Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Langenbeck's Archives of Surgery
Published in: Langenbeck's Archives of Surgery 4/2020

Open Access 01-06-2020 | Hypoparathyroidism | Review Article

Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis—European Society of Endocrine Surgeons (ESES) positional statement

Authors: Kerstin Lorenz, Marco Raffaeli, Marcin Barczyński, Leyre Lorente-Poch, Joan Sancho

Published in: Langenbeck's Archives of Surgery | Issue 4/2020

Login to get access

Abstract

Introduction

Continuous efforts in surgical speciality aim to improve outcome. Therefore, correlation of volume and outcome, developing subspecialization, and identification of reliable parameters to identify and measure quality in surgery gain increasing attention in the surgical community as well as in public health care systems, and by health care providers. The need to investigate these correlations in the area of endocrine surgery was identified by ESES, and thyroid surgery was chosen for this analysis of the prevalent literature with regard to outcome and volume.

Materials and methods

A literature search that is detailed below about correlation between volume and outcome in thyroid surgery was performed and assessed from an evidence-based perspective. Following presentation and live data discussion, a revised final positional statement was presented and consented by the ESES assembly.

Results

There is a lack of prospective randomized controlled studies for all items representing quality parameters of thyroid surgery using uniform definitions. Therefore, evidence levels are low and recommendation grades are based mainly on expert and peer evaluation of the prevalent data.

