Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience

THIEME Original Research Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience Sidhartha Sinha1,2 Matthew Fok1 Ijaz Ahmad2 1 Department of General and Vascular Surgery, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom of Great Britain and Northern Ireland 2 Department of General and Vascular Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, Essex, United Kingdom of Great Britain and Northern Ireland Mustafa Al-Sheikh2 Christopher Backhouse2 Address for correspondence Sidhartha Sinha, FRCS, Department of General and Vascular Surgery, Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon (e-mail: ). Int Arch Otorhinolaryngol 2020;24(3):313–318. Abstract Keywords ► Parathyroidectomy ► length of stay ► surgical outcomes ► quality improvement ► endocrine ► head and neck surgery ► short stay surgery received January 20, 2019 accepted September 8, 2019 published online December 13, 2019 Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas. The length of stay decreased from a median of 3 days (range 2–9 days; mean 3.32) preprotocol to a median of 2 days (range 2–3 days; mean 2.16) postprotocol (p < 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p ¼ 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes. DOI https://doi.org/ 10.1055/s-0039-1698777. ISSN 1809-9777. Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 313 314 Shortening Post-operative Stay after Parathyroidectomy Sinha et al. Introduction anesthetic with endotracheal intubation. Frozen section and wound drains were used selectively at the discretion of the operating surgeon. Primary hyperparathyroidism (PHP) is a common endocrine disorder with incidence rates of between 1 and 2% in certain subsets of the population.1 Parathyroidectomy remains the only method to cure PHP. However, in the UK, parathyroidectomy has historically been excluded from day-case or short-stay surgery due a reliance on Kocher-type full-cervical incisions and consequent concerns about airway-compromise and postoperative bleeding, as well as symptomatic postoperative hypocalcemia.2,3 Despite these concerns, several studies from high-volume, academic centers have demonstrated that parathyroidectomy can be safely performed with discharge on the day of surgery or on the 1st postoperative day.3–10 The purpose of the present study was to report the results of parathyroidectomy at a 'mediumvolume' endocrine unit in a District General Hospital setting before and after the implementation of a protocol intended to reduce the postoperative length of stay (LOS) by focusing on periprocedural patient education and postoperative management of calcium monitoring and supplementation. Methods Patient Cohorts This was a single-center audit and service reconfiguration project comprising a retrospective review of historical outcomes preceding service change, the introduction of a new patient-pathway and a prospective reaudit of outcomes. The historical cohort comprised consecutive patients undergoing parathyroidectomy for PHP from 2010 to 2013. Redo cases and cases with concomitant thyroid pathology requiring surgery were excluded from the cohort. The following cohort comprised consecutive patients with PHP managed under the new short-stay protocol (SSP). All of the surgeries were performed by a single general surgeon with a vascular and endocrine subspecialty interest. Procedural Technique The following steps remained constant throughout the study period. All of the patients underwent dual modality preoperative imaging with sestamibi-technetium 99m scintigraphy (MIBI) and cervical ultrasonography (USS). Computed tomography (CT) was utilized selectively (that is, in cases of suspected mediastinal disease). Patients with concordant USS and MIBI imaging that demonstrated single gland disease underwent targeted (hemicervical) incision. Those with concordant imaging demonstrating multigland disease (or where both modalities failed to identify parathyroid pathology) underwent traditional full-length Kocher cervical incision to allow bilateral neck exploration (BNE) if needed. Those with discordant imaging underwent either targeted or traditional full-length incision. Laryngoscopy was not routinely used preoperatively and was only used postoperatively if recurrent laryngeal nerve injury was suspected clinically. All of the cases were performed under general International Archives of Otorhinolaryngology Vol. 24 No. 3/2020 Perioperative Care Prior to the Introduction of the Short-stay Protocol All of the patients were admitted to a surgical ward postoperatively. Postoperative serum calcium monitoring was performed at 6 hours, 12 hours, 24 hours, 48 hours, on the 5th post-operative day (the latter as an outpatient), and at 6 weeks. Skin closure was performed with a nonabsorbable suture (Prolene, Ethicon Inc., Somerville, NJ, USA) which was removed at the bedside on the morning of the 3rd postoperative day. Patients were discharged with instructions to return to the outpatient phlebotomy department on the 5th postoperative day for a serum calcium check. Patients were (...truncated)