Published on September 30, 2015
1. Daycare thyroidectomy surgery – Our experience
2. Original Article Daycare thyroidectomy surgery – Our experience M. Babu Manohar a , P.S.J. Vikram b, *, V. Vidhya c , Raees Abdurahiman d a Senior Consultant ENT, Head and Neck Surgeon, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road, Chennai 600006, India b Associate ENT, Head and Neck Surgeon, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road, Chennai 600006, India c Senior Registrar, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road, Chennai 600006, India d Registrar, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road, Chennai 600006, India 1. Introduction The advent and betterment of outpatient surgery has dramatically changed the landscape of the profession. Just as other innovations such as antibiotics and improved anaesthetics have led to better outcomes for surgical patients, outpatient surgery has undoubtedly beneﬁted patients and surgeons alike, as it is convenient, safe and cost-effective. However, many surgeons and institutions are hesitant to perform day surgery for some procedures. There are scant reports of daycare thyroid surgeries (DTS) in the literature. Many of the published studies on this topic have a small cohort of patients; others are highly selective and exclude total a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x a r t i c l e i n f o Article history: Received 9 March 2015 Accepted 23 July 2015 Available online xxx Keywords: Daycare thyroidectomy Case series a b s t r a c t Background: Outpatient surgery beneﬁts patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in a stand-alone Daycare Surgery Center in South India. Aim: Our aim is to identify the difﬁculties, to formulate a protocol for daycare thyroidecto- mies and also to discuss its feasibility. Study design: Case series. Methods: We performed a prospective study of 71 patients who underwent total or hemithyroidectomy with or without neck dissection between January 2012 and March 2014 at Apollo Daycare Surgery Center, Chennai. Results: Seventy-one patients met our inclusion criteria. Most patients were women (77%) and men were 23%. Only 1 patient developed haematoma, 1 patient developed tetany, and there was no incidence of stridor or recurrent laryngeal nerve injury. Conclusion: Daycare thyroidectomies are safe and associated with low complication rate provided a strict inclusion and exclusion criteria is followed along with meticulous surgery. # 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved. * Corresponding author. E-mail address: Vikrampsj@yahoo.com (P.S.J. Vikram). APME-306; No. of Pages 5 Please cite this article in press as: Babu Manohar M, et al. Daycare thyroidectomy surgery – Our experience, Apollo Med. (2015), http://dx.doi. org/10.1016/j.apme.2015.07.010 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme http://dx.doi.org/10.1016/j.apme.2015.07.010 0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.
3. thyroidectomies or procedures performed to treat cancer. Finally, in several studies, the procedures are being performed in 23-hour stay units. It may not be that safe to discharge patients on the same day these procedures are performed. Hence, we sought to review the outcomes of patients who underwent thyroidectomies in an ambulatory centre. The procedures were performed to treat benign diseases and cancer and included hemithyroidectomies and total thyroid- ectomies with or without neck dissection. 2. Methods We conducted a prospective study of DTS performed at Apollo Hospital, Chennai between January 2012 to March 2014. Inclusion criteria for our study are outlined in Box 1. Patients considered for this venue are made to meet an anaesthesiologist in the preoperative clinic and the patients are asked to remain in the city (within a 1-hour drive from the hospital) for 48 h after the operation. It is made mandatory that the patients remain in the presence of a second adult for the same period of time. 2.1. Inclusion criteria The following aspects are considered criteria for inclusion: both benign and malignant thyroids, goitre of any size, euthyroid status, hypothyroid status corrected, patient resid- ing in town, within a 1-hour drive from the hospital, for at least 48 h, patient seen in preadmission assessment clinic (by an anaesthesiologist) and cleared for day surgery (ASA grade I and II patients). Every patient was observed in the surgical day care unit for at least 4 h. 2.2. Exclusion criteria The following aspects are considered criteria for exclusion: ASA Grade III and above patients, goitre with compressive symptoms, restrosternal extension, coagulopathy and age more than 65 years. 2.3. Preoperative work up Thyroid function tests: serum calcium, neck ultrasound/CT scan, FNAC, indirect laryngoscopy, chest X-ray including neck, preanaesthetic check up, councelling for day surgery and endocrinologist opinion. 2.4. Procedure Neck extension Superﬁcial cervical plexus block given Local anaesthetic inﬁltrated Standard skin crease incision given Strap muscles retracted Bipolar cautery only Both the recurrent laryngeal nerves always identiﬁed and preserved At least 2 parathyroids identiﬁed and preserved Minivac suction drain placed 3. Results A total of 71 patients underwent procedures during our study period. Most patients were women. The number of total thyroid- ectomies is 48, which includes 3 one side modiﬁed radical neck dissection (MRND), 1 bilateral MRND and 6 central neck node dissections. The number of hemithyroidectomies is 23. N Minimum Maximum Mean Std. deviation Age (years) 71 18 61 38.33 10.029 Valid N (listwise) 71 N Minimum Maximum Mean Std. deviation Clinical size 71 3 10 4.92 1.918 Valid N (listwise) 71 0 Frequency Percent Valid percent Cumulative percent Valid Euthyroidism 86.1 86.1 86.1 Hypothyroidism (corrected) 13.9 13.9 100.0 Total 100.0 100.0 Frequency Percent Valid percent Cumulative percent Valid Benign 57 80.29 80.29 80.29 Malignant 14 19.71 19.71 100.0 Total 71 100.0 100.0 Frequency Percent Valid percent Cumulative percent Valid Total thyroidectomy 48 67.61 67.61 67.61 Hemithyroidectomy 23 32.39 32.39 100.0 Total 71 100.0 100.0 Benign thyroids – 57 Malignants – 14 Papillary carcinoma – 10 Follicular carcinoma – 3 Medullary carcinoma – 1 Mean N Std. deviation Std. error mean Pair 1 Pre op-CA 9.508 71 0.5315 0.0886 Post op-CA 8.894 71 0.6210 0.1035 a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2 APME-306; No. of Pages 5 Please cite this article in press as: Babu Manohar M, et al. Daycare thyroidectomy surgery – Our experience, Apollo Med. (2015), http://dx.doi. org/10.1016/j.apme.2015.07.010
