“ SAME-DAY ” THYROID SURGERY ; FEASIBILITY AND OUTCOME OF DIFFERENT PROCEDURES AFTER 302 THYROIDECTOMIES

This study present and evaluate the feasibility and outcome of same-day different types of thyroidectomy in Sulaimania in the last 8 years. From Jan. 1999 to Jan. 2007, all patients consecutively operated on for thyroid disease, were admitted on the day of operation and discharged the day after. A prospective study was performed for them, the clinico-pathological aspects of the disease and the outcome of the thyroid surgery were assessed regarding hospital stay, the time when the drains were removed, postoperative complications, interventions and readmissions and postoperative requirement for thyroxin. Three hundred and two patients were consecutively operated on, with a mean age of thirtyseven years; they were 265 females and 37 males. All patients were hospitalized less than 24 hours with the mean hospital stay of 15.7 hours (10-23h). Complications were few with 1.6% minor wound infection; 1.3% seroma; 0.9% hematoma; 0.6% for both transient hoarseness of voice and transient stridor. In conclusions, same-day thyroid surgery is a safe and feasible procedure with minimal morbidity and no mortality. Introduction oiter is an endemic disease in the Kurdistan Region of Iraq, especially in Sulaimania territory, because of the mountainous nature of the area, with the lack of iodine in water. Thyroidectomy is a common operation in our locality and also elsewhere. Although thyroid surgery is of low mortality, it still has a high rate of complications. It is associated with specific morbidity which is related to the experience of the surgeon. The least surgical complications for thyroidectomy are reported in specialized centers In Iraq generally and in our locality in particular. Most thyroid surgeries are performed in general hospitals. Recently, a progressive decrease in the length of hospitalizations for common surgical operations has occurred and there is no doubt about the costeffectiveness of ambulatory, same day or short stay major operations. Thyroid surgical diseases are among those pathologies which can be operated on as short stay procedure, but there is no consensus on the length of hospitalization for these cases. There are publications from over ten years ago reporting good results with shorter stays. Since 1999, we have started operating on thyroid diseases on the same-day surgery program, admission less than 24 hours. This regime is different from short stay surgery, where the patients G “Same-day” thyroid surgery; feasibility and outcome of different procedures after 302 thyroidectomies Faruk H Faraj Bas J Surg, March, 16, 2010 ٦٩ are discharged after 2-3 days. The main concern in same day thyroid operations is postoperative complications associated with re-admissions and/or re-operations such as wound hematoma or hypocalcemia. The aim of this study is to evaluate the feasibility and outcome of same-day thyroidectomies in various thyroid diseases in our locality. Patients and Methods A prospective study of 302 patients diagnosed and surgically treated for thyroid pathology from Jan. 1999 to Jan.2007. Preoperative preparations were done for them in outpatient clinics, including ENT checkup of the vocal cords, and assessment by anesthesiologists for GA fitness. All patients were euthyoid preoperatively and were admitted on the same day of operation usually one hour before surgery. They were operated upon in the morning in Sulaimania Teaching Hospital or in the evening in private hospitals. All the patients were informed preoperatively with regards to early discharge. Modified capsular dissection technique was used in which; the tertiary branches of the inferior thyroid arteries were ligated on the capsule of the thyroid gland. This technique is performed so that not to endanger the recurrent laryngeal nerve (RLN) and/or jeopardize the blood supply of the parathyroid glands. In hemithyroidectomy, an entire lobe was removed. Approximately 4 g. of thyroid tissue was left in subtotal thyroidectomy. In near-total thyroidectomy, we performed lobectomy on the larger or more nodular lobe or the side including the dominant nodule, with contralateral subtotal resection leaving an average of 1-2 g of thyroid tissue. Only absorbable sutures were used throughout the procedure. At extubation, vocal cords were checked by anesthesiologist in all cases. Intravenous fluids were administered intravenously for 4-6 hours after operation. The patients were encouraged to start oral fluid intake and ambulation shortly after that. A single dose of intra-muscular Diclofenac was given as analgesia on need, followed by paracetamol oral tablets. All patients were discharged the morning after operation. Data were collected regarding age, sex, occupation, duration of the disease, preoperative investigations, diagnosis, preparation and management. Data were also collected regarding the operative procedure, blood transfusion, number of drain(s) used, duration after which the drains were removed and the hospital stay. Postoperative care, complications, and the histopathological results were recorded. The patients were classified according to diagnosis within five different groups: 1Benign colloid nodular goiter 2Toxic goiter (diffuse or nodular) 3Hashimoto’s thyroiditis. 4Follicular adenoma. 5Malignant thyroid disease (thyroid cancer). Furthermore, the same patients were classified according to the operations performed into three different groups: 1Hemithyroidectomy (H/T). 2Subtotal thyroidectomy (S/T). 3-Near-total thyroidectomy (N/T). All patients were followed up as an outpatient clinically at one week and four weeks, then regularly at twelve weeks, both clinically and biochemically, for one year after operation for the detection and treatment of any complications and the requirement for thyroxin. The hospital stay and the incidence of postoperative complications, the number of drains used, and the time when these drains were removed and thyroxin requirement postoperatively “Same-day” thyroid surgery; feasibility and outcome of different procedures after 302 thyroidectomies Faruk H Faraj Bas J Surg, March, 16, 2010 ٧٠ were all analyzed and compared between diagnoses and the type of operation. The patients were discharged with the drain in situ (if necessary), and hence the hospital stay is not prolonged. Statistical method The data were collected prospectively and recorded in the computer database. The statistical analysis was performed using statgraph software. The analysis of the continuous variables was tested using student’s t-test and the chi-square test was used for nominal variables. A p value of less than 0.05 was considered significant. This study was approved by the ethical committee in the Medical College, Sulaimania University. Results Demographic features: There were 265 females (F) and 37 males (M) with F:M of 7.16:1 and the mean age of the patients was 37 years (15-78 years) Table I: The number and percentage of patients with various thyroid diagnoses and surgical procedures which were performed. Surgical procedure No. and % of patients Thyroid pathology No. and % of patients 40 (13.2) Hemithyroidectomy 223 (73.8) BCNG 238 (78.8) Subtotal thyroidectomy 34 (11.2) Toxic goiter 24 (7.9) Near-total thyroidectomy 15 (4.9) Hashimoto’s thyroiditis 302 Total 15 (4.9) Follicular adenoma 15 (4.9) Thyroid cancer


