GlobalCast MD, along with Cincinnati Children's Hospital,
sharing knowledge to improve child health around the globe.
Hello, pediatric surgery family.
I'm Cecilia Gigena, 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 discuss in roundtable 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 this patient go home the same day?
I'm a 16-year-old female with a concerning 1 centimeter right thyroid nodule on ultrasound.
It undergoes FNA and is found to have atypia of undetermined significance, Bethesda 3.
She undergoes a straightforward right thyroid lobectomy.
Responses from the surgeons show that approximately 44% would actually keep that patient overnight and then start 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 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 what you're saying?
Yeah.
About bleeding complications following a unilateral lobectomy in adults and or in children.
Here's a single institution study.
55 pediatric patients undergoing thyroidectomy.
36 were total thyroids, lobectomy and 13.
Some had central neck dissection or lateral neck dissections and all went home after two hours.
About 10 percent had transient hypoparaperminant was 3.8 percent for hypothyroidism.
They were measuring parathyroid hormone and 1.8 percent had a post-op hematoma requiring re-operation.
But that was on post-op day six.
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 encouraged 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.
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 thyro and lobectomy,
it seems that properly identifying those patients that are suitable prior to the procedure is key to same day discharge success.
But why is holding surgeons back from same day discharges even when the data is favorable?
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 is 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.
And again, it's readmission versus length of stay.
In surgery, by the next day you would know about it.
Most bad thing. 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 objective 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 discuss next.
I think it has to do with the rate of the complication, how serious it is and when does it happen related to surgery.
I think there's a big difference on total or lobe or if you did a central dissection or even lateral dissection.
We shouldn't treat them equally, but the most fear complication that one percent who had a hematoma in this series,
it happened six days after. But that's a complication you could pick up with a 12 or 24 hour post-operative vigilance.
So 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 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 post-operative hematoma, newer technology has largely decreased the likelihood of post-operative bleeding.
Finally, over time with favorable data, same day discharge will become common practice as surgeons adjust their risk tolerance.