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UCSF Mount Zion, Department of Surgery San Francisco, California 94143-1674
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Introduction |
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What are the reasons for ambulatory thyroid surgery? The advocates of this approach document a lower cost (1-4). We would volunteer that patients seem to do better and do not become as sick when they become aware that they will be well enough to go home soon after surgery. We discuss with our patients, before their operations, what they should expect during and after their operative procedures. We inform them that they are almost always well enough to go home the same day as the operation, but they must spend one night in the hospital in case they have bleeding which would require drainage of a neck hematoma. We also discuss the risks and benefits of the procedure. Some surgeons who advocate ambulatory care thyroidectomy may recommend this approach as a marketing ploy to recruit more patients for thyroid operations from the insurance providers.
What are the reasons against ambulatory thyroid surgery? First and most important is that patients after thyroid operations can develop life threatening complications such as hemorrage, laryngeal edema, and tetany (2, 3, 6, 7, 8). When patients who develop these uncommon problems are treated emergently the results are almost universally satisfying, whereas when there is delay in treatment, death may occur from hypoxia and cardiac arrest or brain death. Second, following thyroid operations, patients are frequently nauseated and may vomit (9). Others may have difficulty voiding. These situations are best addressed in the hospital, and in most patients, these conditions usually resolve by the morning after the surgical procedure. Most thyroid operations today are performed under general anesthesia, narcotics are limited to decrease the frequency of nausea and vomiting, and antiemetics are prescribed liberally (9). Advocates suggest that ambulatory thyroid surgery is simple, easy, and less expensive (8). They recommend it for patients having thyroid operations, just as they do for patients having operations for hernias, hemorrhoids, and gallbladder disease. Although the duration of hospitalization is shorter by plan when an ambulatory approach is used, the cost for a prolonged recovery in the ambulatory center is often expensive, and the operation and postoperative care are, often, neither simple nor easy.
In this paper we will briefly review some history relating to thyroid operations that we believe is pertinent for proper patient care, and then we will report the frequency of postoperative nausea and vomiting despite attempts to prevent these unpleasant symptoms that can increase the risk of postoperative bleeding. We will also review some of the articles relating to ambulatory and "short stay" thyroid surgery. We will conclude by analyzing the increased risk we believe patients would be exposed to if hospitalized for only 6 h after thyroidectomy.
Thyroid operations were not always as safe as they are today. The mortality rate of thyroid operations until the mid-nineteenth century was over 40% including 8 of the first 20 patients treated by Theodore Billroth (10). It is therefore not surprising that the surgeon Robert Liston, who had performed five thyroid operations, stated in 1846 that "there was a grave risk of death from hemorrhage during thyroid operations and that it was a proceeding by no means to be thought of" (10). John Dieffenbach, a surgeon from Berlin, stated in 1848 that thyroidectomy was "one of the most thankless, and most perilous undertakings" (11). Thyroid operations were condemned by the French Academy of Medicine in 1850 (10). The introduction of general and local anesthesia, antisepsis, better surgical equipment, and more surgical experience during the second half of the nineteenth century contributed to the dramatic improvement in operative results. For example, Theodore Kocher in 1880 reported that the mortality rate for the 146 patients who had thyroid operations worldwide had fallen from 41 to 21% (12). By 1905, Charles Mayo from the Mayo Clinic reported an operative mortality of 3%, and Kocher reported a death rate at this time in his own patients of 0.2% (13). Beahrs et al. (13) reported the mortality rate during a 10-yr period from 1946 to 1955 at the Mayo Clinic was 0.1%. We have had 1 death among about 2000 consecutive patients having thyroid operations. This occurred in an 80-yr old woman with anaplastic thyroid cancer.
The operative results for patients with toxic and nontoxic goiter as well as for thyroid carcinoma continued to improve, although complications such as hypoparathyroidism were reported to occur in more than 50% of patients after total thyroidectomy at the Mayo Clinic in the 1950s (13). Other centers reported that hypoparathyroidism occurred in more than 20% of their patients having total thyroidectomy for thyroid cancer (14, 15). More recent reports have documented that complications that can occur during thyroid operations, such as hypoparathyroidism and injury to the recurrent laryngeal nerve, now occur in about 1% of patients having total or near total thyroidectomy for thyroid cancer by experienced surgeons in this field (16-19). Bleeding is also an infrequent postoperative problem, about 0.75%, but can cause hypoxia and death unless treated emergently with evacuation of the hematoma (7). Although most postoperative bleeding occurs within 6 h of the operation, patients have died because of a postoperative neck hematoma that occurred after 6 h (7, 20). Other postoperative problems that could be life threatening if not recognized and treated emergently include profound hypocalcemia with tetany, bilateral vocal cord paralysis, laryngeal edema, thyroid storm, and tracheal malacia. Although these complications are rare they must always be considered, and identifying patients who might develop such complications is not always possible.