Introduction
oiter is an endemic disease in the Kurdistan Region of Iraq, especially in Sulaimania territory, because of the mountainous nature of the area, with the lack of iodine in water 1 .Thyroidectomy is a common operation in our locality and also elsewhere 1,2 .Although thyroid surgery is of low mortality 2 , it still has a high rate of complications 3 .It is associated with specific morbidity [2][3][4] which is related to the experience of the surgeon 2,4 .The least surgical complications for thyroidectomy are reported in specialized centers 2,4 In Iraq generally and in our locality in particular.Most thyroid surgeries are performed in general hospitals.
Recently, a progressive decrease in the length of hospitalizations for common surgical operations has occurred and there is no doubt about the costeffectiveness of ambulatory, same day or short stay major operations 5,6 .Thyroid surgical diseases are among those pathologies which can be operated on as short stay procedure 7 , but there is no consensus on the length of hospitalization for these cases 6 .There are publications from over ten years ago reporting good results with shorter stays 8,9 .Since 1999, we have started operating on thyroid diseases on the same-day surgery program, admission less than 24 hours.This regime is different from short stay surgery, where the patients

٦٩
are discharged after 2-3 days 10 .The main concern in same day thyroid operations is postoperative complications associated with re-admissions and/or re-operations such as wound hematoma or hypocalcemia 11,12 .The aim of this study is to evaluate the feasibility and outcome of same-day thyroidectomies in various thyroid diseases in our locality.