Conclusion

In thyroid surgery a volume and outcome relationship exists with respect to the prevalence of complications. Besides volume, cumulative experience is expected to improve outcomes. In accordance with global data, a case load of < 25 thyroidectomies per surgeon per year appears to identify a low-volume surgeon, while > 50 thyroidectomies per surgeon per year identify a high-volume surgeon. A center with a case load of > 100 thyroidectomies per year is considered high-volume. Thyroid cancer and autoimmune thyroid disease predict an increased risk of surgical morbidity and should be operated by high-volume surgeons. Oncological results of thyroid cancer surgery are significantly better when performed by high-volume surgeons.
Literature
1.
Mansky R (2018) Structural change and minimum numbers. AWMF conference 2018
2.
Sackett DL, Haynes RB, Tugwell P (1985) (1985) Clinical epidemiology: a basic science for clinical medicine, 5th edn. Little, Brown, Boston
3.
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendation. BMJ 336:924–926PubMedPubMedCentralCrossRef
4.
Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R (1998) The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330PubMedPubMedCentralCrossRef
5.
Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, Dralle H (2000) Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg 24:1335–1341PubMedCrossRef
6.
Gourin CG, Tufano RP, Forastiere AA, Koch WM, Pawlik TM, Bristow RE (2010) Volume-based trends in thyroid surgery. Arch Otolaryngol Head Neck Surg 136:1191–1198PubMedCrossRef
7.
Loyo M, Tufano RP, Gourin CG (2013) National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope 123:2056–2063PubMedCrossRef
8.
González-Sánchez C, Franch-Arcas G, Gómez-Alonso A (2013) Morbidity following thyroid surgery: does surgeon volume matter? Langenbecks Arch Surg 398:419–422PubMedCrossRef
9.
Kandil E, Noureldine SI, Abbas A, Tufano RP (2013) The impact of surgical volume on patient outcomes following thyroid surgery. Surgery 154:1346–1352PubMedCrossRef
10.
Al-Qurayshi Z, Robins R, Hauch A, Randolph GW, Kandil E (2016) Association of surgeon volume with outcomes and cost savings following thyroidectomy: a national forecast. JAMA Otolaryngol Head Neck Surg 142:32–39PubMedCrossRef
11.
Adam MA, Thomas S, Youngwirth L, Hyslop T, Reed SD, Scheri RP, Roman SA, Sosa JA (2017) Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes? Ann Surg 265:402–407PubMedCrossRef
12.
Liang TJ, Liu SI, Mok KT, Shi HY (2016) Associations of volume and thyroidectomy outcomes: a nationwide study with systematic review and meta-analysis. Otolaryngol Head Neck Surg 155:65–75PubMedCrossRef
13.
Nouraei SA, Virk JS, Middleton SE, Aylin P, Mace A, Vaz F, Kaddour H, Darzi A, Tolley NS (2017) A national analysis of trends, outcomes and volume-outcome relationships in thyroid surgery. Clin Otolaryngol 42:354–365PubMedCrossRef
14.
Duclos A, Peix JL, Colin C, Kraimps JL, Menegaux F, Pattou F, Sebag F, Touzet S, Bourdy S, Voirin N, Lifante JC, CATHY Study Group (2012) Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ 344:d8041PubMedPubMedCentralCrossRef
15.
Mitchell J, Milas M, Barbosa G, Sutton J, Berber E, Siperstein A (2008) Avoidable reoperations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 144:899–906PubMedCrossRef
16.
Melfa G, Porello C, Cocorullo G, Raspanti C, Rotolo G, Attard A, Gullo R, Bonventre S, Gulotta G, Scerrino G (2018) Surgeon volume and hospital volume in endocrine neck surgery: how many procedures are needed for reaching a safety level and acceptable costs? A systematic narrative review. G Chir 39:5–11PubMedPubMedCentralCrossRef
17.
Lifante JC, Duclos A, Couray-Targe S, Colin C, Peix JL, Schott AM (2009) Hospital volume influences the choice of operation for thyroid cancer. Br J Surg 96:1284–1288PubMedCrossRef
18.
Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, Grond S, Mühlig HP, Richter C, Voss J, Thomusch O, Lippert H, Gastinger I, Brauckhoff M, Gimm O (2004) Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136:1310–1322PubMedCrossRef
19.
Thomusch O, Sekulla C, Billmann F, Seifert G, Dralle H, Lorenz K (2018) Prospective Evaluation Study of Thyroid Surgery (PETS 2) Study Group. Risk profile analysis and complications after surgery for autoimmune thyroid disease. Br J Surg 105:677–685PubMedCrossRef
20.
Pesce CE, Shiue Z, Tsai HL, Umbricht CB, Tufano RP, Dackiw AP, Kowalski J, Zeiger MA (2010) Postoperative hypocalcemia after thyroidectomy for Graves’ disease. Thyroid 20:1279–1283PubMedCrossRef
21.
Welch KC, McHenry CR (2011) Total thyroidectomy: is morbidity higher for Graves’ disease than nontoxic goiter? J Surg Res 170:96–99PubMedCrossRef
22.
