Is Outpatient Thyroid Surgery Safe and Effective?

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Is outpatient thyroid surgery safe and effective?

The option of having thyroid surgery, and returning home – instead of a hospital stay – has been the subject of a variety of studies, and represents a change for thyroid surgeons who have long debated the benefits of inpatient versus outpatient surgeries. Let’s take a look at the controversial and conflicting results.

Inpatient vs. Outpatient

Traditionally, surgery to remove the thyroid, known as a thyroidectomy, has involved an overnight stay – at minimum -- and often as much as two to five days of additional hospitalization.

This inpatient surgery is still fairly standard, despite the fact that complications are infrequent after thyroid surgery.

The longer stays for post-surgical observation have often been justified by concerns about post-surgical complications, the thyroid's proximity to the laryngeal nerve and airway, in addition to a risk of bleeding.

But some physicians recommend that routine thyroid surgery be performed as an outpatient procedure, especially if protocols are in place to routinely give calcium and Vitamin D supplementation post-surgery to reduce the risk of hypocalcemia.

Conflicting Studies

In 1998, an article in the Journal of Clinical Endocrinology and Metabolism (JCEM) by Dr. Orlo Clark analyzed the risks for patients who had undergone thyroid surgery. The analysis suggested that as many as 94 hemorrhage-related deaths per 100,000 thyroid operations could be prevented if patients were hospitalized overnight instead of being discharged in as little as six hours.

But in the same year, another article in JCEM, published by the late thyroid surgeon Paul LoGerfo, MD, countered that claim. LoGerfo reported that he went from performing 10 outpatient thyroidectomies in 1992 to doing 80 in 1996, with no ill effect. "To this date, I have not had to readmit any patient who was discharged in an outpatient setting," LoGerfo wrote.

Results of a study presented at the 2006 annual meeting of the American Academy of Otolaryngology, however, suggested that outpatient thyroid surgery is safe and effective for most patients, and may be preferable to traditional inpatient hospital stays. This seems to confirm Dr. LoGerfo’s observations.

The nonrandomized study evaluated patients undergoing thyroidectomy at two Georgia hospitals between December 2004 and October 2005. Patients were divided into two groups. Those who were admitted and stayed at least overnight were considered inpatients. Outpatients were defined as those discharged directly from the recovery unit.

The researchers looked at a number of factors, including the duration of surgery, the time to discharge and the total charges billed to the hospital. During the study period, 91 patients underwent thyroid surgery. Most were female and were an average of 45 years-old. Fifty-two were treated as outpatients, and 39 were given inpatient care (26 stayed overnight, while 13 were admitted for about 3 days).

Because a major concern following partial or total thyroidectomy is hypocalcemia, a potentially dangerous drop in calcium levels, all patients were given calcium supplements. Calcium levels were also monitored for three weeks following the surgery.

The benefits of outpatient procedures cited by the researchers include:

  • Lower cost to both patients and insurers
  • Patient recuperation occurs at home, away from possible nosocomial (hospital-acquired) infections
  • Oral calcium supplements are effective in preventing calcium deficiency after surgery

The researchers still recommended inpatient thyroid surgery for some patients, including:

  • Patients with medical infirmity due to weakness or age
  • Patients with coexisting conditions or blood diseases
  • Patients who will be undergoing other procedures simultaneously that require admission
  • Patients who specifically prefer to be admitted
  • Patients with especially large thyroid lesions

A 2009 study published in Current Opinions in Otolaryngologic Head and Neck Surgery did a meta-analysis of 11 different randomized trials, and found no difference in major complications among patients who did not require a drain after surgery, as long as patients were routinely given calcium and Vitamin D supplementation post-surgery to reduce the risk of hypocalcemia.

Another study, published in 2015 in the journal Surgery, looked at the outcomes for 1,311 thyroid surgeries, of which 1,026 (almost 78%) were outpatient. The researchers found that:

  • Readmission rates for outpatients were .9% and inpatients were readmitted far more often (3.5%)
  • There were no differences in the complication rates

The researchers concluded that outpatient thyroid surgery is safe in appropriately selected patients.

Another study published in 2015 in the Danish Medical Journal disagreed, however. These researchers looked at rates of post-thyroidectomy bleeding in outpatient thyroid surgery, and found that this bleeding occurred within 6 hours of surgery in 63 percent of the cases they studied – all thyroidectomy patients in Denmark – and in 25% of cases between 6 and 24 hours after surgery and 13% of cases after 24 hours.

The researchers concluded that routine outpatient thyroid surgery can’t be recommended, and patients should be observed for at least 6 hours after surgery and should stay near the hospital for at least the following 24 hours.

What Should Patients Do?

How you proceed should depend on your particular situation – your specific type and nature of thyroid surgery, your age, overall health, other risk factors, preferences, and the expertise of your thyroid surgeon. But if you have a routine thyroid surgery, and are working with an experienced thyroid surgeon who recommends an outpatient surgery, it may be a safe and effective option for you.

More Information on Thyroid Surgery and Thyroidectomy

SOURCES:

Clark, Orlo H., M.D., et. al. "Ambulatory Thyroid Surgery: Unnecessary and Dangerous" The Journal of Clinical Endocrinology & Metabolism Vol. 83, No. 4 1100-1103, 1998.

Hopkins B, Steward D. “Outpatient thyroid surgery and the advances making it possible.” Curr Opin Otolaryngol Head Neck Surg. 2009 Apr;17(2):95-9. PMID:19373959

LoGerfo, Paul, MD, "Outpatient Thyroid Surgery," The Journal of Clinical Endocrinology & Metabolism, Vol. 83, No. 4 1097-1100, 1998

Segel JM, et. al. “Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients.” Surgery. 2015 Oct 12. pii: S0039-6060(15)00626-1. doi: 10.1016/j.surg.2015.08.007. [Epub ahead of print] PMID:26471720

Sørensen KR, Klug TE. “Routine outpatient thyroid surgery cannot be recommended.” Dan Med J. 2015 Feb;62(2). pii: A5016. PMID:25634504

Terris, David J., MD 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, September 17-20, 2006, Toronto, Canada

SOURCES:

Clark, Orlo H., M.D., et. al. "Ambulatory Thyroid Surgery: Unnecessary and Dangerous" The Journal of Clinical Endocrinology & Metabolism Vol. 83, No. 4 1100-1103, 1998. (Online)

LoGerfo, Paul, MD, "Outpatient Thyroid Surgery," The Journal of Clinical Endocrinology & Metabolism Vol. 83, No. 4 1097-1100, 1998 (Online)

Terris, David J., MD 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, September 17-20, 2006, Toronto, Canada

 

Mary Shomon, About.com's Thyroid Guide since 1997, is a nationally-known patient advocate and best-selling author of 10 books on health, including "The Thyroid Diet: Manage Your Metabolism for Lasting Weight Loss," "Living Well With Hypothyroidism: What Your Doctor Doesn't Tell You...That You Need to Know," "Living Well With Graves' Disease and Hyperthyroidism," "Living Well With Autoimmune Disease," "Living Well With Chronic Fatigue Syndrome and Fibromyalgia," and the "Thyroid Guide to Fertility, Pregnancy and Breastfeeding Success." 

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