TORONTO — Thyroidectomy can be safely and effectively done on an outpatient basis and at a lower cost than in the hospital, according to results from a prospective, nonrandomized trial presented at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.
Dr. David J. Terris of the Medical College of Georgia, Augusta, presented the results of the 91-patient study. He noted that while minimally invasive techniques have made it possible to perform thyroid removal on an outpatient basis, most surgeons have continued to keep patients at least overnight for observation for complications such as laryngeal nerve damage, airway compromise, and hypoparathyroidism.
Dr. Terris and his colleagues at the medical college enrolled consecutive patients who had thyroidectomy from 2004 to 2005. Patients either had conventional surgery using a Kocher incision, minimally invasive surgery, or endoscopic thyroidectomy.
Overall, 42 patients had a hemithyroidectomy, 38 a total thyroidectomy, and 11 a completion thyroidectomy. Of the 91 patients, 76 were women and 15 were men; the mean age was 46 years. The surgery was performed on an outpatient basis in 52 of the cases and as an inpatient procedure in 39. A procedure was considered inpatient if the patient was observed for at least 23 hours. If a patient had significant comorbidities or required a surgical drain (for a large lesion), he or she was offered an inpatient procedure. Patients who requested admission also were placed into the inpatient arm.
Outpatients were discharged as soon as they were ambulatory and could manage the pain. They were told to seek medical help if they had symptoms such as respiratory compromise or hypocalcemia, and were seen for follow-up 1–2 weeks after thyroid removal.
To deter hypocalcemia, every patient was given a prophylactic regimen of oral calcium carbonate for 3 weeks before the surgery. They took 600 mg three times daily for the first week, 600 mg twice daily in the second week, and 600 mg once a day in the third week.
There was no significant difference in age or gender between the inpatients and outpatients. But the operating room time was shorter for outpatients—102 minutes, compared with 144 minutes for inpatients. Mean estimated blood loss was lower in the outpatient group, at 18 mL, compared with 29 mL for the inpatient arm.
Two patients in the hospital group had complications, including hypocalcemia. One outpatient was anxious after being discharged and returned to the hospital where she was admitted. There were no hemorrhages or expanding hematomas.
Surgeons often argue that thyroidectomy must be done on an inpatient basis so drains can be placed postsurgically to prevent hematomas that might block the airway, Dr. Terris said. But new ultrasonic technology that creates an almost bloodless surgical field reduces the risk of expanding hematomas and makes it possible to decrease reliance on surgical drains. That makes outpatient surgery more feasible, as the Georgia study demonstrated, he said.
The study also showed that giving patients calcium before surgery also curbs the risk of hypocalcemia, he added.
Another argument favors outpatient thyroidectomy. The mean charge was lower: $7,800 for outpatient surgery, compared with $10,200 for inpatient surgery.