2016 November-December; 37(6): 250–256. ISSN: 1971-145X
Published online 2017 March 29. doi: 10.11138/gchir/2016.37.6.250.

Early discharge after total thyroidectomy: a retrospective feasibility study

F. TARTAGLIA,1 A. GIULIANI,2 S. SORRENTI,1 L. TROMBA,1 S. CARBOTTA,1 A. MATURO,1 G. CARBOTTA,1 L. DE ANNA,1 R. MEROLA,1 G. LIVADOTI,1 F. PELLE,1 and S. ULISSE1

1Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy
2Department of Environment and Health, “Istituto Superiore di Sanità”, Rome, Italy

Corresponding author: Francesco Tartaglia, e-mail: francesco.tartaglia@uniroma1.it

Abstract

Aim
The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study.

Patients and methods
Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis.

Results
As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge.

Conclusion
On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.

Keywords: Total thyroidectomy, Early discharge, Hypocalcemia, Postoperative bleeding, Recurrent laryngeal nerve palsy

Introduction

In the last years the need to contain health spending has been a must to research the possibility of outpatient surgical services, day hospital and day surgery, for an increasing number of diseases (1, 2). Thyroid surgery was no exception. In Italy thyroid surgery is performed on an inpatient basis, mostly consisting in short admissions in week surgery departments with discharge to 48–72 hours after surgery, but several were the contributions in the literature in favour of an early discharge surgery (37), and some recommend at least an overnight stay (8, 9). In the United States for years outpatient surgery with discharge on the same day of surgery has had a broad appeal and the rate of thyroid surgical procedures on an outpatient basis over the past 10 years has risen to 39% (10), thanks to the use of outstanding centers.

The causes that are opposed to early discharge are possible bleeding complications, inferior laryngeal nerves palsy and hypocalcemia (1114), but unlike the first two which are generally well detectable within the first 24 hours after surgery, the latest one is called into question, as often detectable beyond 24–48 hours after surgery (6, 1520).

Therefore in recent years the goal of researchers has been to predict which patients will undergo postoperative hypocalcemia or worse symptomatology related to it which could lead to a readmission in Hospital, through the evaluation of certain parameters that could have this predictive role. In particular total serum calcium, ionized calcium, the serum phosphorus, serum intact PTH have been used with different qualitative and quantitative methods, that make it difficult to compare across studies (2130, 31, 32, 33). We too in the past published our studies on the subject (3440) without getting to definitive results. Still open is also the controversy about postoperative calcium and Vit. D supplementation as prophylaxis of hypocalcemia (4044) and the influence that the malignancy can determine on the percentage of transient or permanent hypoparathyroidism (4548).

The aim of this study was to assess whether, having only the serum calcium and PTH values of preoperative and in the first postoperative day, we can identify with sufficient certainty, that is, making few mistakes, which patients can be discharged 24 hours after total thyroidectomy without incurring in hypocalcemic complications that could lead to a readmission in Hospital.

Patients and Methods

Our retrospective study considered 355 consecutive patients treated by total thyroidectomy in our Department, both for benign and neoplastic disease, between January 1, 2013 and June 30, 2016. Exclusion criteria from the study were: completion thyroidectomy, Basedow disease, association of central and/or laterocervical lymphadenectomy procedures, autotransplantation of the parathyroid glands during surgery, occurrence of postoperative bleeding that led to a new surgery, onset of mono or bilateral inferior laryngeal nerves palsy, medications that interfere with the metabolism of calcium. Therefore, the number of patients who met the inclusion criteria of the study were 327 in total, 58 men (17.74%) and 269 women (82.26%).

The average age was 53.25 years of total patients (57.2 for men and 52.42 for women). The values of preoperative serum calcium (Cal0) and in the first day after surgery (Cal1) were evaluated and two new variables (dCal and dCaln) were calculated, corresponding respectively to the difference and the normalized difference in percentage between the preoperative serum calcium values and those of the the first day after surgery (dCal = Cal0 - Cal1; dCaln = dCal/Cal0×100).

