A Novel and Generic Workflow of Indocyanine Green Perfusion Assessment Integrating Standardization and Quantification Toward Clinical Implementation.

OBJECTIVE: This study aims to generate a reproducible and generalizable Workflow model of ICG-angiography integrating Standardization and Quantification (WISQ) that can be applied uniformly within the surgical innovation realm independent of the user. SUMMARY BACKGROUND DATA: Tissue perfusion based on indocyanine green (ICG)-angiography is a rapidly growing application in surgical innovation. Interpretation of results has been subjective and error-prone due to the lack of a standardized and quantitative ICG-workflow and analytical methodology. There is a clinical need for a more generic, reproducible, and quantitative ICG perfusion model for objective assessment of tissue perfusion. METHODS: In this multicenter, proof-of-concept study, we present a generic and reproducible ICG-workflow integrating standardization and quantification for perfusion assessment. To evaluate our model's clinical feasibility and reproducibility, we assessed the viability of parathyroid glands after performing thyroidectomy. Biochemical hypoparathyroidism was used as the postoperative endpoint and its correlation with ICG quantification intraoperatively. Parathyroid gland is an ideal model as parathyroid function post-surgery is only affected by perfusion. RESULTS: We show that visual subjective interpretation of ICG-angiography by experienced surgeons on parathyroid perfusion cannot reliably predict organ function impairment postoperatively, emphasizing the importance of an ICG quantification model. WISQ was able to standardize and quantify ICG-angiography and provided a robust and reproducible perfusion curve analysis. A low ingress slope of the perfusion curve combined with a compromised egress slope was indicative for parathyroid organ dysfunction in 100% of the cases. CONCLUSION: WISQ needs prospective validation in larger series and may eventually support clinical decision-making to predict and prevent postoperative organ function impairment in a large and varied surgical population.

Reoperative Cervical Endocrine Surgery: Appropriate Valuation for the Time and Effort?

BACKGROUND: Controversies currently exist regarding the best way to appropriately quantify complexity and to benchmark reimbursement for surgeons. This study aims to analyze surgeon reimbursement in primary and redo-thyroidectomy and parathyroidectomy using operative time as a surrogate for complexity. METHODS: A retrospective analysis using the National Surgical Quality Improvement Program database was performed to identify patients who underwent primary and redo-thyroidectomy and parathyroidectomy. Calculations of median operative time work relative value units per minute and dollars per minute were compared between primary and redo procedures. RESULTS: Thyroidectomy cases represented 53.5% (22,521 cases), and the other 46.5% (19,596 cases) were parathyroidectomy cases. The median dollars per minute in primary thyroidectomy was $4.97 and for redo-thyroidectomy was $8.12 (P < 0.0001). By the same token, dollars per minute were higher in the redo cases with $15.40 when compared with primary parathyroidectomy cases with $13.14 dollars per minute (P < 0.0001). CONCLUSIONS: By Current Procedural Terminology codes, surgeons appear to be appropriately reimbursed for redo-thyroid and parathyroid procedures indexed to first time parathyroidectomy based on the compensated operative time of these procedures calculated using a nationally representative sample.

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB).

PURPOSE: The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals. METHODS: This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. RESULTS: A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case. CONCLUSIONS: The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Streamlining variability in hospital charges for standard thyroidectomy: Developing a strategy to decrease waste.

BACKGROUND: We assessed the efficiency, consistency, and appropriateness of perioperative processes for standard (total) thyroidectomy and devised a valuable strategy to decrease variability and waste. METHODS: Our multidisciplinary team evaluated <23-hour stay standard thyroidectomy performed by 3 surgical endocrinologists. We used the nominal group technique, process flowcharts, and root cause analysis to evaluate 6 perioperative processes. Anticipated decreases in costs, charges, and resources from improvements were calculated. RESULTS: Median total charge for standard thyroidectomy was $27,363 (n = 80; $48,727 variation). Perioperative coordination between surgery and anesthesia clinics could eliminate unnecessary testing (potential decrease in charges of $1,505). Nonoperating room time was less in the outpatient operating room (43 vs 52 minutes; P < .001). Consistent scheduling could decrease charges by $585.49 per case. By decreasing 20% of nondisposable instruments on the surgical tray, we could decrease sterile processing costs by $13.30 per case. Modification of postoperative orders could decrease charges by $643 per patient. Overall, this comprehensive analysis identified an anticipated decrease in cost/charge of >$200,000 annually. CONCLUSION: Perioperative process analyses revealed wide variability for a single, presumed uniform procedure. Systematic assessment helped to identify opportunities to improve efficiency, decrease unnecessary waste and procedures/instrument usage, and focus on patient-centered, quality care. This multidisciplinary strategy could substantially decrease costs/charges for common operative procedures.

