Update Course Rewind: Who to Send Home from the OR #4 Part 2: Partial Thyroidectomy

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia, a research fellow from Cincinnati Children's Hospital Medical Center. In August 2023, we held our annual update course in pediatric surgery. In this session, the surgeons discussed in round table fashion who can go home from the OR on the same day of their procedure. Let's move on to the next topic. Uncomplicated right thyroid lobectomy. Can these patients go home the same day? 16-year-old female with a concerning 1 cm right thyroid nodule on ultrasound undergoes FNA and is found to have atypia of undetermined significance with AZ3. She undergoes a straightforward right thyroid lobectomy. Responses from the surgeons show that approximately 44% would actually keep that patient overnight and discharge home the next day. Approximately 30% would send the patient home on the same day. So, what drives the surgeons to keep patients overnight? What's interesting to me is that we used to leave drains in the neck because of the potential for bleeding. Everyone was afraid the patient would cough or sneeze and then have a massive hemorrhage and choke themselves. So is this not a problem? I think many of the newer energy devices are quite good, whether you use cool seal or if you use ultrasonic energy plus or minus sometimes clipping. There is is data saying that with that, the incidence is much lower. So, can I ask a question then for a right lobectomy or a lobectomy, the issue for sending them home is bleeding because it's not calcium or anything like you might do for a total. Is that is that what you're saying? Yeah. But is there data about bleeding complications following a unilateral lobectomy in adults and or in children? Here's a single institution study, uh 55 pediatric patients undergoing uh thyroidectomy. 36 were total thyroids, lobectomy and 13, some had central neck dissection or lateral neck dissections and all went home after 2 hours. About 10% had transient hypopara permanent was 3.8% for hypothyroidism. they were measuring parathyroid hormone. Um and uh 1.8% had a post-op hematoma requiring reoperation, but that was on post-op day 6. So that kid probably would have been home anyway at that time. So, it seems like same day discharge is definitely possible in this patient population. The America Thyroid Association has actually put out a statement on outpatient thyroidectomy and encourage looking at clinical, social, and procedural factors to determine if the patient is safe for same day discharge. I think they do a really good job in this paper of going through the things you should think about as far as significant comorbidities, ASA class, team approach, pre-op education, social setting of the patient and in this setting parathyroid hormones. So, do you do this? Do you send your thyroids home the same day after reading all this? So, some selective ones I do. While not every patient is suitable for same day discharge, both thyroid lobectomy, it seems that properly identify those patients that are suitable prior to the procedure is key to same day discharge success. But what is holding searchers back from same day discharges even when the data is favorable? This the gist I'm hearing is that it's basically about playing the odds. This whole talk, we admit patients always because of the possibility something could go wrong. And the question is, how far do we want to push the odds? So, what I would say that the paradigm shifting from we admit something because something might go wrong to we admit them as long as we need to. Yeah, we're just shifting the odd curve to what our risk tolerance. Yeah, and again it's readmission versus length of stay in surgery. By the next day, you would know about it. Most bad things. So, I think that's why we have become accustomed to overnight stay. So, it's a change in mindset based on risk tolerance and that is of course subjective to each surgeon. Perhaps as more favorable data is published, same day discharge for this procedure will become common practice. Of course, each case is different as the surgeons discussed next. I think it has to do with the rate of the complication, how serious it is and when does it happen related to the surgery. I I think there's a big difference on total or lobe or if you did a central dissection or even a lateral dissection. We shouldn't treat them equally, but the most fear complication that 1% who had a hematoma in this series it happened six days after. But that's in complication you could pick up with a 12 or 24-hour post separate vigilance. So uh I think you have to tailor it up. And one thing that was advocated by David Terris who was the author of that paper was uh have them stay close. If needed, they can come right back over. You have to be aware of patient and social and family circumstances as well as the clinical circumstances and fine tune the care based on the specifics of the patient. In summary, for patients undergoing thyroid lobectomy, same day discharge can be acceptable practice. The American thyroid Association encourages looking at clinical, social, and procedural factors to determine if the patient is safe for same day discharge. While the biggest complication is postoperative hematoma, newer technology has largely decreased the likelihood of postoperative bleeding. Finally, over time with favorable data, same day discharge will become common practice as surgeon adjust their risk tolerance. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery.