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Multivariate-adjusted Analysis for Neck Hematoma by Surgeon Volume, Nationwide In-patient Sample 2000-2009
Source publication
The study's objective is to examine the impact of surgeon experience on the incidence and the severity of neck hematoma after thyroid and parathyroid surgery using a nationwide database. The Nationwide In-patient Sample is a nationwide clinical and administrative database. We used the International Classification of Diseases, 9th Revision diagnosis...
Context in source publication
Context 1
... results for the multivariate analysis are pre- sented in Table 2. After adjusting for other patient and hospital characteristics, compared with patients whose operations were performed by low-volume surgeons as a reference group, those whose operations performed by intermediate-volume (OR, 0.7; 95% confidence interval [CI], 0.6 to 0.8; P < 0.01) and high-volume surgeons (OR, 0.5; 95% CI, 0.4 to 0.6; P < 0.01) were less to likely to develop neck hematoma. ...
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Citations
... Total thyroidectomy or thyroid lobectomy continues to be the gold standard for definitive management of symptomatic and malignant thyroid nodules (2,3). While the safety and efficacy of thyroid surgery is well documented when performed by high-volume, experienced surgeons, there is a small but real risk of significant complications including: life threatening neck hematoma, recurrent laryngeal nerve injury, and hypoparathyroidism, all of which can severely affect patients' quality of life (4,5). These risks are increased in patients undergoing a reoperation, have Graves' disease, have a large goiter size, and/or if the surgical indication is for malignancy (3,(6)(7)(8). ...
Background and Objective
Thyroid nodules are frequently incidentally found on physical exam or imaging for an unrelated work-up. Although surgery remains the gold standard for treating symptomatic benign and/or malignant thyroid nodules, radiofrequency ablation (RFA) has emerged as a minimally invasive treatment option for high risk patients and those who decline surgery. The novel application of RFA to treat thyroid disease was originally described for symptomatic, benign thyroid nodules. Since then, several studies have tried to expand its indication to treat primary and recurrent well-differentiated thyroid cancer. The high success rates and the low complication profile, has allowed for quick adoption of RFA as a treatment option for well-selected patients with benign thyroid nodules and locoregional recurrent thyroid malignancy. As such, multidisciplinary guidelines and consensus statements were developed to standardize indications, techniques, outcome measures, and follow-up to ensure the best patient care. This article summarizes the current indications and recommendations to help guide clinicians on how best to effectively and safely utilize RFA to treat thyroid disease.
Methods
A PubMed/MEDLINE search between 2000–2022 using a combination of “radiofrequency ablation”, “RFA”, “thyroid nodule”, and “guidelines” was conducted. The inclusion criteria were articles published in English which offered recommendations on RFA use for thyroid nodules.
Key Content and Findings
For symptomatic, benign thyroid nodules, RFA is effective at significantly reducing nodule volume. For large nodules, multiple RFA sessions may be needed to achieve clinically significant volume reduction. Patients undergoing RFA for autonomously functioning thyroid nodules may see symptomatic relief but success rates are variable. RFA may serve a curative or palliative role in recurrent well-differentiated thyroid cancers. There is little data describing the use of RFA for primary well-differentiated thyroid cancer >1 cm and the role of RFA for thyroid microcarcinomas remains controversial.
Conclusions
RFA is a safe minimally invasive technique and may be considered, in appropriate circumstances, a first-line treatment option for benign thyroid nodules. Practices adopting RFA will likely increase as more clinicians become familiar with this technique, highlighting the importance of developing standardized guidelines.
... Dehal et al, and Narayanan et al, highlighted in their study that hemorrhage/hematoma are the most predominant postoperative complication rates after the total thyroidectomy. The range of hemorrhage/ hematoma varied from 0.3% to 5% (Narayanan, et al., 2016;Dehal, et al., 2014). Whereas Christou and Mathonnet report another range for the two most common early complications of thyroid surgery such as hypocalcemia in a range (20-30%) and recurrent laryngeal nerve injury (5-11%) (Christou & Mathonnet, 2013). ...