In 111 of 327 patients preoperative PTH values (PTH0) and on the first postoperative day (PTH1) were also reported.

Even for PTH two new variables were constructed (dPTH and dPTHn), corresponding respectively to the difference and the normalized difference in percentage between the preoperative PTH values and those of the first postoperative day (dPTH = PTH0 - PTH1; dPTHn = dPTH/PTH0×100).

We classified patients retrospectively into “dischargeable” or “not dischargeable”, on the basis of their postoperative courses and the presence or absence of signs and / or symptoms of hypocalcemia.

We then divided the total of patients into two groups: benign (Diag=0) and neoplastic (Diag=1), according to the definitive histological diagnosis, to see if the presence or absence of neoplasia could influence the performance of the considered variables and the suitability for discharge. In the entire group neoplastic patients were 83, while the benign ones were 244. In the subgroup of 111 patients with PTH values there were 26 neoplastic and 85 benign patients.

The statistical analysis of data was performed with linear discriminant analysis and with two-way analysis of variance (ANOVA); the correlation coefficients were calculated with Pearson’s coefficient; the Student t test was used to compare the two groups of suitability for discharge. A p <0.05 was considered as significant.

Results

Descriptive statistics on the entire set of 327 patients tell us that the dCal value is on average 1.06 mg/dl (SD 0.77), corresponding to a decline average of 11.34% (SD 28.8) while in the 111 patients who also had the PTH values, the dPTH was an average of 24.92 pg/L (SD 24.47) (Table 1).

Table 1Table 1
DESCRIPTIVE STATISTICS OF THE ENTIRE GROUP OF PATIENTS (N=327) AND OF THE SUBGROUP OF PATIENTS WITH PTH VALUES (N=111).

Patients safely dischargeable to 24 hours after surgery were 228 (69.72%) and those not dischargeable were 99 (30.28%).

We then applied a discriminant function to find the best linear criterion, function of the 4 parameters of difference (dCAL, dCaln, dPTH, dPTHn), to separate the two groups of suitability for discharge making the fewest errors. Applying the discriminant function to the total of patients we see that the criterion has a significant but rather low predictive power, at around 73.25%. The same procedure applied to the group of 111 patients with PTH values also shows a predictive power that reaches 78.75% (Table 2).

Table 2Table 2
DISCRIMINANT ANALYSIS. NUMBER OF OBSERVATIONS (ENTIRE GROUP AND PTH GROUP) AND PERCENT CLASSIFIED INTO DISCHARGE24H. THE CASES YES-YES AND NO-NO (IN BOLD) ARE THE RIGHT PREDICTIONS.

The next step was to see if we could identify a threshold, of one or more variables, that would allow us to discharge safely (below the threshold) a patient in the first postoperative day, agreeing to have false positives (not discharging dischargeable patients) but not false negatives (discharging not dischargeable patients). This can be achieved only if there is a sufficient number of dischargeable patients below the not dischargeable patient with the lowest delta. The two groups are significantly different for all 4 parameters but observing the minimum and the maximum values it is not possible to achieve the desired purpose (Table 3).

Table 3Table 3
THE CLASSIC t-test (POOLED) IS USED AS THE VARIANCES IN THE TWO GROUPS ARE COMPARABLE, THEREFORE THE SATTERTHWAITE CORRECTION IS NOT NECESSARY.

Finally, we applied the same statistical tools, dividing patients according to the diagnosis. Descriptive statistics tell us that there are major differences between the two groups, but we wanted to control, with a two-way analysis of variance (GLM procedures), if the differences between dischargeable and not dischargeable patients were different entities for the two diagnostic groups (malignant/benign).

The result is that there are small but significant differences for dCal and dCaln in the malignant/benign comparison, but no significant difference in the interaction between the suitability for discharge and diagnosis (Table 4).

Table 4Table 4
TWO-WAY ANALYSIS OF VARIANCE (GLM PROCEDURE). IN BOLD SIGNIFICATIVE VALUES.

