The healthcare system is under increased scrutiny to reduce costs without undermining the quality of patient care. Patient comfort and economic considerations have had a significant impact on the evolving trend towards ambulatory surgery. In head and neck surgery, SDT surgery has gained popularity for its potential to enhance postoperative recovery and patient satisfaction, whilst favoring the reallocation of resources . However, given the potentially serious complications of thyroid surgery in the early postoperative period, a need arose for greater guidance to support best practices and appropriate postoperative management while ensuring patients’ safety [15–18].
In select patients, the practice of SDT surgery has been supported by the American Thyroid Association and the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS) [3, 19]. Despite the risk of postoperative complications, studies have suggested that serious adverse events in SDT surgery could be treated promptly and effectively [8, 20–22]. The CSOHNS guidelines for SDT include: “Patient Factors, Social Situation, Final Check [physical examination and laboratory results postoperatively], and Protocol [verbal and written instructions to seek medical attention]” . In this study, we sought to examine the safety profile of these guidelines in SDT surgery and searched for the existence of factors predicting complications or adverse outcomes.
We observed that select patients could be safely discharged on the same day as their thyroid surgery when the procedure was performed by experienced thyroid surgeons [8, 20–24]. The SDT postoperative complication, 30-day ED visit and readmission rates were lower than for the inpatient population group, and fewer patients required calcium supplementation for symptomatic hypocalcemia. The remaining outcomes, including cervical hematoma, recurrent laryngeal nerve injury and 30-day reoperation did not reach statistical significance.
Access to medical care for the SDT group was adequate for those who returned to the ED. None of these patients required readmission or reoperation; they were reassured and sent back home. The most common complaint was paresthesia with normal serum calcium levels. Another common concern regarded erythema at the surgical site without evidence of infection.
Previous studies observed that inpatient thyroid surgery could in fact correlate with an increased risk of postoperative complications [4, 25]. These results may be explained by the difference in demographics and comorbidities between SDT and inpatient groups. A younger and healthier population may be at a lesser risk of developing postoperative complications and adverse reactions to general anesthesia. Moreover, the extent of surgery (total vs hemi-thyroidectomy) may also have had an impact on morbidity, as total thyroidectomy requires more dissection and hemostasis, and increases the risk of RLN and a parathyroid gland injury. In our study, the majority of patients undergoing a total thyroidectomy remained in the hospital. As a result, the difference in complication rates may be attributed to the extent of surgery and not whether the patient remained in the hospital or were discharged the same day. Moreover, the extensive work performed at McGill affiliated institutions and worldwide successfully investigated postoperative management of calcium and parathyroid hormones to predict which patients would require active supplementation [26–28]. Combining that work with this study, surgeons at McGill affiliated institutions will be more comfortable sending a larger percentage of total thyroidectomy patients home the same day.
Common barriers to a same-day postoperative discharge following thyroid surgery can be examined with a biopsychosocial framework. Personal attributes favoring a postoperative admission include the presence of comorbidities leading to an increased perioperative risk of complications. Intraoperative adverse events, drain insertion, episodes of apnea or undiagnosed obstructive sleep apnea, and uncontrolled postoperative pain, nausea or vomiting also ought to be factored in . Similarly, the distance from home to hospital, limited at home caregiver abilities, fear and anxiety are also social and emotional factors that need to be considered . Moreover, planned day surgery patients can ultimately be admitted for postoperative observation and monitoring when there are unexpected peri-operative issues such as excessive bleeding. Conversely, some planned postoperative admissions were discharged the same day either due to patient preferences, favorable early postoperative outcomes and direct access to emergency resources. The ultimate responsibility to discharge the patient on the day of surgery requires flexibility on all fronts. A summary of factors ought to be considered in determining patients’ postoperative pathway is presented in Fig. 2.
There are several limitations to this study that need to be recognized. First, there were changes in practice introduced in 2020 that lasted for several months due to the COVID-19 pandemic: 1) surgeries were delayed or cancelled, potentially allowing for the progression of disease and increasing the risk of nerve adherence and complications, 2) flexible laryngoscopy was delayed, 3) longer intubation times, 4) limited access to hospital ED. Overall, these issues may have led to the under-identification of postoperative complications, to a diminution of self-reported symptoms and to fewer hospital visits for non-emergent complaints. Second, ED visits to institutions other than the surgery-based hospital or McGill University hospital network were not accounted for. Finally, other biases may have been introduced due to the retrospective nature of the study. That is to say, the quality of this study lies in its large sample size which we hope will help diminish the impact of these biases on our findings.