Patients and Methods
A prospective study of 302 patients diagnosed and surgically treated for thyroid pathology from Jan. 1999 to Jan.2007.Preoperative preparations were done for them in outpatient clinics, including ENT checkup of the vocal cords, and assessment by anesthesiologists for GA fitness.All patients were euthyoid preoperatively and were admitted on the same day of operation usually one hour before surgery.They were operated upon in the morning in Sulaimania Teaching Hospital or in the evening in private hospitals.All the patients were informed preoperatively with regards to early discharge.Modified capsular dissection technique was used in which; the tertiary branches of the inferior thyroid arteries were ligated on the capsule of the thyroid gland.This technique is performed so that not to endanger the recurrent laryngeal nerve (RLN) and/or jeopardize the blood supply of the parathyroid glands.In hemithyroidectomy, an entire lobe was removed.Approximately 4 g. of thyroid tissue was left in subtotal thyroidectomy.In near-total thyroidectomy, we performed lobectomy on the larger or more nodular lobe or the side including the dominant nodule, with contralateral subtotal resection leaving an average of 1-2 g of thyroid tissue.Only absorbable sutures were used throughout the procedure.At extubation, vocal cords were checked by anesthesiologist in all cases.
Intravenous fluids were administered intravenously for 4-6 hours after operation.The patients were encouraged to start oral fluid intake and ambulation shortly after that.A single dose of intra-muscular Diclofenac was given as analgesia on need, followed by paracetamol oral tablets.All patients were discharged the morning after operation.Data were collected regarding age, sex, occupation, duration of the disease, preoperative investigations, diagnosis, preparation and management.Data were also collected regarding the operative procedure, blood transfusion, number of drain(s) used, duration after which the drains were removed and the hospital stay.Postoperative care, complications, and the histopathological results were recorded.The patients were classified according to diagnosis within five different groups: 1-Benign colloid nodular goiter 2-Toxic goiter (diffuse or nodular) 3-Hashimoto's thyroiditis.4-Follicular adenoma.5-Malignant thyroid disease (thyroid cancer).Furthermore, the same patients were classified according to the operations performed into three different groups: 1-Hemithyroidectomy (H/T).

2-Subtotal thyroidectomy (S/T). 3-Near-total thyroidectomy (N/T).
All patients were followed up as an outpatient clinically at one week and four weeks, then regularly at twelve weeks, both clinically and biochemically, for one year after operation for the detection and treatment of any complications and the requirement for thyroxin.The hospital stay and the incidence of postoperative complications, the number of drains used, and the time when these drains were removed and thyroxin requirement postoperatively Bas J Surg, March, 16, 2010 ٧٠ were all analyzed and compared between diagnoses and the type of operation.
The patients were discharged with the drain in situ (if necessary), and hence the hospital stay is not prolonged.

Statistical method
The data were collected prospectively and recorded in the computer database.The statistical analysis was performed using statgraph software.The analysis of the continuous variables was tested using student's t-test and the chi-square test was used for nominal variables.A p value of less than 0.05 was considered significant.This study was approved by the ethical committee in the Medical College, Sulaimania University.

Demographic features:
There were 265 females (F) and 37 males (M) with F:M of 7.16:1 and the mean age of the patients was 37 years (15-78 years)   ٧١ BCNG = benign colloid nodular goiter, S = significant differences between different diagnoses.Wound infection and hematoma were more common in patients with toxic goiter.Seroma was more common in thyroid cancer (p <0.05).Transient RLN palsy was statistically more significantly found in Hashimoto's thyroiditis.