Introduction: The main aim of this study was to determine the influence of surgery on postoperative complications in patients undergoing total thyroidectomy. Methods: Patients diagnosed with goiter and undergoing total thyroidectomy for more than ten years were retrospectively enrolled, and the main study outcomes were postoperative complications. Statistical analysis was done by chi-square and t-test with a p-value <0.05 as significant. Results A total of 116 patients with goiter were identified (mean age, 45.3 ± 8.75 years, with minimum and maximum age of 23 to 69). The most affected age with goiter resulted in 41-50 years old with 41.4% (95% CI, 37.4 to 45.8%). The majority of patients with goiter were women (85.3%), with a mean age of 47 years. After the thyroid surgery, male patients had significantly higher rates of hospital readmission than females with a risk ratio [RR] of 1.05; 95% CI [0.67–1.52], p-value = 0.02. Either hemorrhage/hematoma occurred in 4.7% and cardiopulmonary and thromboembolic events in 3.1% of the patients undergoing total thyroidectomy. In addition, either hypoparathyroidism was observed in 3.1% and temporary recurrent laryngeal nerve palsy (RLN) in 1.56%. Conclusion: The current study demonstrates that total thyroidectomy is associated with an increased rate of hemorrhagic complications. RLN palsies and hypoparathyroidism are less observed. Male patients undergoing thyroidectomy have higher rates of readmission and ICU admission. Furthermore, male patients revealed higher rates of hemorrhage and wound infection, while hypoparathyroidism or temporary recurrent laryngeal nerve palsy was more frequent among female patients.
... Most studies used chart review, however, bias was assessed based on variables measured, impact of information or observer bias, and outcomes reported from analysis for each study. Most studies used multivariate analysis or propensity matched scores to control for confounders, however, 10 [13,19,[24][25][26][27][28][29][30][31] out of 33 studies failed to demonstrate controlling for confounders when measuring outcomes. Overall risk of bias judgements for each study were determined by evaluating the risk of bias within and across each domain. ...
... In studies of both thyroid and parathyroid surgery, low volume surgeons performed as little as 2 operations per year, whereas high volume surgeons performed >25 to >100 operations annually (Tables 1-3). Adam et al. [32] reported a multivariate logistic regression model with restricted cubic splines to estimate the association between surgeon volume and complications experienced in the post-operative period, and found that a threshold of 26 thyroidectomies/year (95% confidence interval, [22][23][24][25][26][27][28][29][30][31][32] was associated with improved patient outcomes. Similar multivariate logistic analysis was not completed in other studies, and no similar data is available for parathyroid operations. ...
... There were 4 studies that reported patient outcomes for both thyroid and parathyroid operations based on surgeon volume. Parathyroid operations only made up 0.3% (19 out of 6347 cases) of total cases in the study reported by Al-Qurayshi et al. [45], whereas 17.5%, 17.0%, and 17.9% (386, 18,185, and 36 cases) of total cases were parathyroid operations in studies conducted by Dehal et al. [27], Noureldine et al. [47], and Kuy et al. [48], respectively (Supplementary Table 3). The total number of thyroid and parathyroid operations included was not possible to calculate as there was duplication of some included cases. ...
Background
The study aim was to systematically review literature evaluating surgeon volume-outcome relationships for thyroid and parathyroid operations in order to inform surgical quality improvement initiatives. Current literature suggests surgeons who perform a high volume of thyroid and/or parathyroid operations have better outcomes than low volume surgeons, though specific volume definition are not standardized.
Methods
Eligible studies were selected through a literature search focused on the effect of surgeon volume on thyroid and parathyroid surgery patient outcomes. The literature search was conducted in accordance with the PRISMA guidelines. Publication dates extended from January 1998 to February 2021, and were limited to articles published in English.