As expected, the discriminant analysis predictive power is always the same, at around 70%, as in the global set, for the two separate groups (a bit higher, at around 80%, for patients with benign diagnosis in the PTH subgroup) (Table 5).

Table 5Table 5
DISCRIMINANT ANALYSIS. THE CASES YES-YES AND NO-NO (IN BOLD) ARE THE RIGHT PREDICTIONS.

Similar arguments are for the correlations between parameters within classes that follow the same pattern of the undivided group.

Discussion

The possibility to perform thyroid surgery in day surgery regimen must be obviously linked to the achievement, in a shorter time, of the same results as in traditional surgery regimen. Major complications of thyroid surgery that may object to an early discharge are well known and consist essentially in postoperative bleeding, inferior laryngeal nerves palsy and especially hypocalcemia. Risk factors for thyroid surgery complications include older age, male sex, thyroid malignancy, greater extent of operation, reoperative procedures, increasing nodule size, and surgeon inexperience (49, 50). Recent improvements in hemostasis (including proliferation of advanced energy devices), widespread implementation of nerve monitoring, and routine postoperative calcium supplementation appear to have decreased these risks (51). The bleeding is usually evident within the first 24 hours after surgery and more frequent in the first 6 postoperative hours, being late hemorrhages rare (8, 50, 52). Inferior laryngeal nerves palsy also generally arises early, in about 87% of cases, with the appearance of dysphonia within the first 24 hours after surgery, but later onsets are also described, up to 14 days after surgery, in the remaining 13% of cases (5357). Conversely postoperative hypocalcemia may also occur after 48–72 hours after surgery, and is the most common cause of prolonged hospitalization after thyroid surgery (15, 58). Transient hypocalcemia may occur in 25% of patients undergoing bilateral thyroid surgery and is permanent in 0.9–14% of cases (59, 60). So, predicting which patients will be affected by hypocalcemic complication within the first 24 hours, is critical for planning an early discharge. There are many studies in the literature that have used determination of serum calcium and PTH in the immediate postoperative hours, as predictive values for hypocalcemia, In our study we also used these parameters, because they are of easier acquisition, but comparing these to the preoperative values, convinced that the predictive value against suitability for discharge is related more to the variation of these parameters than to their absolute value. For this purpose we have built dCal, dCaln, dPTH and dPTHn variables. Descriptive statistics have revealed to us how the difference between the preoperative serum calcium values, and those in the first postoperative day was 1.06 mg/dl on average, while the dPTH was an average of 24.92 pg/L. So not particularly big differences.

We then applied a discriminant function to find the best straight-line basis, according to the 4-parameter difference (dCal, dCaln, dPTH, dPTHn), to separate the two groups of suitability for discharge making fewer errors. The discriminant function is immediately usable by multiplying its coefficients to the values for each patient. You have thus obtained a score for the “no” and a score for the “yes”. If the score for the no is higher than the score for the yes, the patient is not dischargeable and vice versa. The matrix that is generated is called “confusion matrix” where the rows are the true state of suitability for discharge observed, while the columns are the forecasts of the mathematical criterion (discriminant function). The yes-yes and no-no cases are the right predictions, the others are errors. The predictive power of the criterion for the entire group of patients, around 73%, appeared significant, but still too low and clinically unacceptable because it is unthinkable to apply it without incurring in the 27% of errors. Although the predictive power, calculated only on the group of patients with the values of PTH, is significant and with an almost 79% higher value, even in this case the clinical inapplicability is evident, since in any case we would experience a 21% rate of error. Then the determination of PTH adds something in terms of predictability but it is not sufficient.

Even the attempt to identify a threshold value of one or more parameters that allow us to safely discharge a large number of patients agreeing to have false positives (not discharging dischargeable patients) but not false negatives (discharging not dischargeable patients) has not produced the desired results, as observing the minimum and maximum values of the two groups, it appears how the threshold below which we can be sure that the patient is dischargeable would identify only a small number of patients.

