The danger of sending patients home too soon after thyroid surgery
Study calls into question the standard six-hour discharge
Removal of the thyroid gland is considered by most surgeons to be safe, which is why patients are often discharged from the hospital on the same day as the procedure.
A new international, multicenter study published in the current issue of Surgery and led by UC Davis endocrine surgeon Michael Campbell has found that some of these patients should be monitored in the hospital overnight for potentially deadly bleeding known as a post-surgical hematoma.
“Over the last decade there has been a trend toward observing patients who undergo a thyroidectomy for six hours and then discharging them, but there wasn’t enough good data to support that decision,” said Campbell, who conducted the study while at UC San Francisco. “We hoped to identify the timing and risk factors that can help individualize patient care and make the procedure even safer.”
A variety of disorders, including nodules, cancer and over-production of thyroid hormone, may necessitate removal of the thyroid gland, which is located in the neck and regulates metabolism. The delicate operation is challenging, because the thyroid has many vessels that can bleed easily following surgery. A post-thyroidectomy hematoma is bleeding that can compress the windpipe, putting patients at risk for airway restriction. Observing patients in the hospital improves the chances of early diagnosis and treatment of this life-threatening condition.
The issue is becoming increasingly important as thyroidectomies become more common — from around 66,000 in 1996 to more than 90,000 in 2006. During that time, the number of patients discharged on the same day of their surgeries increased 61 percent, with about 0.5 percent returning to the operating room for hematoma evacuation.
Research on this problem has been scarce because no single institution had enough cases for an adequate evaluation. Campbell and his colleagues overcame this limitation by assessing the records of 207 post-thyroidectomy hematoma patients who were treated at 15 institutions in the U.S., Canada and the Netherlands between 1997 and 2012. Their investigation encompassed dozens of factors related to the patients, surgeons, procedures and follow-up care.
More than half — or 53 percent — of patients in the study had hematoma repairs more than six hours after their thyroidectomies, calling into question the current practice of sending patients home after a six-hour observation period. The researchers also learned that a vast majority of patients — 79 percent — who experienced hematomas did so within 24 hours of their surgeries.
“We were surprised by the number of hematomas that occurred more than six hours after a thyroidectomy, which contradicts conventional wisdom,” said Campbell. “It turns out that most patients who experience hematomas can be captured with a 23-hour hospitalization.”
The team also identified the primary risk factors for hematoma:
- Graves’ disease, an immune system disorder that increases blood vessels in the thyroid
- Use of antiplatelet or anticoagulant medication, typically used to reduce the risk of blood clots
- Use of a drain during surgery to remove blood
- Larger thyroid, increasing the time and complication involved in its removal
“Surgeons should be cautious when sending a thyroidectomy patient with any of these risk factors home after six hours,” Campbell said. “In my own practice, I feel comfortable keeping my patients hospitalized overnight.”
The study’s senior author was Daniel Ruan of Brigham and Women’s Hospital in Boston. Other participating institutions were UCSF, University of Pittsburgh Medical Center, Massachusetts General Hospital, University of Rochester Medical Center, The Cleveland Clinic, McGill University Health Center, University of Wisconsin, University Medical Center Utrecht, University of Chicago, Johns Hopkins School of Medicine, Northwestern Medical Center, Memorial Sloan-Kettering Cancer Center, Virginia Mason Medical Center and University of Arizona Medical Center.
The research had no external funding. A copy of “A Multi-institutional International Study of Risk Factors for Hematoma after Thyroidectomy” is available to reporters on request by emailing firstname.lastname@example.org.