Discussion
In this study, the age varied from fifteen to seventy years, with the mean age of thirty-seven years which is similar to other studies 3,5 .As goiter is more common in females 1-3 , consequently, thyroidectomy is more common in females as in our study with F:M = 7.16:1 which is similar to other studies 3 .The percentages of every diagnosis are the expected ones, according to the epidemiology of this pathology in our locality 1 .Benign colloid nodular goiters were the main pathology (41.25%), which is similar to other studies 2,6 .There is a high percentage of subtotal thyroidectomy, due to the fact that until 2005, it was the standard operation for most benign thyroid diseases in our locality, but after that the new policy is to do near-total thyroidectomy for multinodular goiters to decrease the rate of recurrence of goiter after, similar to Antonio Rios et al study of postoperative complications after total and /or thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery at 2004 13 .Although the overall complication rate in this study was low (5%), minor wound infection was the most common complication, which occurred in 1.6% of the cases and were encountered more significantly in patients with toxic goiter (table3) and then in patients with benign colloid nodular goiter, but in the latter group, this was statistically not significant.This complication was found in patients for who subtotal or near-total thyroidectomy were performed.No infection was reported in hemithyroidectomy group.All the cases with wound infection were treated in outpatient clinic with no readmission.The incidence of wound infection after thyroidectomy varied in other studies from zero to 10% 2,3,6,13 .Insignificant seroma and mild localized wound hematoma were the next most encountered complications in this study and were treated conservatively with needle aspiration on few occasions in outpatient clinic.Seroma was detected more frequently in patients with thyroid cancer, and hematoma in patients with toxic goiter.Seroma and hematoma occurred in subtotal and near-total thyroidectomy groups only (table IV).In other studies, the incidence of these two complications varied from zero to 7% 2,3,6 .Recurrent laryngeal nerve (RLN) palsy, manifested as hoarseness of voice, is the most feared complication after thyroidectomy, but it usually affects postoperative hospital stay when it is bilateral 6 .The reported incidence of transient unilateral RLN palsy in this study was 0.6 % (table II), which was less than other studies 2,3,6 .The low incidence of this complication is attributed to the policy of avoiding damage to RLN by using modified capsular technique, as the nerve is always extracapsular 14 and not manipulating or identifying the nerve, and this goes with the policy of Torre et al who do not consider identification of RLN necessary 15,16 .In our study, transient unilateral RLN palsy occurred more in patients with Hashimoto's thyoiditis and this was statistically significant between different pathologies (table III), and this was attributed to the hardness of the gland that made resection difficult.The postoperative airway obstruction (stridor) caused by laryngeal or subglottic edema, is a rare complication after thyroidectomy and when it is accompanied by significant cervical hematoma, it makes re-intervention necessary 2,6,17,18 .This classically occurs when there is postoperative bleeding with an associated wound hematoma 6,17,18 .
However, it is important to appreciate that the complication can occur without hematoma 18 .In the present study, this In other studies, the most common complication after thyroidectomy is hypocalcemia secondary to transient hypoparathyroidism 5,12,19,20 .In our present study, none of our patients developed hypocalcemia, which is attributed to our modified capsular dissection and tertiary ligation of thyroidal branches of inferior thyroid arteries, hence avoiding the inadvertent damage to the blood supply of parathyroid glands.Our results regarding the duration of our admissions (table V) were very expressive, and all the cases were discharged within the next 23 hours after operation.There were significant differences (p value < 0.05) between the groups.A shorter hospital stay found in patients with follicular adenoma and in patients with hemithyroidectomy.A longer hospital stay was encountered in patients with Hashimoto's thyroiditis and thyroid cancer and also in near-total thyroidectomy procedure.Hence with our programmed protocols for thyroid surgery, all the procedures could be performed on a same day regime with good results.The incidence of readmission and/or re-intervention was nil.
We still do routinely use cervical drain(s) after thyroid surgery (table VI).The decision of draining or not draining cervicotomy after thyroid surgery remains controversial, and there are many authors who report systematic drainage 7,21 , and others who don't 6,22,23 .The efficiency of postoperative Lthyroxin (T4) suppressive treatment, in patients with benign colloid nodular goiter, is still controversial 24 .In our study, there was significant differences among the three groups in relation to the type of operation (table VI).The highest percentage was in the near-total thyroidectomy group (p < 0.05), and the least requirement for postoperative T4 supplementation or suppression was in hemithyroidectomy group as the residual thyroid tissue was capable for production of sufficient thyroxine and this was comparable to other studies 25,26 .In conclusion, the procedure hemithyroidectomy and the diagnosis thyroid adenoma do not usually have early postoperative morbidity and we believe that in all hospitals, this type of operation can be achieved on the same day basis or even as day case (ambulatory) surgery.Regarding other thyroid operations, they can be performed as same day surgery, either when there is a specialist surgeon with enough experience in thyroid surgery or the procedure is achieved in a specialist endocrine center, and under these circumstances the results will be excellent with minimal morbidity.Goiter size, toxic goiter, Hashimoto's thyroiditis and thyroid cancer are the independent risk factors for the development of complications.

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"Same-day" thyroid surgery; feasibility and outcome of different procedures after 302 thyroidectomies

Table III : The distribution of postoperative complications by the diagnosis in percentage (%).
Bas J Surg, March,16, 2010

Table VI : The percentage (%) of cases in which drains were used, the time these drains were removed and the percentage (%) of thyroxin (T4) requirement by surgical procedure.
Bas J Surg, March,16, 2010