Finally the analysis made by dividing patients according to the diagnosis (benign vs malignant) has shown us that, apart from the great differences already known about the suitability for discharge, there are slightly significant differences for dCal and dCaln but no differences in the interaction between suitability for discharge and diagnosis in the two groups. This means that although there is a global difference in serum calcium values between benign patients and those with cancer, this difference is unsignificant as to the differential suitability for discharge of the two groups, because the differences dischargeable/not dischargeable are of the same magnitude.

Several studies have shown that the costs of traditional thyroid surgery are significantly higher than those of thyroid surgery in the short hospitalization regimen (6163), but we believe that, beyond a fair health economical planning, patient safety must always be a priority.

Conclusion

Our study has shown that no one can use the values of serum calcium and PTH, 24 hours after total thyroidectomy, to define which and how many patients can be discharged without incurring in hypocalcemic complication. Of course, along with laboratory criteria, also clinical considerations can affect the choice. We believe that early discharge to 24 hours after surgery, in the absence of structures such as American outstanding centers, is not safe and we will continue to monitor our patients for at least 48 hours after surgery, until a safe criterion of early discharge is identified.

Footnotes

Disclosure

The Authors have no conflict of interest or any financial support.

References
1.
Guzzanti E, Mastrilli F. Analisi costi-benefici. Aspetti organizzativo sanitari. Tecnologie per la Sanità. 1991;10:85–98.
2.
Pepe N, Actis Dato GM, Vennarecci G, Anselmo A. Office surgery: problematiche organizzative, legislative e medico-legali. Min Chir. 1993;48:1361–6.
3.
Steckler RM. Outpatient thyroidectomy: a feasibility study. Am J Surg. 1986;152:417–9.
4.
Lo Gerfo P. Local/regional anesthesia for thyroidectomy: evaluation as an outpatient procedure. Surgery. 1998;124:975–8.
5.
Spanknebel K, Chabot JA, Di Giorgi M, Cheung K, Curty J, Allendorf J, LoGerfo P. Thyroidectomy using monitored local or conventional general anesthesia: an analysis of outpatient surgery, outcome and cost in 1,194 consecutive cases. World J Surg. 2006;30:813–24.
6.
Lo Gerfo P, Gates R, Gazetas P. Outpatient and short-stay thyroid surgery. Head Neck. 1991;13:97–101.
7.
Mowschenson PM, Hodin RA. Outpatient thyroid and parathyroid surgery: a prospective study of feasibility, safety, and costs. Surgery. 1995;118:1051–3.
8.
Ayala MA, Yencha MW. Outpatient Thyroid Surgery in a Low-Surgical Volume Hospital. World J Surg. 2015;39:2253–2258.
9.
Menegaux F. Ambulatory thyroidectomy: recommendations from the Association Francophone de Chirurgie Endocrinienne (AFCE). Investigating current practices. J Visc Surg. 2013;150(3):165–171.
10.
Sun GH, De Monner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996–2006. Thyroid. 2013;23:727–33.
11.
Pironi D, Pontone S, Vendettuoli M, Podzemny V, Mascagni D, Arcieri S, Panarese A, Felli E, Filippini A. Prevention of complications during reoperative thyroid surgery. Clin Ter. 2014;165(4):285–90.
12.
Pironi D, Panarese A, Candioli S, Manigrasso A, La Gioia G, Romani AM, Arcieri S, Mele R, Filippini A. Reoperative thyroid surgery: personal experience and review of the literature. G Chir. 2008;29(10):407–12.
13.
Calò PG, Tatti A, Farris S, Piga G, Malloci A, Nicolosi A. Substernal goiter: personal experience. Ann Ital Chir. 2005;76(4):331–5.
14.
Calò PG, Erdas E, Medas F, Pisano G, Barbarossa M, Pomata M, Nicolosi A. Late Bleeding after Total Thyroidectomy: Report of Two Cases occurring 13 Days after Operation. Clin Med Insights Case Rep. 2013;23(6):165–70.
15.
Schlottmann F, Campos Arbulú AL, Sadava EE, Mendez P, Pereyra L, Fernández Vila JM, Mezzadri NA. Algorithm for early discharge after total thyroidectomy using PTH to predict hypocalcemia: prospective study. Langenbecks Arch Surg. 2015;400:831–836.
16.
Snyder SK, Hamid KS, Roberson CR, Rai SS, Bossen AC, Luh JH, Scherer EP, Song J. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg. 2010;210:575–584.
17.
Scurry WC, Beus KS, Hollenbeak CS, Stack BC Jr. Perioperative parathyroid hormone assay for the diagnosis and management of post-thyroidectomy hypocalcemia. Laryngoscope. 2005;115:1362–1366.
18.
Bukey SH, van Heerden JA, Thompson GB, Grant CS, Schleck CD, Farley DR. Reexploration for symptomatic hematomas after cervical exploration. Surgery. 2001;130:914–920.
19.
Leyre P, Desurmont T, Lacoste L, Odasso C, Bouche G, Beaulieu A, Valagier A, Charalambous C, Gibelin H, Debaene B, Kraimps JL. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg. 2008;393:733–737.
20.
Rutledge J, Siegel E, Belcher R, Bodenner D, Stack BC Jr. Barriers to Same-Day Discharge of Patients Undergoing Total and Completion Thyroidectomy. Otolaryngol Head Neck Surg. 2014;150(5):770–4.
21.
Grodski S, Farrell S. Early postoperative PTH levels as a predictor of hypocalcemia and facilitating safe early discharge after total thyroidectomy. Asian J Surg. 2007;30:178–82.
22.
Khafif A, Pivoarov A, Medina JE, Avergel A, Gil Z, Fliss DM. Parathyroid hormone: a sensitive predictor of hypocalcemia following total thyroidectomy. Otolaryngol Head Neck Surg. 2006;134:907–10.
23.
Vescan A, Witterick I, Freeman J. Parathyroid hormone as a predictor of hypocalcemia after thyroidectomy. Laryngoscope. 2005;115:2105–8.
24.
Sywak MS, Palazzo FF, Yeh M, Wilkinson M, Snook K, Sidhu SB, Delbridge LW. Parathyroid hormone assay predicts hypocalcemia after total thyroidectomy. ANZ J Surg. 2007;77:667–670.
25.
Lombardi CP, Raffaelli M, Princi P, Santini S, Boscherini M, De Crea C, Traini E, D’Amore AM, Carrozza C, Zuppi C, Bellantone R. Early prediction of post-thyroidectomy hypocalcemia by one single iPTH measurement. Surgery. 2004;136:1236–1241.
26.
Sam AH, Dhillo WS, Donaldson M, Moolla A, Meeran K, Tolley NS, Palazzo FF. Serum phosphate predicts temporary hypocalcemia following thyroidectomy. Clin Endocrinol (Oxf). 2011;74:388–393.
27.
AlQahtani A, Parsyan A, Payne R, Tabah R. Parathyroid hormone levels 1 hour after thyroidectomy: an early predictor of postoperative hypocalcemia. Can J Surg. 2014;57(4):237–240.
28.
Sands N, Young J, Mac Namara E, Black MJ, Tamilia M, Hier MP, Payne RJ. Preoperative parathyroid hormone levels as a predictor of post-thyroidectomy hypocalcemia. Otolaryngol Head Neck Surg. 2011;144:518–521.
29.
Chapman DB, French CC, Leng X. Parathyroid hormone early percent change: an individualized approach to predict post-thyroidectomy hypocalcemia. Am J Otolaryngol. 2012;33:216–220.
30.
Edafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg. 2014;101(4):307–320.
31.
Noureldine SI, Genther DJ, Lopez M, Agrawal N, Tufano RP. Early Predictors of Hypocalcemia After Total Thyroidectomy: An Analysis of 304 Patients Using a Short-Stay Monitoring Protocol. JAMA Otolaryngol Head Neck Surg. 2014;140(11):1006–1013.
32.
Youngwirth L, Benavidez J, Sippel R, Chen H. Postoperative parathyroid hormone testing decreases symptomatic hypocalcemia and associated emergency room visits after total thyroidectomy. Surgery. 2010;148:841–844.
33.
Nelson KL, Hinson AM, Lawson BR, Middleton D, Bodenner DL, Stack BC Jr. Postoperative Calcium Management in Same-Day Discharge Thyroid and Parathyroid Surgery. Otolaryngology-Head and Neck Surgery. 2016;154(5):854–860.
34.
Tartaglia F, Blasi S, Giuliani A, Merola R, Livadoti G, Krizzuk D, Tortorelli G, Tromba L. Parathyroid autotransplantation during total thyroidectomy. Results of a retrospective study. Int J Surg. 2016;28(Suppl 1):S79–83.
35.
Conzo G, Avenia N, Ansaldo GL, Calò P, De Palma M, Dobrinja C, Docimo G, Gambardella C, Grasso M, Lombardi CP, Pelizzo MR, Pezzolla A, Pezzullo L, Piccoli M, Rosato L, Siciliano G, Spiezia S, Tartaglia E, Tartaglia F, Testini M, Troncone G, Signoriello G. Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series. Endocrine. 2016 Apr 13;
36.
Tartaglia F, Giuliani A, Sgueglia M, Patrizi G, Di Rocco G, Blasi S, Russo G, Tortorelli G, Giannotti D, Redler A. Is ionized calcium a reliable predictor of hypocalcemia after total thyroidectomy? A before and after study. G Chir. 2014;35(1–2):27–35.
37.
Baldini E, Tuccilli C, Prinzi N, Sorrenti S, Falvo L, De Vito C, Catania A, Tartaglia F, Mocini R, Coccaro C, Alessandrini S, Barollo S, Mian C, Antonelli A, De Antoni E, D’Armiento M, Ulisse S. Deregulated expression of Aurora kinases is not a prognostic biomarker in papillary thyroid cancer patients. PLoS One. 2015;10(3):e0121514.
38.
Tartaglia F, Salvatori FM, Pichelli D, Sgueglia M, Blasi S, Custureri F. Preoperative embolization of thyroid arteries in a patient with a large cervicomediastinal hyperfunctioning goiter. Thyroid. 2007;17(8):787–92.
39.
Tartaglia F, Sgueglia M, Muhaya A, Cresti R, Mulas MM, Turriziani V, Campana FP. Complications in total thyroidectomy: our experience and a number of considerations. Chir Ital. 2003;55(4):499–510.
40.
Tartaglia F, Giuliani A, Sgueglia M, Biancari F, Juvonen T, Campana FP. Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy. Am J Surg. 2005;190(3):424–9.
41.
Tartaglia F, Blasi S, Tromba L, Sgueglia M, Russo G, Di Matteo FM, Carbotta G, Campana FP, Berni A. Duplex ultrasound and magnetic resonance imaging of the supra-aortic arches in patients with non recurrent inferior laryngeal nerve: a comparative study. G Chir. 2011 May;32(5):245–50.
42.
Tromba L, Blasi S, Vestri A, Kiltzanidi D, Tartaglia F, Redler A. Prevalence of chronic cerebrospinal venous insufficiency in multiple sclerosis: a blinded sonographic evaluation. Phlebology. 2015 Feb;30(1):52–60.
43.
Roh JL, Park CI. Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy. Am J Surg. 2006;192:675–58.
44.
Carter Y, Chen H, Sippel RS. An iPTH based protocol for the prevention and treatment of symptomatic hypocalcemia after thyroidectomy. J Surg Res. 2014;186(1):1–13.
45.
Baldini E, Sorrenti S, Di Gioia C, De Vito C, Antonelli A, Gnessi L, Carbotta G, D’Armiento E, Miccoli P, De Antoni E, Ulisse S. Cervical lymph node metastases from thyroid cancer: does thyroglobulin and calcitonin measurement in fine needle aspirates improve the diagnostic value of cytology? BMC ClinPathol. 2013;13:7.
46.