Results
A total of 33 studies were included: 25 studies evaluating thyroid surgery outcomes, 4 studies evaluating parathyroid surgery outcomes, and 4 studies evaluating both thyroid and parathyroid (mixed) surgery outcomes. Higher volume thyroid and parathyroid surgeons were found to be associated with fewer surgical and medical complications, shorter length of hospital stay, and reduced total cost when compared to lower volume surgeons. This volume-outcome relationship was also found to specifically affect the complication and recurrence rates for thyroid cancer patients undergoing surgery, especially for individuals with advanced stage disease.
Conclusion
The heterogeneity in cut-offs used for characterizing surgeons as high versus low volume, and also in subsequent patient outcome measures, limited direct study comparisons. The trend of improved patient outcomes with higher surgeon volume for both thyroid and parathyroid surgeries was consistently present in all studies reviewed.
... Parathyroid surgeries have historically been performed as inpatient procedures due to the possibility of severe complications including hematoma, laryngeal nerve damage, and airway compromise. [1][2][3][4] However, current literature demonstrates comparable quality outcomes among settings, and outpatient parathyroid surgery is considered be as effective and safe as in inpatient surgery. 5,6 As such, continued advances in surgical techniques enable the transition to more parathyroidectomies being performed in the ambulatory setting. ...
Background:
Parathyroidectomy is frequently performed as ambulatory surgery. This study seeks to characterize the socioeconomic factors that may impact the patient selection for outpatient parathyroidectomy.
Methods:
The 2016 Florida State Inpatient Database (SID) and the 2016 Florida State Ambulatory Surgery Database (SASD) were queried for all patients undergoing parathyroidectomy using the International Classification of Diseases 10 (ICD-10) procedure codes. Univariable comparison and multivariate logistic regression were performed for outpatient versus inpatient parathyroidectomy using all relevant patient and hospital characteristics from the database.
Results:
Seven hundred and sixteen patients underwent parathyroidectomy in Florida in 2016; 322 parathyroidectomies were performed in the ambulatory setting (45.0%). After multivariate logistic regression, patients over age 65 and parathyroidectomies performed at high-volume centers were more likely to be performed at an outpatient center. Those patients who were black, Hispanic, had a Charlson Comorbidity Index ≥3, Medicare, Medicaid, and Self-pay were associated with a decreased likelihood of having an outpatient procedure.
Discussion:
Access to ambulatory parathyroidectomy is more common in patients with private insurance, white ethnicity, and fewer comorbidities.
... Liu et al. (5) described their 2-year experience of thyroid reexplorative surgery; the authors reported that the occurrence of postoperative bleeding was 0.85%, and the individual risk factors included male sex, hypertension, benign pathology, and previous thyroid surgery. Different surgical procedures were included in these studies (3)(4)(5)(6)(7)(8)(9)(10)(11)(12), and some underlying factors, such as the type of surgical instruments and chemotherapy, were not fully analyzed. Therefore, in the current study, the main goal was to analyze postoperative bleeding in patients undergoing total thyroidectomy and to explore the possible risk factors. ...
... Predictors of postoperative bleeding have been frequently evaluated (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(17)(18)(19)(20); common risk factors include smoking, hypertension, diabetes, high BMI, operation time, disease stage, and neck dissection, and similar findings were also observed in our results. Smoking and systemic diseases can increase vascular brittleness and decrease coagulation, and postoperative cough induced by thyroid surgery can increase blood pressure (21). ...
... Similar findings were also noted in the current study. Previous studies have usually analyzed tracheotomy as an adverse consequence because of postoperative bleeding (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(17)(18)(19)(20). No authors have aimed to clarify whether tracheotomy can increase the risk of postoperative bleeding. ...
Purpose: Our goal was to analyze postoperative bleeding in patients undergoing total thyroidectomy and to explore the possible risk factors.
