Day case hemithyroidectomy is safe and feasible: experience in Scotland

Background and aims

In the 19th century early attempts to remove the thyroid were so disastrous that they eventually led to the practice being banned by the French Academy of Medicine in 1850. With the advent of improved antiseptic and surgical techniques, the mortality of thyroid surgery began to fall. As mortality dropped, an increased number of survivors allowed for the identification of the postoperative complications. ¹ The major complications of thyroid surgery include compressive haematoma, recurrent laryngeal nerve palsy and hypocalcaemia secondary to hypoparathyroidism. ² Other complications include superior laryngeal nerve injury, dysphagia, inability to urinate, wound infection and pain.

However, despite the postoperative dangers of thyroid surgery, it is increasingly performed on a day case basis, ‘especially for hemithyroidectomy’. ³ A 1995 American study of 100 patients showed a ‘30% saving in hospital costs’ when thyroid and parathyroid surgery were performed on an outpatient basis. ⁴ A more recent study in 2012 looked at patient satisfaction in almost 200 patients who underwent outpatient thyroid surgery. This study showed an average ‘patient satisfaction and feeling of security was 9.3 on a 10 point scale’. ⁵ Both studies illustrate the key point that day case thyroid surgery is a desirable option if it can be performed safely.

Hemithyroidectomy is theoretically more amenable to day surgery than total thryoidecotmy as only the parathyroid glands on one side are affected. This therefore results in less risk of postoperative hypocalcaemia. A study in 2008 conducted by Cannon CR and Replogle WH showed that in general calcium replacement or prolonged hospitalisation was not necessary for hemithyroidectomies. ⁶ Additionally any damage to the laryngeal nerve is theoretically unlikely to be life threatening, given that nerve supply will be maintained on the contralateral side.

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Table 1.

All patients: (N = 180).

Patient characteristics	Planned as day case (n = 145)			Planned as inpatient (n = 35)		All patients (n = 180)
Age (mean)	46.4			55.5		48.2
ASA score of 1	53		36.6%	9	25.7%	62	34.4%
ASA score of 2	85		58.6%	16	45.7%	101	56.1%
ASA score of 3	7		4.8%	10	28.6%	17	9.4%
	N	%		N	%	N		%
Gender female	117	80.7%		24	68.6%	141		78.3%
Gender male	28	19.3%		11	31.4%	39		21.7%
Hypocalcaemia	0	–		0	–	0		–
Laryngeal nerve palsy	0	–		0	–	0		–
Haematoma	0	–		0	–	0		–
Surgical site infection	6	4.1%		3	8.6%	9		5%
Additional procedures	8	5.5%		4	11.4%	12		6.7%
Intraoperative complications	1	0.7%		0	–	1		0.6%
Same-day discharge	106	73.1%		0	–	106		58.9%
Readmission to hospital	1	0.7%		1	2.9%	2		1.1%
A&E presentation Post-op	7	4.8%		0	–	7		3.9%

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Table 2.

Planned day case procedures: (n = 145).

Patient characteristics	Same-day discharge (n = 106)		Stayed overnight (n = 39)
Age (mean)	44		53.2
ASA score of 1	39	36.8%	14	35.9%
ASA score of 2	60	56.6%	25	64.1%
ASA score of 3	7	6.6%	0	–
	N	%	N	%
Next day discharge	–	–	37	95%
Gender female	88	83%	29	74.4%
Gender male	28	26.4%	10	25.6%
Surgical site infection	2	1.9%	4	10.3%
Additional procedures	5	4.7%	3	7.7%
Intraoperative complications	0	–	1	2.6%
Readmission to hospital	1	0.9%	0	–
A&E presentation Post-op.	3	2.8%	4	10.3%

Note. Results included in tables have been rounded to the nearest 0.1.

The American Thyroid Association’s statement on outpatient thyroidetcomy is that it ‘may be undertaken safely in a carefully selected patient population provided that certain precautionary measures are taken to maximise communication and minimise the likelihood of complications’. ⁷ This is supported by a variety of studies^5,8,9 looking at outpatient thryoidectomies. Fewer studies have looked specifically at outpatient hemithyroidectomies, until recently. In the past few years, some smaller studies have concluded that in select patients outpatient hemithyroidectomies can be safe, cost effective and associated with high patient satisfaction.^10,11 Our study aims to complement these by confirming the safety of these procedures, as well as assess the feasibility of performing hemithyroidectomy as a day surgery.

Methods

All hemithyroidectomies performed by two surgeons across two institutions, from the start of 2010 to the end of 2013, were retrospectively reviewed and patients were divided up into either ‘planned inpatient’ or ‘planned day case’. Some patients were converted to inpatient procedures perioperatively and these were also recorded. Completion thyroid surgery was excluded from this study.

The reasons why some patients were planned as inpatient rather than day case were based on the availability of someone to drive them home after the operation, as well as the patients’ relevant co-morbidities.

The parameters recorded about these patients include: age, gender, American Society of Anaesthesiologists (ASA) score, day of discharge, indication for surgery, postoperative emergency room visit within one month (and reason), postoperative readmission to hospital within one month (and reason) and postoperative complications. Patients with intraoperative complications and additional procedures were noted and included in this study. The reason why ‘planned day case patients’ were not discharged on the day of surgery was also recorded.

Drains were used for nine patients, seven of which were for planned inpatients.

Results

A total of 180 hemithyroidectomies were performed. Of these 35(19.5%) were planned as inpatient procedures and 145 (80.5%) were planned as day case procedures. Of these 145 patients, only 106 (73.1%) were ‘same-day discharges’.

Thirty-nine (26.9%) of the ‘planned day case group’ admitted to hospital overnight; 37 (95%) of which were discharged on the next day. Of these 39 admitted patients, 11 (28.2%) had been converted to inpatient procedures perioperatively and 28 (71.8%) had been told postoperatively ‘home later if well’. The reasons why these 28 ‘home later if well’ patients were not discharged on the day of surgery include: seven (25%) for pain relief, five (17.9%) feeling unwell, three (10.7) for lowered oxygen saturations, three (10.7%) for nausea and vomiting, three (10.7%) for patient preference, one (3.5%) for high temperature, two (7.1%) for hypertension, one (3.5%) for an irregular ECG, one (3.5%) to monitor calcium levels, one for confusion and one (3.5%) because they had no one to stay with overnight until the day after the operation.

Eight (5.5%) of the planned day case patients had additional procedures, including two (1.4%) isthmusectomies, one (0.7%) level 6 lymph node dissection, one (0.7%) lymph node excision, three (2.1%) panendoscopies and one (0.7%) direct laryngoscopy.

Postoperatively, six (4.1%) planned day case patients had wound infections, none had vocal cord palsies, none had compressive haematomas, none had symptomatic hypocalcaemia and seven (4.8%) presented to the emergency room (Table 1). The reasons for presentation to the emergency room included: two (1.4%) for wound breakdown, one (0.7%) for pain management, two (1.4%) wound infections and one (0.7%) cardiac arrest.

This cardiac arrest, which resulted in the death of one of the patients in this study, was a 49-year-old lady who was known to have a BMI of 43 as well as a blood pressure of 183/99 in her left arm on preoperative assessment. She had no intraoperative complications or additional procedures and was discharged on the same day as the procedure. Her ASA score was 2, meaning that she had mild systemic disease. ¹² The cardiac arrest resulted from a chronic deep vein thrombosis (DVT) which only became apparent after surgery. The postmortem examination revealed that the surgery was not responsible for the DVT or its movement, and the DVT could not have been identified preoperatively. Rapid mobilisation of patients postoperatively is thought to be prophylactic for deep venous thromboemboli and hence day case surgery should have a lower incidence of DVTs than inpatient procedures. ¹³

Only one (0.7%) of planned day case patients required readmission to hospital. This patient required readmission for a deliberate paracetamol overdose, and it is known that this was related to mental illness, rather than a desire to medicate pain postoperatively.

The indications for surgery included: 12 (6.7%) biopsy THY 1, 107 (59.4%) biopsy THY 3, 11 (6.1) biopsy THY 4, 38 (21.1%) compressive symptoms and 12 (6.7%) for recurrent cyst.

Conclusion

We conclude that in the hands of experienced surgeons, hemithyroidectomy can be performed safely as a day case procedure. This is based on the 0% incidence of the typically associated life-threatening complications of thyroid surgery found in ‘planned day case patients’ group of this study.

Because a large number of patients require overnight admission (26.9%), we recommend that hemithyroidectomy be classified as a 23 h procedure rather than a day case procedure. This classification would allow most patients to still be done as day case, while accounting for those patients that require an overnight admission, either due to necessity or preference.

Ninety-five per cent (37) of planned day case patients, who were not discharged on the day of surgery, were discharged on the day after the operation. This is suggestive that a 23 h is appropriate. The British association of Day Surgery states that ‘23-hour and short stay surgery apply the same principles of care as day surgery, and can improve the quality of patient care whilst reducing the length of stay’. ¹⁴

The application of patient demographics as exclusion/inclusion criteria is likely to result in a higher percentage of ‘same-day discharges’. In 2008, Dionigi et al. advised that stricter selection criteria be applied for outpatient thyroid surgery. Dionigi et al. advocate that ‘only patients of ASA grades 1--2 must be treated’. ¹⁵ Doing this however would eliminate the vast majority of patients in our study, as only 9.4% of patients in this study had ASA scores ≥3.

There was a higher percentage of ‘planned inpatients’ (74.3%) than ‘planned day case’ patients (63.4%) with ASA scores greater or equal to 2. Although ASA scores are may have a role in determining which patients will be performed as inpatients, there was a relatively small difference between the ASA scores of the ‘planned day case patients’ that were ‘same-day discharges’ and the ‘planned day case patients’ that were not discharged on the same day. A total of 63.2% of the ‘same-day discharges’ and 64.1% of the ‘not same-day discharge’ had ASA scores of ≥2 in the ‘planned day case group’. ASA scores therefore have little application in predicting which ‘planned day case patients’ are likely to require an overnight stay.

Other studies such as that of Lacroix et al. in 2014 apply such vigorous exclusion criteria that they would eliminate almost three quarters of the hemithyroidectomies performed during the study period. One of the criteria that they use to eliminate patients is ‘age >55’. ¹⁰ The number of ‘planned day case patients’ aged under 55 in our study is 106 (73.1%). If we apply the age >55 exclusion criterion, then the number of same-day discharges as a percentage of ‘planned day case’ procedures rises from ‘73.1%’ to ‘79.2%’. Age can also be helpful in predicting which ‘planned day case patients’ are likely to actually be discharged on the same day and which will require admitting overnight. The difference between the average age of those ‘planned day case’ patients that were discharged on the same day (44) and those that were not (53.2) was 9.2 years (Table 2).

Larger studies should follow this one in order to confirm our findings. Although no planned day case patients developed life-threatening complications in this study, this does not prevent their occurrence in larger studies. For thyroidectomies as a whole, the incidence of postthyroidectomy haemorrhage is between 0.25 and 1%. This exemplifies the importance of a larger study. Performing thryoidectomy as a 23 h procedure is likely to have a lower incidence of mortality from haemorrhage, as between 80 and 90% of haemorrhages occur before 24 h. ⁹ Exclusion criteria should also be further investigated by other studies, with the aim of further minimising postoperative haemorrhages.