and cons of outpatient thyroid surgery are presented herein. In the end, the patient and surgeon must decide what is in the patient’s best interest.
Pros The pros of outpatient thyroidectomy include reduced cost, patient preference, and patient safety. The actual cost of medical care can be elusive, but a recent large database study found charges from outpatient vs inpatient thyroidectomy of $7000 vs $22 000.1 In this era of cost-conscious medicine and the Patient Protection and Affordable Care Act, this is an important difference. While not all patients prefer outpatient surgery, the majority would prefer convalescence in their home environment and in the care of loved ones. A survey of patients undergoing outpatient thyroidectomy noted that 95% were satisfied or very satisfied, with only 5% dissatisfied with their experience.8 Social criteria to be considered for same-day surgery include autonomy after discharge; possession of a telephone; suitable living situation; and adequate home support. Thus 1074
some older patients who live alone or young mothers with small children may prefer to stay overnight. Further patient or family insecurity regarding outpatient surgery may factor in a decision for overnight stay. Patientsafetyisparamountwhenconsidering outpatient surgery, and the Institute of Medicine report on medical errors highlights the potential morbidity and mortality David L. Steward, MD fromhospitalization.9 Thus,whileitmayseem counterintuitive, same-day discharge may potentially be safer than an overnight stay in the hospital. Medical comorbidities likely influence the decision regarding safety of hospitalization vs discharge.5,8 Proposed eligibility criteria for safe outpatient thyroidectomy include American Society of Anesthesiologists (ASA) class 1 to 3 and no major medical comorbidities; understanding postoperative instructions and potential complications by patient and available caregiver in a safe outpatient setting; and proximity to skilled medical care facility.5
Cons The primary cons of outpatient thyroidectomy involve management of postoperative complications related to anesthesia and surgery. The primary complications of thyroidectomy that challenge outpatient management include hematoma or bleeding, airway compromise, and hypocalcemia with possible tetany, with the risk of these complications proportional to extent of surgery (hemithyroidectomy less than total thyroidectomy, total thyroidectomy less than total + central neck dissection). Late postoperative hemorrhage and hematoma with potential airway compromise appears to be the greatest potential con of outpatient thyroidectomy. Numerous studies have documented the safety of outpatient thyroidectomy, and the majority of hematomas appear during emergence or within the first 6 hours postoperatively.5,10,11 However, a small number of hematomas occur more than 6 hours after thyroidectomy (0.2% of patients), and the risk is likely greater in coagulopathic patients or those undergoing anticoagulation or antiplatelet therapy.5 Eleven randomized trials and a meta-analysis have failed to demonstrate that routine drain placement prevents hematomas,12 and several studies report increased pain and prolonged hospitalization with their use. However, drain placement in selectedpatientswithlargevascularand/orsubsternalgoiters,thosewith significant intraoperative bleeding, or those with coagulopathy or requiring anticoagulation may require overnight stay.6 Prevention and management of delayed postthyroidectomy hematoma involves a combination of good surgical and anesthetic technique; educated and experienced nursing personnel in recovery and same-day surgery; and patient and family understanding of signs, symptoms, and management plans. Written instructions given to the
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/08/2015
jamaotolaryngology.com
Clinical Challenges in Otolaryngology Clinical Review & Education
patient and caregivers preoperatively and postoperatively should include this information. Given the unpredictable nature of hematoma formation, this small but profound risk must be accepted by the surgeon and patient prior to undergoing outpatient thyroidectomy. Transient hypoparathyroidism is the most common complication of total or completion thyroidectomy, affecting approximately 25% of patients, with higher rates associated with concomitant central neck dissection. Patients undergoing first-time hemithyroidectomy are not at significant risk of hypoparathyroidism, making this less of a concern with outpatient surgery. Left untreated, hypoparathyroidism manifests in hypocalcemia and neuromuscular symptoms progressing from mild paresthesias to tetany in the extreme. Hypocalcemic symptoms of untreated or undertreated hypoparathyroidism may not manifest early on postoperative day 1, sometimes manifesting on postoperative day 2 or 3. Thus, overnight observation alone may not rule out potential complications later. Prevention of postthyroidectomy hypocalcemia requires either routine oral calcium and vitamin D supplementation5 or early identificationofhypoparathyroidismusingrapidparathyroidhormone(PTH) testing in recovery with selective oral supplementation with calcium and calcitriol (1,25-OH vitamin D) for the minority of patients with a PTH level lower than 15 to 20 pg/mL (picograms per milliliter to nanograms per liter is a 1-to-1 conversion).5,13 Load dosing with 3-μg calcitriol may improve calcium absorption for patients with low PTH levels.13 Given that vitamin D is fat soluble, it may be dosed daily at 0.5 to 1.0 μg, but calcium requires more frequent dosing, often 1 g administered 3 or 4 times daily. Calcium citrate may be better absorbed