Hallgrimsson P, Nordenström E, Almquist M, Bergenfelz AO (2012) Risk factors for medically treated hypocalcemia after surgery for Graves’ disease: a Swedish multicenter study of 1,157 patients. World J Surg 36:1933–1942PubMedCrossRef
23.
Edafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP (2014) Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg 101:307–320PubMedCrossRef
24.
25.
Rubio GA, Koru-Sengul T, Vaghaiwalla TM, Parikh PP, Farra JC, Lew JI (2017) Postoperative outcomes in Graves’ disease patients: results from the nationwide inpatient sample database. Thyroid 27:825–831PubMedCrossRef
26.
27.
28.
Bergamaschi R, Becouarn G, Ronceray J, Arnaud JP (1998) Morbidity of thyroid surgery. Am J Surg 176:71–75PubMedCrossRef
29.
Wang TS, Roman SA, Sosa JA (2008) Predictors of outcome following pediatric thyroid and parathyroid surgery. Curr Opin Oncol 21:23–28CrossRef
30.
Perera M, Ananabell L, Page D, Harding T, Gnaneswaran N, Chan S (2016) Risk factors for post-thyroidectomy haemtoma. J Laryngol Otology 130:20–25CrossRef
31.
Lorenz K, Sekulla C, Kern J, Dralle H (2015) Management of postoperative hemorrhage following thyroid surgery. Chirurg 86:17–23PubMedCrossRef
32.
Gurrado A, Bellantone R, Cavallaro G, Citton MC, Constantinides V, Conzo G, Di Meo G, Docimo G, Franco IF, Iacobone M, Lombardi CP, Materazzi G, Minuto M, Palazzo F, Pasculli A, Raffaelli M, Sebag F, Tolone S, Miccoli P, Testini M (2016) Can total thyroidectomy be safely performed by residents? Medicine 95:e3241:1-8CrossRef
33.
Meltzer C, Klau M, Gurushanthaiah D, Tsai J, Meng D, Radler L, Sundang A (2016) Surgeon volume in thyroid surgery: surgical efficiency, outcomes, and utilization. Laryngoscope 126:2630–2639PubMedCrossRef
34.
Sosa JA, Tuggle CT, Wang TS, Thomas DC, Boudourakis L, Rivkees S, Roman SA (2008) Clinical and economic outcomes of thyroid and parathyroid surgery in children. J Clin Metab 93:3058–3065CrossRef
35.
Tuggle CT, Roman S, Udelsman R, Sosa JA (2011) Same-day thyroidectomy: a review of practice patterns and outcomes for 1,168 procedures in New York State. Ann Surg Oncol 18:1035–1040PubMedCrossRef
36.
Mishra A, Agarwal G, Agarwal A, Mishra SK (1999) Safety and efficacy of total thyroidectomy in hands of endocrine surgery trainees. Am J Surg 178:377–380PubMedCrossRef
37.
Stavrakis AI, Ituarte P, Ko CY, Yeh MW (2007) Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery 142:887–899PubMedCrossRef
38.
Sosa JA, Mehta PJ, Wang TS, Boudourakis L, Roman SA (2008) A population-based study of outcomes from thyroidectomy in aging Americans: at what cost? J Am Coll Surg 206:1097–1105PubMedCrossRef
39.
Hauch A, Al-Qurayshi Z (2014) Total thyroidectomy is associated with increased risk of complications for low- and high volume surgeons. Ann Surg Oncol 21:3844–3852PubMedCrossRef
40.
Boudourakis LD, Wang TS, Roman SA, Desai R, Sosa JA (2009) Evolution of the surgeon-volume, patient-outcome relationship. Ann Surg 250:159–165PubMedCrossRef
41.
Promberger R, Ott J, Kober F, Koppitsch C, Seemann R, Freissmuth M, Hermann M (2012) Risk factors for postoperative bleeding after thyroid surgery. Br J Surg 99:373–379PubMedCrossRef
42.
Campbell MJ, McCoy KL, Shen WT, Carty SE, Lubitz CC, Moalem J, Nehs M, Holm T, Greenblatt DY, Press D, Feng X, Siperstein AE, Mitmaker E, Benay C, Tabah R, Oltmann SC, Chen H, Sippel RS, Brekke A, Vriens MR, Lodewijk L, Stephen AE, Nagar S, Angelos P, Ghanem M, Prescott JD, Zeiger MA, Aragon P, Sturgeon C, Elaraj DM, Nixon IJ, Patel SG, Bayles SW, Heneghan R, Ochieng P, Guerrero MA, Ruan DT (2013) A multi-institutional international study of risk factors for hematoma after thyroidectomy. Surgery 154:1283–1291PubMedCrossRef
43.
Tuggle CT, Roman SA, Wang TS, Boudourakis L, Thomas DC, Udelsman R, Sosa JA (2008) Pediatric endocrine surgery: who is operating on our children? Surgery 144:869–877PubMedCrossRef
44.
Adkisson CD, Howell GM, McCoy KL, Armstrong MJ, Kelley ML, Stang MT, Joyce JM, Hodak SP, Carty SE, Yip L (2014) Surgeon volume and adequacy of thyroidectomy for differentiated thyroid cancer. Surgery 156:1453–1460PubMedCrossRef
45.
Godballe C, Madsen AR, Pedersen HB, Sørensen CH, Pedersen U, Frisch T, Helweg-Larsen J, Barfoed L, Illum MJE, Becker B, Nielsen T (2009) Post-thyroidectomy hemorrhage: a national study of patients treated at the Danish departments of ENT head and neck surgery. Eur Arch Otorhinolaryngol 266:1945–1952PubMedCrossRef
46.
Weiss A, Lee KC, Brummund KT, Chang DC, Bouvet M (2014) Risk factors for hematoma after thyroidectomy: results from the nationwide inpatient sample. Surgery 156:399–404PubMedCrossRef
47.
Dehal A, Abbas A, Al-Tememi M, Hussain F, Johna S (2014) Impact of surgeon volume on incidence of neck hematoma after thyroid and parathyroid surgery: ten years’ analysis of nationwide in-patient sample database. Am Surg 80:948–952PubMedCrossRef
48.
Maneck M, Dotzenrath C, Dralle H, Fahlenbach C, Paschke R, Steinmüller T, Tusch E, Jeschke E, Günster C (2017) Complications after thyroid gland operations in Germany. A routine data analysis of 66,902 AOK patients. Chirurg 88:50–57PubMedCrossRef
49.
Morton RP, Vandal AC (2015) Postoperative systolic blood pressure as a risk factor for haematoma following thyroid surgery. Otolaryngol Head Neck Surg 40:462–467
50.
Bartsch DK, Dotzenrath C, Vorländer C, Zielke A, Weber T, Buhr HJ, Klinger C, Lorenz K (2019) J Clin Med 8(477):1–10
51.
Shoback DM, Bilezikian JP, Costa AG, Dempster D, Dralle H, Khan AA, Peacock M, Raffaelli M, Silva C, Thakker RV, Vokes T, Roger Bouillon R (2016) Presentation of hypoparathyroidism: etiologies and clinical features. J Clin Endocrinol Metab 10:2300–2312CrossRef
52.
Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, Pelizzo MR, Pezzullo L (2004) Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 28:271–276PubMedCrossRef
53.
Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, Wallin G, Lausen I (2008) Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 393:667–673PubMedCrossRef
54.
Kim HI, Kim TH, Choe J-H, Kim J-H, Kim JS, Kim YN, Kim H, Kim SW, Chung JH (2018) Surgeon volume and prognosis of patients with advanced papillary thyroid cancer and lateral nodal metastasis. Br J Surg 105:270–278PubMedCrossRef
55.
Papaleontiou M, Hughes DT, Guo C, Banerjee M, Haymart MR (2017) Population-based assessment of complications following surgery for thyroid cancer. J Clin Endocrinol Metab 102:2543–2551PubMedPubMedCentralCrossRef
56.
Youngwirth LM, Adam MA, Scheri RP, Roman SA, Sosa JA (2016) Patients treated at low volume centers have higher rates of incomplete resection and compromised outcomes: analysis of 31,129 patients with papillary thyroid cancer. Ann Surg Oncol 23:403–409PubMedCrossRef
57.
Oltmann SC, Schneider DF, Leverson G, Sivashanmugam T, Chen H, Sippel RS (2014) Radioactive iodine remnant uptake after completion thyroidectomy: not such a complete cancer operation. Ann Surg Oncol 21:1379–1383PubMedCrossRef
58.
Yap BK, Homer J, Parrott N, Loughran S, Murby B, Swindell R, Ghandi A (2013) Use of pre-ablation radioiodine-131 scan to assess the impact of surgical volume and specialisation following thyroidectomy for differentiated thyroid carcinoma. Eur Thyroid J 2:27581CrossRef
59.
60.
Bilimoria KY, Zanocco K, Sturgeon C (2008) Impact of surgical treatment on outcomes for papillary thyroid cancer. Adv Surg 42:1–12PubMedCrossRef
61.
Raffaelli M, De Crea C, D’Amato G, Moscato U, Bellantone C, Carrozza C, Lombardi CP (2016) Post-thyroidectomy hypocalcemia is related to parathyroid dysfunction even in patients with normal parathyroid hormone concentrations early after surgery. Surgery 159:78–84PubMedCrossRef
62.
Lorente-Poch L, Sancho JJ, Ruiz S, Sitges-Serra A (2015) Importance of in situ preservation of parathyroid glands during total thyroidectomy. Br J Surg 102:359–367PubMedCrossRef
63.
Coan KE, Wang TS (2017) Importance of surgeon experience in the surgical management of thyroid cancer. In: Roman SA, Sosa JA, Solórzano CC (eds) Management of thyroid nodules and differentiated thyroid cancer, 1st edn. Springer International Publishing, Cham, Switzerland., pp 187–198CrossRef
Metadata
Title
Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis—European Society of Endocrine Surgeons (ESES) positional statement
Authors
Kerstin Lorenz
Marco Raffaeli
Marcin Barczyński
Leyre Lorente-Poch
Joan Sancho
Publication date
01-06-2020
Publisher
Springer Berlin Heidelberg
Published in
Langenbeck's Archives of Surgery / Issue 4/2020
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI
https://doi.org/10.1007/s00423-020-01907-x

Other articles of this Issue 4/2020

Langenbeck's Archives of Surgery 4/2020 Go to the issue

Systematic Reviews and Meta-analyses

Fixation versus no fixation in laparoscopic totally extraperitoneal repair of primary inguinal hernia—a systematic review and meta-analysis of randomized controlled trials

Letter to the Editor

Public expectations, consenting rules and professional probity require a change in the current provision of surgical care for endocrine tumours

How-I-Do-It articles

Prevention of intra-thoracic recurrent laryngeal nerve injury with robot-assisted esophagectomy

Original Article

Results of laparoscopic resection in high-risk rectal cancer patients

How-I-Do-It articles

Non-flap hand-sewn esophagogastrostomy as a simple anti-reflux procedure in laparoscopic proximal gastrectomy for gastric cancer

Original Article

Atypical femoral hernia called Laugier’s hernia: clinical features, radiological findings, and management at a single center