Materials and Methods: Patients undergoing total thyroidectomy were retrospectively enrolled, and the main study outcomes were postoperative bleeding and 30-day mortality. Univariate and multivariate analyses were used to determine the independent risk factors for postoperative bleeding.
Results: A total of 31,706 patients were enrolled for analysis during January 2010 and December 2018 from the Affiliated First Hospital of Zhengzhou University. Benign and malignant disease was reported in 4,521 and 27,185 patients, respectively. Postoperative bleeding occurred in 48 patients with benign disease and in 263 patients with malignant disease. There was one bleeding site in 243 patients. The branch of the superior thyroid artery was the most common arterial bleeding site, occurring in 124 patients, and the anterior jugular vein was the most common venous bleeding site, occurring in 85 patients. Multivariable analysis confirmed that hypertension, diabetes, BMI, and disease pathology were independent factors affecting postoperative bleeding in patients with benign disease and that hypertension, diabetes, BMI, operation time, tumor stage, and tracheotomy were independent factors affecting postoperative bleeding in patients with malignant disease. In patients with postoperative bleeding, there were 5 deaths; in patients without postoperative bleeding, there were 42 deaths, and the difference was significant (p < 0.001).
Conclusions: Compared with malignant disease patients, benign disease patients have a similar postoperative bleeding rate. A previous history of chemotherapy or radiotherapy has no significant effect on postoperative bleeding.
... 3.8% (p < 0.005) for low-volume surgeons. Dehal et al. [47] describe a graduated bleeding rate for surgeon volume categories high, intermediate, and low of 0.9%, 1.4%, and 2.1% at an over all rate of 1.5%. In these, bleeding rates range from 0.8 to 3.8%. ...
... Pieracci et al. [51] describe a linear association of increasing volume with decreasing overall complications (bleeding p = 0.01). Other studies show inconsistent or marginal effects of hospital volume on outcome [12,19,38,40,45,47,48,50] (see Table 6). HT hemithyroidectomy, LOS length of hospital stay, TT total and near-total thyroidectomy, proc. ...
IntroductionContinuous efforts in surgical speciality aim to improve outcome. Therefore, correlation of volume and outcome, developing subspecialization, and identification of reliable parameters to identify and measure quality in surgery gain increasing attention in the surgical community as well as in public health care systems, and by health care providers. The need to investigate these correlations in the area of endocrine surgery was identified by ESES, and thyroid surgery was chosen for this analysis of the prevalent literature with regard to outcome and volume.Materials and methodsA literature search that is detailed below about correlation between volume and outcome in thyroid surgery was performed and assessed from an evidence-based perspective. Following presentation and live data discussion, a revised final positional statement was presented and consented by the ESES assembly.ResultsThere is a lack of prospective randomized controlled studies for all items representing quality parameters of thyroid surgery using uniform definitions. Therefore, evidence levels are low and recommendation grades are based mainly on expert and peer evaluation of the prevalent data.Conclusion
In thyroid surgery a volume and outcome relationship exists with respect to the prevalence of complications. Besides volume, cumulative experience is expected to improve outcomes. In accordance with global data, a case load of < 25 thyroidectomies per surgeon per year appears to identify a low-volume surgeon, while > 50 thyroidectomies per surgeon per year identify a high-volume surgeon. A center with a case load of > 100 thyroidectomies per year is considered high-volume. Thyroid cancer and autoimmune thyroid disease predict an increased risk of surgical morbidity and should be operated by high-volume surgeons. Oncological results of thyroid cancer surgery are significantly better when performed by high-volume surgeons.
... Neben patientenspezifischen Risikofaktoren stehen der Einfluss des Operateur-und Krankenhausvolumens auf das Komplikationsrisiko im Fokus wissenschaftlicher Forschung. In verschiedenen Studien konnte gezeigt werden, dass mit steigendem Operationsvolumen, sowohl auf Krankenhaus-als auch auf Operateurebene, das Komplikationsrisiko sank [1,5,8,12,14,16,21,26]. ...
