Day-case thyroid surgery

In 2000 the National Health Service in England set the target that 75 per cent of all elective surgical procedures should be undertaken on an outpatient basis1. Given the usually limited physiological insult and good analgesic control achievable, thyroidectomy appears a suitable addition to the list of recommended day-case procedures. With the arrival of haemostatic technologies that allow bloodless thyroid surgery and anaesthetic techniques that minimize postoperative hangover, the argument in favour of day-case thyroidectomy seems overwhelming. However, although over 25 years have passed since ambulatory thyroid surgery was first described2 and it is a decade since the British Association of Day Surgeons added thyroidectomy to their ‘basket’ of day-case procedures, ambulatory thyroid surgery still accounts for fewer than 1 per cent of thyroidectomies in the UK3. A similar picture appears to prevail in mainland Europe and there remains no consensus on selection criteria for this approach4,5. During periods of economic pressure on healthcare systems, hospital management may legitimately question why patients undergoing thyroidectomy cannot be discharged on the day of their surgery to improve cost-effectiveness. Most of the evidence supporting day-case thyroidectomy comes from North America, where data suggest that the approach is clearly feasible and outcomes encouraging. However, the numbers of patients involved represent a proportion of all thyroidectomies performed nationally that is difficult to quantify6–9. The selection criteria for day-case thyroid surgery are not well defined, but there appears to be a disproportionate number of young and healthy white patients with health insurance in a recent US statewide review10. Some series may be subject to the criticism of being liberal with their definition of day surgery. Indeed, discharge may be to a hotel or other low-intensity care facility rather than to the patient's own home. This, and inevitable publication bias, results in limited knowledge about the effectiveness of same-day discharge following thyroidectomy. In particular, there appear to be few data on outcomes in patients experiencing complications after thyroidectomy, with some complications notable by their very low incidence or complete absence in nearly all published single-centre series. In addition to the generic complications that may follow any general anaesthetic surgical procedure, thyroidectomy is associated with three specific postoperative risks: hypoparathyroidism, recurrent laryngeal nerve palsy and postoperative haemorrhage. Only recently with the publication of national endocrine surgical registries has the true incidence of post-thyroidectomy complications become clearer11,12. Recurrent laryngeal nerve paralysis occurs after 1–2 per cent of thyroidectomies and is seven times more common following reoperations. Airway-compromising bilateral nerve injury is rare (0·2 per cent)12 and is apparent immediately after surgery. Postoperative hypocalcaemia occurs in up to a sixth of cases11,12, but the risk of clinically significant hypocalcaemia is much lower, and the condition is treatable and rarely life-threatening if appropriately managed. Furthermore, there are accurate predictors of high risk for hypocalcaemia13,14, which, if available and employed appropriately, allow prevention or timely intervention with prophylactic or therapeutic calcium and vitamin D supplementation2,6,7. It is the third potential complication, postoperative airway-compromising haemorrhage, that makes thyroid surgery unique among the list of approved day-case operations in that hypoxic brain injury or death may result in minutes rather than hours without prompt intervention. Post-thyroidectomy haemorrhage with associated laryngeal oedema and airway compromise occurs after 0·9–2·1 per cent of all thyroidectomies12. A quarter of these patients require immediate life-saving neck decompression15 and 0·3 per cent may require a tracheostomy16. Mortality from inpatient postthyroidectomy bleeding is unknown, but the 30-day mortality rate after thyroid surgery in the UK is at least one in 50011, equivalent to a minimum of 20 deaths per annum. It is a fair supposition that a proportion of these deaths are attributable to postoperative bleeding. The key question is whether discharging patients home a few hours after thyroidectomy will increase the risk of death, or whether patients at risk of bleeding can be identified and excluded from the day-case pathway. In addition, can systems realistically be put in place that make the sequelae of an adverse outcome—hypoxic brain injury or death—no more likely if a significant bleed occurs at home rather than in hospital? Certain situations, such as thyrotoxicosis, concomitant lateral neck dissection, retrosternal goitre and recurrent disease, are unsuitable for short-stay surgery let alone same-day discharge4. Current evidence suggests that, beyond experienced clinical judgement, reliable and reproducible patient- and disease-specific criteria to risk stratify patients specifically for postoperative bleed risk after thyroidectomy remain elusive. Although readmission is frequently quantified, to the authors' knowledge no published day-case thyroidectomy series has specifically discussed the sequelae of a major bleed that occurs at home following discharge. An emergency room visit rate and readmission rate of 7·8 and 2·3 per cent respectively seem typical7,10, but a total bleed rate of just 0·2 per cent in a statewide review of over 1000 thyroidectomies is either a reflection of the high-volume surgeons involved in this series or a reflection of under-reporting. Indeed, the incidence of bleeds documented in national registries and two separate reviews of around 7000 patients each demonstrate significantly higher bleed rates and the fact that over half of all post-thyroidectomy bleeds occur after 6 h15,17. Furthermore, given that a quarter of all postoperative bleeds are known to be of such severity that they require bedside decompression, the outcome after experiencing such a bleed while at home is unlikely to be good. Inpatient costs represent a significant proportion of the total cost of surgery, so same-day discharge offers desirable cost savings. Approximately 30 per cent can be achieved by performing thyroid surgery as an outpatient7–9. However, any potential savings need to be balanced against additional patient risk and potential litigation costs incurred following a statistically predictable serious complication at home. Until the incidence of postoperative bleeding can be eliminated, or robust criteria that allow prediction of patients at risk of life-threatening haemorrhage after thyroidectomy are identified, the risks of discharge home 6–8 h after thyroidectomy outweigh any financial benefit in mainstream surgical practice. Given that nearly all significant post-thyroidectomy bleeds occur within 24 h of surgery, for the time being a target of 23-h surgery with one night in hospital should be an achievable and safe compromise. The authors declare no conflict of interest.