Outpatient thyroid surgery safe for most patients, study shows

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With careful selection, 52 of the patients, or 57 percent, were able to leave the hospital about two hours after surgery, according to the study being presented during the 110th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology-Head and Neck Surgery Sept. 17-20 in Toronto.

Of the patients operated on at MCG Medical Center and the Veterans Affairs Medical Center in Augusta, Ga., between December 2004 and October 2005, 26 were kept in the hospital just under a day and 13 were admitted.

Smaller incisions, reduced use of surgical drains and prophylactic calcium supplementation have enabled thyroid surgery - which just a few years ago required a four-inch neck incision and several days in the hospital - to be done safely on an outpatient basis, Dr. Terris says.

"Three or four years ago, the dissection we did, raising skin and muscle flaps and cutting muscle to get the thyroid gland out, meant we had to put a drain in and we had to watch patients carefully overnight or for two or maybe even three nights," he says. "Now that we are doing much less dissection, many patients can go home the same day.

"There are advantages to patients convalescing in their own bed with their own food and their loved ones around," he says. The shortened stay also reduces the risk of hospital-borne infections.

Dr. Terris, a pioneer in minimally invasive and endoscopic thyroid surgery, now typically operates through a three-quarter-inch incision and doesn't use drains. In fact, up to 70 percent of his patients, who tend to be otherwise healthy young women, are candidates for outpatient surgery.

Obvious exceptions include patients whose diseased thyroids are too big to remove through a small incision - typically the same patients who still need drains - and those with complicating medical conditions such as heart disease.

Patients whose entire thyroid needs to be removed also have been a concern because of the potential for major drops in calcium levels following surgery. Calcium helps muscles contract and a deficiency may cause tingling in the lips, fingertips or toes; muscles may even stay contracted; and heart problems can eventually result, Dr. Terris says.

While the thyroid regulates metabolism, the parathyroid glands, which sit just behind it at the base of the neck, regulate critical calcium. "We gently, carefully dissect the thyroid away from the parathyroid glands and try not to injure them but there is always a chance that one or more glands could be injured temporarily or permanently," Dr. Terris says.

Work at Harvard University about a decade ago showed prophylactic calcium supplementation could help reduce hospital stays to about two days, which was short at that time. "In the old days, you would monitor calcium levels multiple times after surgery and, when it seemed to plateau, you'd figure it was OK to send patients home," Dr. Terris says. "If it didn't plateau, we'd put them on a calcium supplement and send them home." He now routinely prescribes a three-week tapered dose of calcium supplement beginning the day after surgery regardless of length of hospitalization.

Drains also are becoming rare. Dr. Terris considered using fewer drains as his incisions got smaller, but there also is mounting scientific evidence, including nine randomized studies, showing drains rarely improve outcomes. "We still use drains when somebody has a really big gland and we are going to have what we call dead space when we remove it. If you have this big open space, there is a tendency for fluid to fill that space, so we put a drain in for 24 hours," he says.

Dr. Terris reiterated that while outpatient surgery is a logical next step in the evolution of thyroid surgery, careful patient selection is essential. "We don't just send everybody home," he says. The fact that the patient feels uncomfortable leaving the hospital that quickly is reason enough for him to stay longer than two hours, he says.

Co-authors on the study include Brent Moister, medical student; Dr. Melanie W. Seybt, otolaryngology resident; Dr. Christine G. Gourin, otolaryngologist; and Dr. Edward Chin, endocrinologist, all from MCG.

Medical College of Georgia