Baldini E, Sorrenti S, D’Armiento E, Di Matteo FM, Catania A, Ulisse S. The urokinase plasminogen activating system in thyroid cancer: clinical implications. G Chir. 2012;33(10):305–10.
47.
Conzo G, Calo’ PG, Sinisi De Bellis AA, Pasquali D, Iorio S, Tartaglia E, Mauriello C, Gambardella C, Cavallo F, Medas F, Polistena A, Santini L, Avenia N. Impact of prophylactic central compartment neck dissection on locoregional recurrence of differentiated thyroid cancer in clinically node-negative patients: A retrospective study of a large clinical series. Surgery. 2014;155(6):998–1005.
48.
Pezzolla A, Docimo G, Ruggiero R, Monacelli M, Cirocchi R, Parmeggiani D, Conzo G, Gubitosi A, Lattarulo S, Ciampolillo A, Avenia N, Docimo L, Palasciano N. Incidental thyroid carcinoma: a multicentric experience. Recenti Prog Med. 2010;101(5):194–8.
49.
Terris DJ, Snyder S, Carneiro-Pla D, Inabnet WB 3rd, Kandil E, Orloff L, Shindo M, Tufano RP, Tuttle RM, Urken M, Yeh MW. American Thyroid Association Surgical Affairs Committee Writing Task Force. American Thyroid Association Statement on Outpatient Thyroidectomy. Thyroid. 2013;23:1193–202.
50.
Lang BH, Yih PC, Lo CY. A review of risk factors and timing for postoperative hematoma after thyroidectomy: is outpatient thyroidectomy really safe? World J Surg. 2012;36:2497–502.
51.
Segel MD, Duke WS, White JR, Waller JL, Terris DJ. Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients. Surgery. 2016;159(2):518–23.
52.
Zarnegar R, Brunaud L, Clark OH. Prevention, evaluation and management of complications following thyroidectomy for thyroid carcinoma. Endocrinol Metab Clin North Am. 2003;32:483–502.
53.
Il’icheva EA, Shpakova EA, Ro TA, Makhutov VN, Tarnueva IF, Moshkova ES. Specific features of laryngeal paresis following surgical treatment of diffuse toxic goiter (a prospective longitudinal passive study). Vestn Otorinolaringol. 2011;3:51–4.
54.
Serpell JW, Lee JC, Yeung MJ, Grodski S, Johnson W, Bailey M. Differential recurrent laryngeal nerve palsy rates after thyroidectomy. Surgery. 2014;156(5):1157–66.
55.
Jensen PV, Jelstrup SM, Homøe P. Long-term outcomes after total thyroidectomy. Dan Med J. 2015;62(11):A5156.
56.
Enomoto K, Uchino S, Watanabe S, Enomoto Y, Noguchi S. Recurrent laryngeal nerve palsy during surgery for benign thyroid diseases: risk factors and outcome analysis. Surgery. 2014;155(3):522–8.
57.
Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery: a meta-analysis. Formos Med Assoc. 2013;112(8):463–72.
58.
Randolph GW, Kamani D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery. 2006;139:357–62.
59.
Chow TL, Choi CY, Chiu AN. Postoperative PTH monitoring of hypocalcemia expedites discharge after thyroidectomy. Am J Otolaryngol. 2014;35:736–40.
60.
Carr AA, Yen TW, Fareau GG, Cayo AK, Misustin SM, Evans DB, Wang TS. A single parathyroid hormone level obtained 4 hours after total thyroidectomy predicts the need for postoperative calcium supplementation. J Am Coll Surg. 2014;219:757–64.
61.
Marino M, Spencer H, Hohmann S, Bodenner D, Stack BC Jr. Costs of outpatient thyroid surgery from the University Health System Consortium (UHC) database. Otolaryngol Head Neck Surg. 2014;150(5):762–9.
62.
Terris DJ, Moister B, Seybt MW, Gourin CG, Chin E. Outpatient thyroid surgery is safe and desirable. Otolaryngol Head Neck Surg. 2007;136:556–559.
63.
McHenry CR. “Same-day” thyroid surgery: an analysis of safety, cost savings, and outcome. Am Surg. 1997;63:586–590.