The Journal of Clinical Endocrinology & Metabolism Vol. 83, No. 4 1103-1105
Copyright © 1998 by The Endocrine Society
The Choice
Arthur E. Schwartz, M.D.
Mount Sinai School of Medicine
City University of New York
New York, New York 10028
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Introduction
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HOSPITAL stays are becoming shorter. This
particularly applies to surgical procedures. The driving force is
economic pressure exerted by government-sponsored programs and
for-profit health organizations. The results have been beneficial
overall; patients leave the hospital earlier, and in most cases are
happy to do so. In general the quality of care has not suffered.
The maximum benefit of this movement, however, has probably been
achieved. Further pressure to reduce hospital stays is producing a
backlash, as evidenced by legislation to insure a minimum stay for
postpartum patients and growing complaints that patients are being
forced out too early.
Hospital stays for thyroid and parathyroid surgery have also decreased.
Experienced surgeons like Dr. Lo Gerfo now advocate outpatient handling
for these procedures because it is more cost-effective, more
convenient, and equally safe. Dr. Clark and Dr. Ituarte disagree,
cautioning that this method is not safe and that the savings do not
warrant the risk.
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Conflicting points of view
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In the accompanying Therapeutic Controversy, Dr. Lo Gerfo points
out that most patients who bleed postoperatively manifest evidence of
it within 4 h after surgery and that the problem can be easily
controlled under local anesthesia. If there is need for further
observation the patient is admitted overnight. This was the case in 5%
of his experience. Hospital stays for his patients have decreased to
less than 8 h, often less than 6.
Dr. Lo Gerfo believes that much of his success is the result of the use
of local and regional anesthesia, which, he states, results in less
postoperative pain and nausea. He trains patients to medicate
themselves with calcium and vitamin D for possible postoperative
hypocalcemia, facilitating their postoperative care. During 1996 he
performed 80 thyroid and parathyroid operations, 45 under local
anesthesia, and did not have to re-admit any patient.
Dr. Clark and Dr. Ituarte point out, in their contribution to this
discussion, that postoperative bleeding into the closed space of the
neck is life threatening. In their experience 75% of bleeding occurs
within 6 h of surgery, but 25% occurs from 7–24 h after surgery.
Those who advocate ambulatory surgery advise keeping patients in the
surgical care unit only 6–8 hours after the operation.
They also cite studies demonstrating that the savings are less than
they seem. The major portion of hospital cost involves the use of the
operating room and the recovery care unit; the additional expense of
observing the patient overnight is minimal. Furthermore, if outpatient
surgery patients are to be discharged during the day, preferential
scheduling is required, which may be disruptive for others.
Nausea and vomiting occurred in approximately 50% of their
patients, conditions that can be controlled more satisfactorily in
a hospital setting. Hypocalcemia with the risk of tetany usually
appears early, but can sometimes present later. When it occurs, urgent
attention is required. The median duration of patient hospitalization
was 1.2 days. It is the belief of Dr. Clark and Dr. Ituarte that this
period of hospitalization makes the difference between safe
inpatient surgery and ambulatory surgery that is dangerous.
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Incision
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Dr. Lo Gerfo employs a 3–4 cm incision high in the neck at
the level of the hyoid bone, stating that, since the superior pole
vessels are constant at this level, he is able to divide them early and
bring the thyroid gland up into the incision. This enables him to avoid
a lower, longer, and in his opinion, less cosmetic incision. I find
this method useful in only a minority of patients because it does not
offer enough visibility of the structures requiring careful dissection.
A thyroid of any significant size requires mobilization of the lower
portion of the gland. When this is performed without sufficient
visualization there is risk of tearing blood vessels and producing
hemorrhage that cannot be easily controlled. If the gland is
adherent to adjacent structures the problem is compounded. Even if the
thyroid appears mobile on preoperative physical examination,
adhesions may be moving upward with the gland, engendering a false
sense of security. A longer and somewhat lower incision in a crease
line of the neck makes it possible to perform the surgery under direct
vision. The cosmetic result is still excellent. For surgeons who are
not as skillful or experienced as Dr. Lo Gerfo (and this constitutes
most who are doing the work), direct visualization is safer.
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Local anesthesia
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Dr. Lo Gerfo states that 50% of his thyroid surgery is performed
under local and regional anesthesia. He maintains that this method
reduces postoperative nausea and pain, facilitating early discharge. I
have used local anesthesia for some neck procedures and for breast
surgery. Although I have not used local anesthesia for thyroid or
parathyroid surgery, I have had the opportunity to watch others do so.
This method requires a cooperative and stable patient. These qualities
cannot always be reliably predicted. In major head and neck procedures,
conversion from local to general anesthesia is a formidable endeavor
should the patient develop nausea, vomiting, or become unable to
tolerate the procedure. The requisite endotracheal intubation becomes a
difficult task; it requires discontinuation of the operation, removal
of the drapes, and after intubation, a repeat preparation and redraping
of the skin. Performing the operation under general anesthesia offers
the comfort of knowing that the patient is asleep, with a reliable
endotracheal airway in place and an indwelling gastric tube to protect
against vomiting.
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Neck closure
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Dr. Lo Gerfo states that he closes only the upper portion of the
strap muscles to assure that postoperative bloody drainage will not be
trapped against the trachea. Fluid then drains into the subcutaneous
space, making it easier to detect. Blood, however, does not remain
liquid. The usual finding on re-exploration for bleeding is a mixture
of clotted and liquid material. This means that clots may block the
egress of fluid. Failure to close the strap muscles allows the
possibility that the trachea will adhere to the overlying skin,
producing an ugly indentation that moves up and down with
swallowing.