The basic rule we should all follow when treating our patients is to treat them the same way we would like to be treated. Although we have advocated early discharge after thyroid and other operations, and our mean and median duration of hospitalization is 1.2 days after thyroidectomy, we are strongly opposed to ambulatory thyroid surgery because we believe it is dangerous. We know from reviewing the literature and from analyzing our own experience that about 1 in 100 up to 1 in 500 patients will have a post operative bleeding episode that requires an urgent or emergent return to the operating room (2, 4, 6, 7, 20). Such bleeding can be initiated by severe vomiting or coughing, but may occur on its own. Occasionally it is necessary to open the incision or wound in the recovery room or on the ward because of acute respiratory distress. A surgical maxim is that a patient having respiratory distress after a thyroid operation has a neck hematoma until proven otherwise. Until recently in many hospitals tracheostomy sets were kept at the bedside of patients who had thyroid operations. There must have been some reason why this precautionary measure was instituted.
We recently did a prospective study in 118 Anesthesia Society Assessment patients, physical status I and II, age 18 yr and older, to determine the incidence of postoperative nausea and emesis after thyroid and parathyroid operations (9). Patients received either isoflurane or propofol for maintenance of anesthesia. All patients also received propofol for induction of anesthesia, succinylcholine or vecuronium, nitrous oxide, and fentanyl. Postoperative pain was treated with ketorolac, fentanyl, or acetaminophen. Overall, 54% of our patients experienced nausea and or vomiting during the 24-h postoperative period. Postoperative nausea and vomiting was more common in patients receiving isoflurane than propofol for maintenance of anesthesia (64 vs. 44%). Women receiving isoflurane experienced more postoperative nausea and vomiting than those receiving propofol (71 vs. 42%). Interestingly there was no difference in postoperative nausea and vomiting in men receiving either isoflurane or propofol (47 vs. 50%). These studies document that nausea and vomiting are frequent sequelae after thyroid and parathyroid operations, and better agents must be developed to prevent it. All patients in this study were discharged on the first postoperative day, except one who experienced both nausea and vomiting and developed a hematoma that required reoperation. This patient was discharged on postoperative day two (9). Interestingly Marohn and LaCivita (2) recently reported a similar experience in 150 patients having total or near total thyroidectomies who were hospitalized for 23 h. One of their patients also developed a postoperative hematoma that required emergent evacuation. At reoperation a ligature had apparently became dislodged from the left middle thyroid vein. The average duration of hospitalization of their patients was 1.06 days (2). McHenry (4) also recently reported his results in 71 patients having thyroidectomy and 23-h hospitalizations. One of his patients developed a neck hematoma, 2 developed recurrent nerve paresis, and 8 developed transient hypocalcemia. One other patient required rehospitalization for anxiety possibly due to hypocalcemia.
Steckler (21) in a feasibility study was the first to report in 1986 that outpatient thyroidectomy could be done safely (3). Lo Gerfo et al. (1) have also been advocates for this approach. He and his colleagues reported that outpatient thyroidectomy could be done safely in selected patients as he demonstrated in 134 patients (1). Mowschenson and Hodin reported their results in 61 patients having outpatient thyroid operations (3). Although no patient required readmission, 2 patients were seen in the emergency room, one for anxiety and one for transient hypocalcemia. Samson et al. (8) compared the overall results of inpatient and outpatient thyroidectomy in 1178 patients having thyroid operations (809 as outpatients and 369 as inpatients). One 49-yr-old woman who had an outpatient thyroidectomy apparently died of "postoperative toxic crisis" from "an unrecognized toxic goiter" (8). Although the authors remain advocates of outpatient thyroidectomy, this patient might have had a better outcome if she were observed in the hospital overnight and appropriately diagnosed and treated.
To analyze whether there is an increased risk of death after ambulatory care thyroidectomy, that is, with about 6 h of hospitalization after thyroidectomy compared with patients hospitalized 23 or 24 h, we used data from an article by Foster (7). He reviewed the records of the Professional and Hospital Activities concerning 24,108 thyroid operations performed in 1970. This was estimated to include about one third of all thyroidectomies performed in the United States that year. During this time patients were usually hospitalized for at least several days. Overall there were 72 deaths following thyroidectomy among the 24,108 patients, or 0.3%. Mortality was less than 0.1% for those younger than 50 yr of age and 2% for those 70 yr of age or older.
Using decision analysis (22) we compared the potential mortality
outcomes of two time periods for patients following ambulatory thyroid
surgery, 0–6 h postthyroidectomy (with hospitalization) vs.
7–24 h (without hospitalization) postthyroidectomy. We estimated death
rates per 100,000 operations and assumed that 75% of bleeding would
occur within the first 6 h postthyroidectomy and 25% during the
period from 7–24 hours. We also assumed that 0.75% would have enough
bleeding to require a reoperation to evacuate a hematoma, (data
extrapolated from Foster) and, if treated within 6 h or 24 h,
98% of patients would survive, whereas if released and not treated
within 7–24 h, approximately 50% would die (Table 1
).Using these numbers there would be approximately 94 hemorrhage related
deaths per 100,000 thyroid operations that could be prevented with 24
vs. 6 h postthyroidectomy hospitalizations. Other
complications such as vocal cord paralysis, tetany, thyroid storm, and
tracheal malacia are not included in this number; although these
postoperative complications are rare, they could certainly make the
situation worse.
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