1 00:00:00,000 --> 00:00:05,000 GlobalCast MD, along with Cincinnati Children's Hospital, 2 00:00:05,000 --> 00:00:08,000 sharing knowledge to improve child health around the globe. 3 00:00:13,000 --> 00:00:15,000 Hello, pediatric surgery family. 4 00:00:15,000 --> 00:00:20,000 I'm Cecilia Gigena, a research fellow from Cincinnati Children's Hospital Medical Center. 5 00:00:20,000 --> 00:00:25,000 In August 2023, we held our annual update course in pediatric surgery. 6 00:00:25,000 --> 00:00:33,000 In this session, the surgeons discuss in roundtable fashion who can go home from the OR on the same day of their procedure. 7 00:00:33,000 --> 00:00:37,000 Let's move on to the next topic, uncomplicated right thyroid lobectomy. 8 00:00:37,000 --> 00:00:40,000 Can this patient go home the same day? 9 00:00:40,000 --> 00:00:46,000 I'm a 16-year-old female with a concerning 1 centimeter right thyroid nodule on ultrasound. 10 00:00:46,000 --> 00:00:51,000 It undergoes FNA and is found to have atypia of undetermined significance, Bethesda 3. 11 00:00:51,000 --> 00:00:54,000 She undergoes a straightforward right thyroid lobectomy. 12 00:00:54,000 --> 00:01:04,000 Responses from the surgeons show that approximately 44% would actually keep that patient overnight and then start home the next day. 13 00:01:04,000 --> 00:01:08,000 Approximately 30% would send the patient home on the same day. 14 00:01:08,000 --> 00:01:12,000 So what drives the surgeons to keep patients overnight? 15 00:01:12,000 --> 00:01:18,000 What's interesting to me is that we used to leave drains in the neck because of the potential for bleeding. 16 00:01:18,000 --> 00:01:23,000 Everyone was afraid the patient would cough or sneeze and then have a massive hemorrhage and choke themselves. 17 00:01:23,000 --> 00:01:25,000 So is this not a problem? 18 00:01:25,000 --> 00:01:37,000 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. 19 00:01:37,000 --> 00:01:42,000 There is data saying that with that, the incidence is much lower. 20 00:01:42,000 --> 00:01:47,000 So can I ask a question then for a right lobectomy or a lobectomy? 21 00:01:47,000 --> 00:01:56,000 The issue for sending them home is bleeding because it's not calcium or anything like you might do for a total. 22 00:01:56,000 --> 00:01:58,000 Is that what you're saying? 23 00:01:58,000 --> 00:01:59,000 Yeah. 24 00:01:59,000 --> 00:02:05,000 About bleeding complications following a unilateral lobectomy in adults and or in children. 25 00:02:05,000 --> 00:02:08,000 Here's a single institution study. 26 00:02:08,000 --> 00:02:12,000 55 pediatric patients undergoing thyroidectomy. 27 00:02:12,000 --> 00:02:16,000 36 were total thyroids, lobectomy and 13. 28 00:02:16,000 --> 00:02:21,000 Some had central neck dissection or lateral neck dissections and all went home after two hours. 29 00:02:21,000 --> 00:02:28,000 About 10 percent had transient hypoparaperminant was 3.8 percent for hypothyroidism. 30 00:02:28,000 --> 00:02:37,000 They were measuring parathyroid hormone and 1.8 percent had a post-op hematoma requiring re-operation. 31 00:02:37,000 --> 00:02:40,000 But that was on post-op day six. 32 00:02:40,000 --> 00:02:43,000 So that kid probably would have been home anyway at that time. 33 00:02:43,000 --> 00:02:48,000 So it seems like same day discharge is definitely possible in this patient population. 34 00:02:48,000 --> 00:02:54,000 The America Thyroid Association has actually put out a statement on outpatient thyroidectomy 35 00:02:54,000 --> 00:03:03,000 and encouraged looking at clinical, social and procedural factors to determine if the patient is safe for same day discharge. 36 00:03:03,000 --> 00:03:09,000 I think they do a really good job in this paper of going through the things you should think about 37 00:03:09,000 --> 00:03:18,000 as far as significant comorbidities, ASA class, team approach, pre-op education, social setting of the patient 38 00:03:18,000 --> 00:03:20,000 and in this setting parathyroid hormones. 39 00:03:20,000 --> 00:03:24,000 Do you do this? Do you send your thyroids home the same day after reading all this? 40 00:03:24,000 --> 00:03:26,000 So some selective ones I do. 41 00:03:26,000 --> 00:03:31,000 While not every patient is suitable for same day discharge both thyro and lobectomy, 42 00:03:31,000 --> 00:03:38,000 it seems that properly identifying those patients that are suitable prior to the procedure is key to same day discharge success. 43 00:03:38,000 --> 00:03:45,000 But why is holding surgeons back from same day discharges even when the data is favorable? 44 00:03:45,000 --> 00:03:48,000 The gist I'm hearing is that it's basically about playing the odds. 45 00:03:48,000 --> 00:03:54,000 This whole talk, we admit patients always because of the possibility something could go wrong. 46 00:03:54,000 --> 00:03:56,000 And the question is, how far do we want to push the odds? 47 00:03:56,000 --> 00:04:06,000 So what I would say that the paradigm is shifting from we admit something because something might go wrong to we admit them as long as we need to. 48 00:04:06,000 --> 00:04:10,000 Yeah, we're just shifting the odd curve to what our risk tolerance. 49 00:04:10,000 --> 00:04:13,000 And again, it's readmission versus length of stay. 50 00:04:13,000 --> 00:04:17,000 In surgery, by the next day you would know about it. 51 00:04:17,000 --> 00:04:22,000 Most bad thing. So I think that's why we have become accustomed to overnight stay. 52 00:04:22,000 --> 00:04:29,000 So it's a change in mindset based on risk tolerance and that is of course objective to each surgeon. 53 00:04:29,000 --> 00:04:36,000 Perhaps as more favorable data is published, same day discharge for this procedure will become common practice. 54 00:04:36,000 --> 00:04:40,000 Of course, each case is different as the surgeons discuss next. 55 00:04:40,000 --> 00:04:46,000 I think it has to do with the rate of the complication, how serious it is and when does it happen related to surgery. 56 00:04:46,000 --> 00:04:51,000 I think there's a big difference on total or lobe or if you did a central dissection or even lateral dissection. 57 00:04:51,000 --> 00:04:57,000 We shouldn't treat them equally, but the most fear complication that one percent who had a hematoma in this series, 58 00:04:57,000 --> 00:05:04,000 it happened six days after. But that's a complication you could pick up with a 12 or 24 hour post-operative vigilance. 59 00:05:04,000 --> 00:05:06,000 So I think you have to tailor it up. 60 00:05:06,000 --> 00:05:12,000 And one thing that was advocated by David Terris, who was the author of that paper, was have them stay close. 61 00:05:12,000 --> 00:05:14,000 If needed, they can come right back over. 62 00:05:14,000 --> 00:05:20,000 You have to be aware of patient and social and family circumstances as well as the clinical circumstances 63 00:05:20,000 --> 00:05:23,000 and fine tune the care based on the specifics of the patient. 64 00:05:23,000 --> 00:05:30,000 In summary, for patients undergoing thyroid lobectomy, same day discharge can be acceptable practice. 65 00:05:30,000 --> 00:05:36,000 The American Thyroid Association encourages looking at clinical, social and procedural factors 66 00:05:36,000 --> 00:05:40,000 to determine if the patient is safe for same day discharge. 67 00:05:40,000 --> 00:05:49,000 While the biggest complication is post-operative hematoma, newer technology has largely decreased the likelihood of post-operative bleeding. 68 00:05:49,000 --> 00:05:57,000 Finally, over time with favorable data, same day discharge will become common practice as surgeons adjust their risk tolerance.