... Routine data · Benign goiter · Vocal cord palsy · Case number threshold · Volume outcome für Chirurgen mit weniger als 9 Eingriffen pro Jahr [5,26]. Mögliche Ursachen hierfür sind Unterschiede in den Definitionen des Endpunktes oder innerhalb der untersuchten Patientenkollektive. ...
Background
Many studies showed that hospital and surgeon volume have a significant influence on the complication rates of thyroid surgery. The present study investigates whether this relationship applies in subtotal as well as total lobe resections. Furthermore, it is still unclear which threshold for the hospital-related case volume can be determined, above which the risk of complications lies below the current national average.Material and methodsThe study was based on nationwide routine data for persons insured with the Local General Sickness Fund (AOK) who had undergone thyroid surgery in 2014–2016. Permanent vocal cord palsy, bleeding and wound infection needing revision were recorded using indicators. The effect of the case volume on the indicators and the case number threshold was determined using logistic regression.ResultsPermanent vocal cord palsy was observed in 1.3% and bleeding or wound infections needing revision in 1.6% and 0.3% of the cases. Compared to hospitals with >450 surgeries per year, the risk of permanent vocal cord palsy in hospitals with fewer than 201, 101 and 51 surgeries was significantly increased (OR [95% CI]: 1.5 [1.1–2.1]; 1.5 [1.1–2.1]; 1.8 [1.3–2.5]). The threshold needed to achieve a risk for permanent vocal cord palsy below the national average (1.3%) was 265 thyroid surgeries per year (95% CI: 110–420). For bleeding or wound infection in need of revision, no association between volume and outcome was found.Conclusion
The present study showed that the risk of postoperative permanent vocal cord palsy decreased with increasing case volume. The broad confidence interval of the threshold makes clear case volume recommendation difficult. In order that the risk for a postoperative permanent vocal cord palsy is not likely above the national average, the annual case volume should reach 110 thyroid interventions.
... [25] Several studies have suggested that the high-volume and specialized surgeons significantly reduce bleeding and hematoma resulting from thyroidectomy. [1,2,4,17,26] However, no significant difference regarding the rate of bleeding that required reexploration was found between the AS and BS groups in this study (p=0.500). ...
INTRODUCTION[|]The relationship between the surgeon's experience/volume of performed operations and postoperative results of thyroid surgery is a pressing issue that has been widely discussed in recent publications. This study aimed to compare the complication rates in thyroidectomy operations performed before and after specialization and evaluate the effect of specialization on the outcomes of thyroid surgeries.[¤]METHODS[|]The study included patients who had undergone thyroidectomy with or withoutneck dissection due to benign or malign thyroid diseases in a single tertiary reference hospital between April 2013 and March 2017. The patients were divided into two groups: those who were operated on before specialization (BS) and after specialization (AS). Age, gender, operation type, postoperative hypocalcemia, incidental parathyroidectomy, recurrent laryngeal nerve (RLN) injury, and postoperative bleeding or hematoma were compared between the groups.[¤]RESULTS[|]Of the thyroid patients, 776 were operated on (367 (47%) and 409 (53%) of the BS and AS groups, respectively). No significant difference was found between the two groups regarding the postoperative Ca2+ level, while the parathormone was significantly lower in the BS group (p=0.2 and p=0.02, respectively). In addition, postoperative transient hypocalcemia was significantly less common in the AS group (p<0.001). The incidental parathyroidectomy rate was significantly higher in the BS group (p<0.01). Postoperative transient hoarseness developed in 15 (4%) patients in the BS group and in 2 (0.5%) patients in the AS group. Twelve patients had unilateral vocal cord paralysis, all of whom were in the BS group (p<0.01). No significant difference exists between the groups regarding bleeding (p=0.5).[¤]DISCUSSION AND CONCLUSION[|]This study indicated that specialization in thyroid surgery significantly reduced complications (e.g., hypocalcemia, incidental parathyroidectomy, and RLN injury).[¤]
... Surgeon volume and, to a lesser degree, hospital volume are inversely related to the prevalence of recurrent laryngeal nerve injury and postoperative hypoparathyroidism. Different correlation analyses between surgeon [5,7,[9][10][11][12] or hospital volume [9,[13][14][15][16] and postoperative bleeding have revealed conflicting results. Surgery for thyroid cancer is a predictor of increased risk of recurrent laryngeal nerve injury and postoperative hypoparathyroidism and therefore should be performed by highvolume surgeons [2,3,8,17]. ...