than calcium carbonate in patients receiving proton pump inhibitor therapy or in those having undergone prior gastric surgery. Intravenous calcium gluconate has a very short half-life and is reserved for acute treatment of symptomatic hypocalcemia. Anxiety and hyperventilation may exacerbate hypocalcemia due to pH effect on ionized calcium levels and slow deep breathing may temporarily improve symptoms. Preoperative vitamin D supplementation seems reasonable in those with vitamin D deficiency who are considering outpatient thyroidectomy. Written instructions should be given to patient and caregivers preoperatively and postoperatively, including signs, symptoms, and management plans for hypocalcemia. Transient recurrent laryngeal nerve injury may occur in approximately 5% of cases, with higher rates associated with invasive or metastatic thyroid carcinoma. Unilateral injury may cause dysphonia, dysphagia, and mild dyspnea on exertion and may not preclude outpatient management. Dexamethasone administered
ARTICLE INFORMATION Author Affiliation: Department of Otolaryngology– Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
preoperatively may reduce transient laryngeal nerve injury,14 but its postoperative role is uncertain. Bilateral recurrent laryngeal nerve injury is rare but can cause severe dyspnea and stridor, potentially resulting in severe upper airway obstruction, which may require tracheotomy. Patients with bilateral recurrentlaryngealnerveinjurymayhavesurprisinglygoodphonation, andanyaudiblestridorshouldbeevaluatedimmediately.Patientscomplaining of dyspnea and/or dysphagia postoperatively require laryngoscopy to assess vocal cord function prior to discharge. Laryngeal nerve integrity monitoring has not been shown to significantly reduce recurrent laryngeal nerve injury in otherwise uncomplicated cases, but it has been shown to be useful prognostically regarding postoperative vocal cord function. Recurrent laryngeal nerves that initially stimulate well but fail to stimulate at the end of the case are at significant risk for paresis.Ifbothrecurrentnervesfailtostimulateintraoperatively,ahigh level of concern for postoperative respiratory distress should be maintained and extubation should be undertaken cautiously. Complications from anesthesia may be exacerbated by medical comorbidities such as obesity and obstructive sleep apnea, as well as underlying cardiac, pulmonary, or neurologic disorders.5 Other complications include slow emergence, nausea, and vomiting. Outpatient surgery may be relatively contraindicated in these patients.
Bottom Line Overall, outpatient thyroidectomy is increasingly used and cost advantageous and appears safe and well tolerated in selected patients. Patient satisfaction is high, and the risk of symptomatic hypocalcemia, delayed hematoma, and airway compromise are low with contemporary techniques in the hands of experienced surgeons and high-volume centers. Outpatient thyroidectomy, especially following total or completion, is clearly not for every patient or surgeon, and hospital administrators and third-party payers should defer to the patient and surgeon regarding this option. Education of perianesthesia nurses, patients, and other caregivers regarding recognition and management of postthyroidectomy complications is critical. Patients should be given both verbal and written instructions preoperatively and postoperatively and must have continuous access to a physician. Despite all precautions, complications are inevitable, and both patient and surgeon must accept the low risk of potentially life-threatening complication occurring in the outpatient setting. Surgeons interested in starting to perform outpatient thyroidectomy may want to begin with straightforward hemithyroidectomy in patients residing locally and establishing a record of success before advancing to more challenging cases.
Published Online: October 9, 2014. doi:10.1001/jamaoto.2014.2353. Conflict of Interest Disclosures: None reported.
Corresponding Author: David L. Steward, MD, Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0528 ([email protected]).
REFERENCES
Section Editor: Marion Boyd Gillespie, MD, MSc.
2. Stack BC Jr, Moore E, Spencer H, Medvedev S, Bodenner DL. Outpatient thyroid surgery data from the University Health System (UHC) Consortium. Otolaryngol Head Neck Surg. 2013;148(5):740-745.
Submitted for Publication: October 25, 2013; final revision received March 26, 2014; accepted April 16, 2014.
jamaotolaryngology.com
1. Sun GH, DeMonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006. Thyroid. 2013;23(6):727-733.
3. Loyo M, Tufano RP, Gourin CG. National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope. 2013;123(8): 2056-2063. 4. Snyder SK, Hamid KS, Roberson CR, et al. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg. 2010;210(5): 575-584. 5. Terris DJ, Snyder S, Carneiro-Pla D, et al; American Thyroid Association Surgical Affairs Committee Writing Task Force. American Thyroid Association statement on outpatient thyroidectomy. Thyroid. 2013;23(10):1193-1202.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/08/2015
1075
Clinical Review & Education Clinical Challenges in Otolaryngology
6. Houlton JJ, Steward DL. Ambulatory endocrine surgery. In: Terris DJ, Miccoli P, eds. Minimally Invasive and Robotic Thyroid and Parathyroid Surgery. New York, NY: Springer; 2014:21-29. 7. Hopkins B, Steward D. Outpatient thyroid surgery and the advances making it possible. Curr Opin Otolaryngol Head Neck Surg. 2009;17(2):95-99. 8. Materazzi G, Dionigi G, Berti P, et al. One-day thyroid surgery: retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period. Eur Surg Res. 2007;39(3):182-188.
9. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press; 1999. 10. Leyre P, Desurmont T, Lacoste L, et al. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg. 2008;393(5):733-737. 11. Burkey SH, van Heerden JA, Thompson GB, Grant CS, Schleck CD, Farley DR. Reexploration for symptomatic hematomas after cervical exploration. Surgery. 2001;130(6):914-920.
12. Sanabria A, Carvalho AL, Silver CE, et al. Routine drainage after thyroid surgery—a meta analysis. J Surg Oncol. 2007;96(3):273-280. 13. Houlton JJ, Pechter W, Steward DL. PACU PTH facilitates safe outpatient total thyroidectomy. Otolaryngol Head Neck Surg. 2011;144(1):43-47. 14. Schietroma M, Cecilia EM, Carlei F, et al. Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial. JAMA Otolaryngol Head Neck Surg. 2013;139(5):471-478.
Invited Commentary CLINICAL CHALLENGES IN OTOLARYNGOLOGY
Advantages and Disadvantages of Outpatient Thyroid Surgery Ralph P. Tufano, MD, MBA
Outpatient thyroidectomy, defined as a discharge from medical care the same day of surgery, is gaining favor by physicians and other clinicians and third-party payers as an option for many surgical patients w ith thyroid disease beRelated article page 1074 cause it enables significant cost savings in health care expenditures. However, quality and patient safety remain the principal objectives in the delivery of health care and should never be compromised. In recent years, there has been an increasing emphasis on outpatient thyroidectomy, with an ever-growing number of published studies reporting on it since 2006. In this issue, Steward1 expertly reviews the eligibility criteria for outpatient thyroidectomy, in addition to the perioperative factors that should be considered in order to optimize the safe and efficient performance of outpatient thyroid surgery. Traditionally, thyroidectomy has entailed at a minimum, an overnight stay and often up to 3 days of inpatient observation to ensure that no substantial complications occurred outside of the hospital. The longer hospital stay had been justified because of the inherent risk of delayed complications, such as postoperative hemorrhage with airway obstruction and parathyroid gland dysfunction with subsequent life-threatening hypocalcemia. Postoperative hemorrhage can acutely compromise the airway, necessitating an emergency procedure to decompress the central neck hematoma. This, of course, is more likely to be a catastrophic problem if it occurs outside of a health care facility. Perioperative anesthesia preparation with antiemetic medication and the evolution of hemostatic aids and energy devices, together with a meticulous technique, have helped reduce the incidence of neck hematomas, especially more than 6 hours postoperatively. The risk of postoperative hypocalcemia can now be assessed more reliably in the early postoperative period using established predictors of hypocalcemia such as postoperative intact parathyroid hormone measurement and serum calcium trends. Mild postoperative hypocalcemia typically can be managed with patient education, along with oral calcium and vita1076
min D supplementation. The routine use of postoperative oral calcium and/or vitamin D supplementation has been advocated by some surgeons to minimize the incidence of hypocalcemia for all patients and to shorten the hospital stay.2 However, not every surgeon and patient is comfortable with the routine administration of calcium and/or vitamin D supplements.
Pros The concept of short stay and outpatient thyroidectomy was born in the 1990s, owing to a few high-volume thyroid surgeons observing a very low rate of substantial complications necessitating inpatient management. In particular, patients with minimal comorbidities usually convalesced quickly, with a rapid return to their baseline daily function.3,4 In more recent years, the practice of outpatient thyroidectomy has increased substantially with similar satisfactory results, in part owing to patient preference, surgeon comfort, and the relative strain of the inpatient stay on the US health care system.5,6 The potential advantages associated with outpatient thyroidectomy include decreased risk of nosocomial infections; decreased exposure to medical errors and/or iatrogenic complications; patient recovery in a quiet and comfortable familiar setting with support from family and friends; conservation of critical hospital resources; and decreased health care expenses.
Cons The cons of outpatient thyroidectomy are significant. The majority of thyroid surgical procedures in the United States is performed by low-volume thyroid surgeons.6 They may not be familiar or experienced with the latest techniques and algorithms to minimize outpatient surgical complications. Patients often present with multiple comorbidities, making it difficult for surgeons to know when to even consider outpatient thyroidectomy. A framework for the safe implementation of outpatient thyroidectomy has been outlined to help guide patients, surgeons, and society as a whole as to when to consider outpatient thyroidectomy.2 Nonetheless, individual surgeon and patient/caregiver comfort with outpatient thyroidec-
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
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