I prefer to place a suction drain in the bed of the resected thyroid
lobe if I have any concern that hemostasis is not secure. Because there
may be clotting, this is no guarantee that all blood will be evacuated.
It does, however, take care of most bleeding. Monitoring the drainage
offers a guide to the amount of hemorrhage.
There is no infallible way to protect against the disastrous
effect of postoperative bleeding into the neck. Vigilant observation by
trained personnel is the patient’s best guardian.
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Hypocalcemia
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Dr. Lo Gerfo has advanced the management of postoperative
hypocalcemia following thyroidectomy and parathyroidectomy by educating
his patients to diagnose and treat their own hypocalcemia. They are
provided with calcium tablets at their bedside and vitamin D, as
needed. He states that he does not obtain serum calcium levels, even if
the patients are symptomatic, until the seventh postoperative day. By
that time he finds that most are asymptomatic.
I prefer the old fashioned way; I believe that knowing the status of
the serum calcium tells me where I am and can warn of trouble to come.
Calcium levels of patients who have had hemithyroidectomy are not
routinely followed, but patients having total thyroidectomy and those
who have had resections for parathyroid hyperplasia or recurrent
hyperparathyroidism are monitored twice daily. Supplemental calcium or
vitamin D is administered as required, under careful nursing
supervision.
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Economics
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The greatest pressure to perform outpatient surgery is generated
by the desire to save money. There are savings, but not as great as
might be expected.
The major portion of the cost is the use of the operating room and the
recovery suite—the same as inpatient surgery. The remaining cost is
that of maintaining the patient in a hospital bed overnight, which is
determined by the general room rate of the hospital. Routine nursing
costs are semivariable because, in general, nurses are already present
on the floor. In a recent study by Moschenson and Hodin (1), the
savings of ambulatory surgery was 30% of the overnight procedure.
At Mount Sinai Hospital, in New York City, the average inpatient cost
for my last seven thyroidectomies was $3,125. The calculated cost for
these procedures, if they had been performed on an outpatient basis,
would have been $2,718, a savings of 13% (Scanlon, D., Vice President,
Finance, Mount Sinai Hospital, personal communication).
Cost of inpatient surgery $3,125
(seven consecutive patients) Calculated
cost $2,718 (if performed as
outpatient) Savings $407
(13%)
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Postoperative bleeding
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The most serious criticism of ambulatory surgery is the risk of
hemorrhage in a situation where it cannot be controlled. Bleeding into
the neck postoperatively creates pressure in a closed space that can
threaten the airway and the life of the patient. In a hospital setting
with close monitoring, experienced personnel can open the wound and
preserve the airway. If bleeding occurs where trained help is not
available, the result can be catastrophic.
The incidence of postoperative hemorrhage requiring return to the
operating room is 0.5–1%, as cited by Dr. Clark and Dr. Ituarte.
Seventy-five percent occurs within 6 h, and 25% within 7–24 h.
However, late hemorrhage can also occur.
It is the threat of postoperative bleeding in a closed space, with its
devastating effect on the airway, that constitutes the most compelling
criticism of ambulatory surgery.
Dr. Lo Gerfo is correct in stating that most bleeding can be
anticipated and controlled during a 6-h period of observation. But not
all. And that is the concern. He presents a series of 67 cases managed
in this way, though 5% were kept overnight for further observation.
The ability to evaluate the patient for discharge after 6 h and to
retain those who are a concern provides a safety valve. But is this
sufficient?
Late bleeding, though infrequent, can occur. Dr. Kaplan (2) cites a
patient who bled severely 24 h postoperatively and would have been
a fatality if she had not been in the hospital. Several years ago, I
performed a routine thyroidectomy on a college student. No problems
were encountered postoperatively, but at midnight at the end of the
first postoperative day, I received a call that the patient’s neck was
distended and he was having difficulty breathing. I rushed to the
hospital to find him in the operating room. The resident had performed
an emergency tracheotomy. Bleeding was controlled; the patient was
discharged a few days later. If this had occurred at home the outcome
would have been tragic. The patient would have become an unfortunate
statistic and an almost certain lawsuit.
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Patient convenience
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The ability of the patient to return home the day of surgery is
advanced as a benefit of ambulatory surgery. This requires surgery to
be performed early in the day, not always possible without offering
preferential scheduling to these patients and inconveniencing others.
The head and neck surgeon may not always be able to command early use
of the operating room.
What is the home condition to which the patient returns? Does he
or she live alone? Is there a concerned and competent family who will
provide comfort and care? Are they able to take care of problems of
pain, nausea, or vomiting? Are they qualified to observe for neck
swelling and prepared to act promptly to manage the situation quickly
and effectively?
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The crux of the issue
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In evaluating the advantages and risks of outpatient
thyroidectomy, it becomes obvious that the driving force is economic. A
savings of 13–30% in hospital cost accrues to HMO’s and insurance
companies. There is no economic benefit to the patient.
Economy is not cheap. In this case the cost is decreased patient
safety. Let us weigh the choice carefully.
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References
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Mowschenson PM, Hodin RA. 1995 Outpatient
thyroid and parathyroid surgery: A prospective study of feasibility,
safety, and costs. Surgery. 118:1051–1054.[Medline]
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Kaplan E. 1995 In: Mowschenson PM, Hodin RA:
Outpatient thyroid and parathyroid surgery: A Prospective study of
feasibility, safety, and costs. Surgery. 118:1051–1054.\.
Top
Introduction
Conflicting points of view
