Thyroidectomy safe for outpatient setting
Reduced bleeding, prophylactic meds bring patients
Although thyroidectomies now are performed using minimally invasive techniques, surgeons have been reluctant to move the procedure to an outpatient setting for a variety of reasons including risk of bleeding and the threat of low blood calcium levels. These risks can be minimized, which makes thyroidectomy an appropriate procedure for outpatient, according to a study conducted at the Medical College of Georgia in Augusta.
In a study of 91 patients undergoing thyroidectomies, 52 underwent the procedure on an outpatient basis, 26 were observed in a 23-hour stay unit, and 13 were admitted for a hospital stay that averaged about three days.1 A total of two complications occurred in the group managed as outpatients, and one complication occurred in the groups that were observed for 23 hours or admitted as inpatients, according to David J. Terris, MD, lead author of the study and chairman of the Otolaryngology Department at the Medical College of Georgia.
Reducing the risk
Surgeons have been hesitant to perform thyroidectomies as outpatient procedures mainly because of the risk of bleeding or fluid buildup near the incision that can cause pressure on the trachea and restrict the patient's airway, explains Terris. "We found that there are a number of steps that can be taken to reduce this risk and make the procedure safer for outpatient settings," he says.
Minimally invasive dissection is preferred to the traditional approach of raising flaps of skin and muscle to expose the thyroid, says Terris. "I also use a harmonic scalpel that reduces the loss of blood during the procedure from 150 to 300 cc of blood for the traditional method to 2 or 3 cc of blood with the harmonic scalpel," he says. "The less bloody the procedure is during surgery, the less chance of blood seepage following surgery."
Because his minimally invasive approach and the use of the harmonic scalpel reduce the amount of blood during the thyroidectomy, Terris does not insert drains in the incision. "When I routinely used drains, I had to admit the patient overnight because I don't like sending a patient home with drains," he explains. Even though many surgeons now use a minimally invasive approach to thyroidectomies, they still use drains, Terris says. "I learned that drains don't make a difference in outcomes, but we are creatures of habit, so it does take time to change a surgeon's behavior," he adds.
In addition to bleeding, hypocalcemia is a risk that prevents surgeons from recommending thyroidectomy as an outpatient procedure, points out Terris. To address this risk, Terris places his patients on a prophylactic calcium supplementation regimen that tapers off over a three-week period. "The medications are not dangerous, so there is no risk for patients who do not develop hypocalcemia to take the additional supplement," he says.
23-hour stay an option
Most of the thyroidectomy patients at the Thyroid Surgery Center of Texas are discharged less than 18 hours after the procedure, says R. Anders Rosendahl, MD, FACS, in Austin, TX. Because he doesn't use a prophylactic calcium supplementation regimen, he prefers to keep patients on a 23-hour stay basis to monitor their calcium levels and to check for bleeding, he says.
Whether you choose to use a 23-hour stay unit or discharge directly from the outpatient surgery center, select patients carefully, says Rosendahl. Younger patients have fewer comorbidities, and women usually suffer fewer side effects than men in his experience, he says.
There was no difference in outcomes based on gender or age in the Medical College of Georgia study,1 says Terris. "I do choose patients carefully to be sure that no other medical conditions are exacerbated by the surgery or the anesthesia."
There is a learning curve for this procedure, Rosendahl says. Surgery program managers should check training and experience carefully before allowing surgeons to perform the procedure on an outpatient basis, he says.
Typically, the best surgeon will be a high-volume thyroid surgeon who does not use drains, says Terris. "There's no way to identify a specific number of cases the surgeon should have performed, but he or she must use minimally invasive techniques and avoid drains in order to even consider performing this procedure on an outpatient basis," he says.
Costs are much lower
Costs for outpatient thyroidectomy are lower than for inpatient thyroidectomy with the average outpatient procedure in Terris' study costing $7,814 compared to $10,288 for inpatients. A handpiece suitable for thyroidectomy and a harmonic scalpel are necessary, but most surgery programs have these available, Terris points out.
When the Surgery Center of Aiken [SC] accepted Terris' first outpatient thyroidectomy patients, the equipment already was in place, says Todd Fields, business manager of the center. "Reimbursement for this procedure is good and more than covers our costs," he says.
Although costs for the procedure are lower and more attractive to payers, the real reason to consider outpatient thyroidectomies is the patient's preference, says Terris. "Pain medication, other than Tylenol, is rarely used and some patients are back at work the following day," he says. "Patients want to recover at home, and they want to return to their normal routine as quickly as possible."
Reference
- Terris, DJ, Moister B, Seybt MW, et al. Outpatient thyroid surgery is safe and desirable. Presentation at the 110th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology's Head and Neck Surgery Foundation, Toronto; Sept. 17-20, 2006.
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