... The definition for low-volume parathyroid surgeons ranges from < 4 to < 20 and for high-volume parathyroid surgeons from 20 to > 100 surgeries per year [1,15,[18][19][20][21][22][23][24]. The experience, and therefore the individual surgeon volume, seems to be more relevant than the hospital volume, especially in nonstandard cases (multiglandular disease, hereditary primary hyperparathyroidism (PHPT), ectopic or unlocalized glands). ...
Background/purpose
A key measure to maintain and improve the quality of healthcare is the formal accreditation of provider units. The European Society of Endocrine Surgeons (ESES) therefore proposes a system of accreditation for endocrine surgical centers in Europe to supplement existing measures that promote high standards in the practice in endocrine surgery.
Methods
A working group analyzed the current healthcare situation in the field of endocrine surgery in Europe. Two surveys were distributed to ESES members to acquire information about the structure, staffing, caseload, specifications, and technology available to endocrine surgery units. Further data were sought on tracer diagnoses for quality standards, training provision, and research activity. Existing accreditation models related to endocrine surgery were included in the analysis.
Results
The analysis of existing accreditation models, available evidence, and survey results suggests that a majority of ESES members aspire to a two-level model (termed competence and reference centers), sub-divided into those providing neck endocrine surgery and those providing endocrine surgery. Criteria for minimum caseload, number and certification of staff, unit structure, on-site collaborating disciplines, research activities, and training capacity for competence center accreditation are proposed. Lastly, quality indicators for distinct tracer diagnoses are defined.
Conclusions
Differing healthcare structures, existing accreditation models, training models, and varied case volumes across Europe are barriers to the conception and implementation of a pan-European accreditation model. However, there is consensus on accepted standards required for accrediting an ESES competence center. These will serve as a basis for first-stage accreditation of endocrine surgery units.
... Godballe et al. 9 reported that bilateral thyroid surgery had a significant influence on the frequency of POH. Possible explanations for our findings might be that all the procedures were performed by extremely experienced surgeons, so the risk of POH was reduced 6 . ...
... A conflicting result was described regarding the association between POH and disease pathology [4][5][6][7][8][9][10][11][12][13] . It could be explained by a range of different surgical procedures and various disease categories, including Graves' disease. ...
The aim of this study was to analyse postoperative haemorrhage (POH) after a total thyroidectomy and explore the possible risk factors. Records of patients receiving a total thyroidectomy were reviewed and analysed for risk factors of POH. From the 2,678 patients in this study, a total of 39 patients had POH, representing an incidence of 1.5%. The majority (59.0%) of POH events occurred within four hours after surgery. Arterial haemorrhage was the primary cause of POH and was identifiable prior to venous bleeding, making it the first sign of POH. A univariate analysis revealed an association between POH, certain disease factors and BMI, but only a BMI greater than 30 was found to significantly increase the risk of POH (almost 6-fold). At the first sign of POH, all patients showed an obvious red drainage, and 92.3% of the patients had neck swelling. In summary, arterial bleeding is the main cause and first sign of postoperative haemorrhage, as it starts earlier than venous bleeding. A BMI greater than 30 significantly increases the risk of neck haematoma.
