Multimodal analgesia after thyroid or parathyroid surgery: A randomized controlled trial.

BACKGROUND: The opioid epidemic prompted reevaluation of surgeons' opioid prescribing practices. This study aimed to demonstrate noninferiority of a staged analgesic regimen after endocrine surgery. METHODS: We conducted a randomized controlled trial comparing analgesic regimens after thyroidectomy and/or parathyroidectomy. Adult patients (≥18 years) were randomized to study arm (A) as-needed acetaminophen + codeine or (B) scheduled acetaminophen/as-needed tramadol. Patients recorded pain scores and analgesics consumed in a study log. Clinical variables were collected from the medical record. RESULTS: Target enrollment was achieved (n = 126), and randomization was even (A: 44.5%, B: 55.6%). There was no difference between enrolled patients and those who returned the study log (52.4%) by sex (P = .667), age (P = .513), final pathology (P = .137), procedure (P = .667), or randomization arm (P = .795). Most patients (50.8%) reported moderate pain scores (4-6) with no difference between study arms (P = .451). There was no difference in average consumption by morphine milligram equivalents (A: 11.5 ± 12.1 vs B: 12.49 ± 18.07; P = .792) nor total analgesic doses (A: 7.29 ± 7.48 vs B: 8.5 ± 5.36; P = .445). However, a significant difference in average percentage of opioid doses was noted (A: 79.71 ± 33.31 vs B: 27.38 ± 31.88; P < .001). CONCLUSION: Patients reported moderate pain scores with low requirements for analgesics after endocrine surgery. The staged analgesic regimen is noninferior to combination opioids and led to reduced overall consumption.

A Review of Postoperative Pain Management for Thyroid and Parathyroid Surgery.

BACKGROUND: Perioperative opioid use has been linked to abuse potential by patients, leading surgeons to scrutinize their postoperative prescribing practices. The goal of the study was to review analgesic regimens for patients undergoing thyroidectomy and parathyroidectomy and extrapolate changes that could be made to decrease opioid use while maintaining adequate pain control. MATERIALS AND METHODS: A literature review was performed. Inclusion criteria were studies 1) written in English, 2) published within the last 20 years, and 3) that included human subjects. Exclusion criteria were studies that 1) evaluated anesthesia regimens exclusively, 2) compared surgical approaches and their effects on pain (e.g., open neck exposure vs. transoral route for thyroidectomy), or 3) included patients undergoing concurrent lateral neck dissection. Of 951 studies originally identified, 10 studies met the criteria. RESULTS: Ten studies were identified, and each evaluated a different analgesic regimen. Five of the studies found a decrease in pain with multimodal regimens. Of the remaining studies, three found no difference in pain control, one found an increase in pain when only an opioid patient-controlled analgesia was used, and one found that 93% of patients required less than 20 oral morphine equivalents postoperatively. CONCLUSIONS: There is no postoperative analgesic regimen that has been established as optimal for patients undergoing parathyroidectomy and thyroidectomy in the current medical literature. However, half of the studies included in this review found that nonopioid adjuncts decreased patients' need for postoperative opioids.

Same day discharge after thyroidectomy is safe and effective.

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. METHODS: This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. RESULTS: A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. CONCLUSION: Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

Transarterial embolization of renal tumors improves surgical outcomes: A case series.

INTRODUCTION: Operative treatment of renal tumors can be associated with a high rate of perioperative morbidity related to hemorrhage and injury to adjacent anatomical structures. This morbidity of solid organ surgery is especially prevalent when the lesion involves chronic inflammation or a desmoplastic reaction from a rapidly growing tumor. No consensus on the use of transarterial embolization has been fashioned as the number of prospective studies is small. This study proposes to examine the beneficial effects of selective transarterial embolization of the kidney prior to surgical resection. PRESENTATION OF CASE: A retrospective case matched review was performed of consecutive nephroureterectomies evaluating outcomes of patients receiving transarterial embolization versus those patients who received no embolization. The records were obtained from University Medical Center of El Paso for the time period of 05/2011-12/2014. Data examined included patient demographics, operative blood loss, operative time, transfusion requirements, and pathology. Previous studies have shown that preoperative embolization of renal tumors resulted in a decreased need for blood transfusion. CONCLUSION: Our review showed transarterial embolization had a decrease in blood loss and required no transfusions. It also facilitated a larger and more advanced tumor resection. Our series of patients tolerated transarterial embolization well and had good surgical outcomes. Transarterial embolization of kidneys prior to radical nephroureterectomy results in a safe and uncomplicated operative course with less perioperative morbidity when compared to resection alone.