Health technology assessment and thyroid surgery.

The growth of technological innovation, the request for assistance, the rising patient's expectations and the interest of the industry have led to a rise in the cost of health care systems. In this context the role of the National Health System is not to delay the development or adoption of new technologies, but rather to drive the development selecting priorities and promoting its use. Health Technology Assessment (HTA) is a multidisciplinary and multidimensional approach for analyzing the medical-clinical, social, organizational, economic, ethical and legal implications of a technology (devices, drugs, procedures) through the assessment of multiple parameters such as effectiveness, safety, costs of the social and organizational impact. A health technology assessment is a comprehensive, systematic evaluation of the prerequisites for estimating the consequences of using health technology. Main characteristic of HTA is that the problem is tackled using an approach focused on four main elements: - technology; - patient; - organization; - economy. The authors have applied the HTA method for the analysis of the ultrasonic focus dissector on thyroid surgery. They compared the cost of the surgical procedure using the ultrasonic dissector and without it in a case study of 440 patients who underwent thyroidectomy.

Effects of a cost-effective surgical workflow on cosmesis and patient's satisfaction in open thyroid surgery.

PURPOSE: In thyroid surgery, minimally invasive procedures are thought to improve cosmesis and patient's satisfaction. However, studies using standardized tools are scarce, and results are controversial. Moreover, minimally invasive techniques raise the question of material costs in a context of health spending cuts. The aim of the present study is to test a cost-effective surgical workflow to improve cosmesis in conventional open thyroid surgery. METHODS: Our study ran between January 2009 and November 2010, and was based on a prospectively maintained thyroid surgery register. Patients operated for benign thyroid diseases were included. Since January 2010, a standardized surgical workflow was used in addition to the reference open procedure to improve the outcome. Two groups were created: (1) G1 group (patients operated with the reference technique), (2) G2 group (patients operated with our workflow in addition to reference technique). Patients were investigated for postoperative outcomes, self-evaluated body image, cosmetic and self-confidence scores. RESULTS: 820 patients were included in the present study. The overall body image and cosmetic scores were significantly better in the G2 group (P < 0.05). No significant difference was noted in terms of surgical outcomes, scar length, and self-confidence. CONCLUSIONS: Our surgical workflow in conjunction with the reference technique is safe and shows significant better results in terms of body image and cosmesis than do the reference technique alone. Thus, we recommend its implementation in order to improve outcomes in a cost-effective way. The limitations of the present study should be kept in mind in the elaboration of future studies.

Comprehensive assessment of thyroidectomy skills development: a pilot project.

OBJECTIVES/HYPOTHESIS: To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. STUDY DESIGN: Prospective validation study. METHODS: A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills-based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. RESULTS: Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showing a mean difference of 0.9 (95% confidence interval: 0.5-1.3, P<.001) between the contiguous clinical levels senior versus intermediate. Cronbach α, a measure of internal consistency, was 0.96 for both components of the instrument. The correlation between the TBC and GRS was also high within trainee (r=0.62, n=94, P<.001) and across trainees (r=0.96, n=17, P<.001). CONCLUSIONS: Our tool proved to be a valid, reliable, and feasible instrument for assessing competency in thyroid surgery. It is effective in providing timely formative feedback during and upon the conclusion of the surgical procedure by identifying procedural tasks for which additional training is necessary. In addition, it enables longitudinal tracking of residents' surgical performance, thus ensuring their appropriate development.

German Association of Endocrine Surgeons practice guidelines for the surgical treatment of benign thyroid disease.

INTRODUCTION: Benign thyroid disorders are among the most common diseases in Germany, affecting around 15 million people and leading to more than 100,000 thyroid surgeries per year. Since the first German guidelines for the surgical treatment of benign goiter were published in 1998, abundant new information has become available, significantly shifting surgical strategy towards more radical interventions. Additionally, minimally invasive techniques have been developed and gained wide usage. These circumstances demanded a revision of the guidelines. METHODS: Based on a review of relevant recent guidelines from other groups and additional literature, unpublished data, and clinical experience, the German Association of Endocrine Surgeons formulated new recommendations on the surgical treatment of benign thyroid diseases. These guidelines were developed through a formal expert consensus process and in collaboration with the German societies of Nuclear Medicine, Endocrinology, Pathology, and Phoniatrics & Pedaudiology as well as two patient organizations. Consensus was achieved through several moderated conferences of surgical experts and representatives of the collaborating medical societies and patient organizations. RESULTS: The revised guidelines for the surgical treatment of benign thyroid diseases include recommendations regarding the preoperative assessment necessary to determine when surgery is indicated. Recommendations regarding the extent of resection, surgical techniques, and perioperative management are also given in order to optimize patient outcomes. CONCLUSIONS: Evidence-based recommendations for the surgical treatment of benign thyroid diseases have been created to aid the surgeon and to support optimal patient care, based on current knowledge. These recommendations comply with the Association of the Scientific Medical Societies in Germany requirements for S2k guidelines.

Clinical pathways improve hospital resource use in endocrine surgery.

BACKGROUND: Clinical pathways are increasingly adopted to streamline care after elective surgery. Here, we describe novel clinical pathways developed for endocrine operations (ie, unilateral thyroid lobectomy, total thyroidectomy, parathyroidectomy) and evaluate their effects on economic end points at a major academic hospital. STUDY DESIGN: Length of stay (LOS), hospital charges, and hospital costs for 681 patients undergoing elective endocrine surgery during a 30-month period were compared between patients managed with or without a specific pathway. Hospital costs were subcategorized by cost center. The analysis arms were conducted concurrently to control for institutional effects and end points were adjusted for demographic factors and comorbidity. RESULTS: Clinical pathways were observed to significantly reduce LOS, charges, and costs for endocrine procedures. LOS was reduced for thyroid lobectomy (nonpathway 1.6 days versus pathway 1.0; p < 0.001), total thyroidectomy (2.8 versus 1.1; p < 0.0001), and parathyroidectomy (1.6 versus 1.1; p < 0.001). Nonpathway patients were 6.2 times more likely to be admitted to the intensive care unit than pathway patients (p < 0.05). Clinical pathways reduced total charges from $21,941 to $17,313 for all cases (21% reduction; p < 0.0001), with 47% of savings attributable to reduced LOS. Significant improvements were observed for laboratory use (73% reduction; p < 0.0001) and nonroutine medication administration (73% reduction; p < 0.0001). The readmission rate within 72 hours of discharge was not significantly lower in the pathway group. CONCLUSIONS: Implementation of clinical pathways improves efficiency of care after elective endocrine surgery without adversely affecting safety or quality. Because these system measures optimize resource use, they represent an important component of high-volume subspecialty surgical services.

Improvements in health care for patients undergoing thyroidectomy.

OBJECTIVE: In this study, we evaluated the effect on cost and clinical outcome of the implementation of departmental subspecialization and a clinical care pathway for patients undergoing thyroidectomy. METHODS: Subspecialization and a clinical thyroidectomy pathway were implemented in 2001 at the Department of Surgery, National University Hospital, Singapore. A total of 150 patients (Group A) who served as controls were compared with 143 patients who were managed after implementation of subspecialization and the clinical thyroidectomy pathway (Group B). Length of stay, postoperative complications and cost per patient were compared between the two groups. RESULTS: The mean age was 46 years and females comprised 77% of all patients. The mean length of hospital stay was shorter in Group B (1.9 days) compared with Group A (3.3 days; p < 0.001). The mean hospital charges also fell significantly after implementation, at 3,524 dollars per patient in Group B compared with 3,929 dollars in Group A (p = 0.003). There was no difference in morbidity between the two groups (2.0% and 1.4% in Groups A and B, respectively). CONCLUSION: This study confirms that length of hospital stay and hospital costs are effectively reduced through the combination of subspecialization and a clinical pathway for patients undergoing thyroidectomy. Subspecialty units and pathways reduce variation in patient care. This effectively leads to better-quality outcomes, more efficient discharge planning and improved cost-effectiveness of clinical services.

[Design and use of patient pathways in general surgery]. / Entwicklung und Einsatz von Patientenpfaden in der Allgemeinchirurgie.

BACKGROUND: Clinical pathways are a new initiative intended to reduce costs while maintaining or even improving the quality of care. Based on treatment guidelines, patient pathways display an optimal sequence of staff actions in the preoperative, operative, and postoperative in- and outpatient treatment. METHODS: In this study, patient pathways were developed for selected elective general surgical disease entities following a new modular approach. All elements of care and their direct costs to the hospital were identified. Multidisciplinary teams of physicians, nurses, and administrative staff constructed and implemented the patient pathways. RESULTS: In the 1-year pilot phase, we developed and implemented 7 pathways with 16 subpathways: open herniorrhaphy, laparoscopic cholecystectomy and fundoplication, thyroidectomy, surgical treatment of diverticulitis and colon carcinoma and kidney transplantation. CONCLUSIONS: Patient pathways combine the management of care, hospital processes, and costs in a new integrated concept. Patient pathways streamline and standardize care, facilitate communication, and contribute to cost control efforts.

[Regional function in thyroid surgery. Assessment of the specialty function and surgical risk factors]. / Landsdelsfunktion i thyroideakirurgi. Evaluering af specialefunktionen og kirurgiske risikofaktorer.

INTRODUCTION: It is recommended that a subset of benign thyroid operations, defined by The Danish National Board as potentially complicated thyroid surgery, is referred to surgical units specialised in thyroid surgery. The aim of the present study was to compare indications for operation and operative complications in patients referred as high risk operations with patients referred from the primary catchment area to a surgical unit specialising in thyroid surgery. MATERIAL AND METHODS: The study includes 570 consecutive operations performed between January 1st 1994 and December 31st 1998. RESULTS: Out of 570 operations, 239 were referred as high risk operations. Complications were significantly more frequent after high risk operations. Delayed wound bleeding requiring reoperation occurred in 3.3 per cent vs. 0.3 per cent of cases (p = 0.01), whereas the risk of unilateral recurrent nerve palsy (1 per cent vs 0.5 per cent, p = 0.3) and permanent hypocalcemia in 1.7 per cent vs. 0 per cent (p = 0.06) was statistically insignificant between the two risk groups. DISCUSSION: The study confirms an elevated risk of complications in the defined high risk group and demonstrates that the referring hospitals comply with the recommendations laid down by the National Board of Health.

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.

OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.

Same-day admission thyroidectomy programme: quality assurance study.

OBJECTIVE: This study was conducted to evaluate the effectiveness of a same-day admission thyroidectomy programme. DESIGN: Prospective patient surveys and a retrospective quality assurance study were conducted. METHOD: Management of the initial 58 patients having a thyroidectomy at St. Joseph's Hospital, London, Ontario, after May 1992 when a same-day admission thyroidectomy programme was initiated, was evaluated. Early in the process, staff evaluation of the programme was also surveyed. RESULTS: The average length of stay for these patients was reduced from 4.5 to 3.2 days. No operative delays, cancellations, readmissions, or increased complications resulted from the new protocol. Also, patient and staff acceptance of the new programme was high. CONCLUSION: Our success with this programme has encouraged us to apply these concepts to more complex surgical patients.

Cirugia ambulatoria: colecistectomia y tiroidectomia / Ambulatory Surgery: cholecystectomy and thyroidectomy

En el Hospital Universitario del Valle, en Cali, se efectuaron 10 intervenciones quirurgicas de nivel III, a saber, 4 tiroidectomias subtotales y 6 colecistectomias, sin hospitalizar a los pacientes. El cuidado post-operatorio se llevo a cabo en la casa. No hubo complicaciones anestesicas ni quirurgicas que pongan en duda la factibilidad de realizar estos procedimientos si se cumplen unos requisitos minimos que se discuten con algun detalle