4. Paired differences t df Sig. (2-tailed) Mean Std. deviation Std. error mean 95% conﬁdence interval of the difference Lower Upper 0.614 0.4051 0.0675 0.477 0.751 9.093 35 0.000 3.1. Postoperative hypocalcaemia Different studies showing low postoperative morbidity and mortality (RLN transient and permanent injury) in daycare thyroidectomy. 3.2. Postoperative haematoma Different studies showing low postoperative morbidity and mortality (postoperative haematoma) in day care thyroidecto- my. 3.3. Postoperative haematoma timing interval Different studies showing low postoperative morbidity and mortality (postoperative cervical haematoma timing interval) in day care thyroidectomy. 3.4. Postoperative RLN injury Different studies showing low postoperative morbidity and mortality (postoperative RLN transient and permanent injury) in day care thyroidectomy. 4. Discussion Even though DTS has been performed since the early 1980s, it remains a controversial topic with two distinct schools of thought. Most of the controversy revolves around the time duration the patients should be observed for life-threatening complications following the procedure. Many agree that this depends on the type of thyroid surgery performed, as procedures performed to treat cancer, completion or total thyroidectomies have a greater potential for complications given the extensive dissection involved. The existing literature on short-stay thyroid surgery exhibits a great deal of variability a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3 APME-306; No. of Pages 5 Please cite this article in press as: Babu Manohar M, et al. Daycare thyroidectomy surgery – Our experience, Apollo Med. (2015), http://dx.doi. org/10.1016/j.apme.2015.07.010
5. in deﬁnitions, inclusion criteria and results. Some authors deﬁne same-day surgery, whereas others admit patients before their surgeries for optimisation. Other authors exclude patients with cancer because of the theoretical implications of greater complications related to more exten- sive dissection. Finally, a large study from the Philippines did not include total thyroidectomies. Airway compromise due to haematoma formation is an immediately life-threatening complication that requires close monitoring. These situations may require immediate evacuation of the haematoma and sometimes a second operation to obtain haemostasis. This complication typically occurs early in the postoperative period, and it did not occur in our study, suggesting that an observation period ranging from 4 to 10 h is appropriate. Hypocalcaemia is more common, usually occurring within 14–72 h after surgery. Hypocalcaemia rates are reported to range from 6% to 30%. Most of the higher rates have been observed in patients who had total thyroidectomies. Many authors report on methods used to predict which patients will experience hypocalcaemia. Despite useful predictors of hypocalcaemia such as measure- ment of parathyroid hormone that permit early discharge of certain groups of patients, most methods are expensive, time- consuming and not readily available in all centres. In our study, we instructed patients to document and report symptoms of paraesthesia, which is indicative of hypocalcae- mia. The incidence of hypocalcaemia in our series was only 1.4%, which is substantially lower than in other series. We did not examine the potential ﬁnancial beneﬁts of DTS. As with other types of outpatient surgeries, hospital costs are reduced when patients are safely discharged home on the day of their surgeries. Outpatient thyroid surgeries are no exception. In fact, many studies have shown ﬁnancial beneﬁts to OTS. Some American studies have shown a savings of as much as 22–56% compared with the same procedures performed on an inpatient basis. It is unclear what the cost beneﬁt would be in an Indian centre. 5. Conclusion Our review of ambulatory thyroidectomy demonstrates that the feasibility of daycare surgery depends on the following factors such as proper patient selection, mandatory preanaes- thetic check-ups, preoperative patient counselling, short acting anaesthetic drugs, standardised surgical technique, good pain management, proper control of postoperative nausea and vomiting, less expenditure, very alert and trained recovery team. Our review of OTS demonstrates that a short period of observation (4–10 h) is safe and that thyroid surgery can be performed as an outpatient procedure with an acceptable complication rate. However, due diligence is essential, as it will undoubtedly serve to establish quality controls and safeguards to potential complications, which in turn will improve the safety of such procedures. Patient education is an essential ﬁrst step in establishing such a program. Careful patient selection and preoperative assessment provide important safeguards. The facility of Accessible emergency services is also critical for such procedures. Further studies assessing patient satisfaction with day surgery will reinforce the beneﬁts of this approach. Conﬂicts of interest The authors have none to declare. r e f e r e n c e s 1. Canadian Institute for Health Information. Trends in acute inpatient hospitalizations and day surgery visits in Canada, 1995– 2006 [database]. Ottawa, ON: The Institute; 2007 Available at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=bl_hmdb_ 3jan2007_e [accessed 10.01.07]. 2. Steckler RM. Outpatient thyroidectomy: a feasibility study. 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