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Outcomes of Outpatient Thyroidectomy for High-Risk Patients: A Single-Site Retrospective Cohort Study
Emery Boudreau
*1, Alice Jo
1, Laura E. Newton
1, Aidan Wright
2, Meredith Sorensen
11General Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; 2Geisel School of Medicine, Lebanon, NH
Background - Over the past decade there has been a shift towards outpatient thyroidectomy for many patients. The 2013 American Thyroid Association consensus statement on outpatient thyroidectomy describes relative contraindications including uncompensated cardiac or respiratory disease, obstructive sleep apnea (OSA), dialysis-dependent renal failure, bleeding disorder, antiplatelet (AP) or anticoagulant (AC) use, massive or substernal goiter, or Graves’ disease. While current literature describes the safety of outpatient thyroidectomy in healthy patients, data are limited for those with relative contraindications as these populations are typically excluded from studies. As a high-volume endocrine surgery center, we consider each patient’s perioperative risks individually. We are able to routinely perform outpatient thyroidectomy for patients on AP or AC therapy, and those with Graves’ disease. This study evaluates the safety of outpatient thyroidectomy in these high-risk patients, and compares these outcomes to our lower-risk patient population.
Study Design - Retrospective cohort study.
Results - From February 2021 to February 2024, 346 patients underwent outpatient total thyroidectomy, with 226 (65%) cases classified as low risk and 120 (35%) classified as high risk (AC or AP use, or Graves’ disease) (
Table 1). Of the 120 patients classified as high-risk, 40 (33.3%) were on AC or AP therapy, 71 (59.2%) had Graves’ disease, and 9 (7.5%) had both Graves' disease and were on AC or AP therapy. Complications were overall low and similar between the two groups. A total of 4 postoperative hematomas were seen in the 346 patients, two in each group. In the high-risk group, one hematoma was seen in patient with Graves’, and one in a patient on AC which did require operative intervention. There was a statistically significant difference in the rates of transient hypocalcemia (p=0.032) and RLN injury (p=0.035), both of which were slightly higher in the low-risk group. Only one patient had long-term changes from RLN injury in the low-risk group. There was no difference in unplanned postoperative admissions or 30-day emergency department encounters between the two groups.
Conclusion - Outpatient thyroidectomy was completed in 120 patients typically classified as high-risk, with no increase in complication rate compared to a lower-risk patient population. Previous studies have largely excluded high-risk patients with relative contraindications from analysis. Our results indicate outpatient surgery may be considered for patients on AC or AP therapy, or for patients with Graves’ disease at a high-volume endocrine surgery center with no increased risk of complications.
Table 1. Comparison of cohort characteristics and complications between high-risk and low-risk patient populations who underwent outpatient thyroidectomy.
| Factor | High-Risk Population
(n=120) | Low-Risk Population
(n=226) | p value | SMD (95% CI) |
| AC or AP use (n, %) | 40 (33.3) | --- | --- | --- |
| Graves’ (n, %) | 71 (59.2) | --- | --- | --- |
| AC or AP use + Graves’ (n, %) | 9 (7.5) | --- | --- | --- |
| Patient Characteristics |
| Age, years (mean, SD) | 48.5 (+/-16.8) | 48.1 (+/-15.7) | 0.817 | 0.0255 (-3.52, 3.58) |
| Female Sex (n, %) | 105 (87.5) | 192 (84.9) | 0.525 | -0.04 (-0.113, 0.038) |
| White Race (n, %) | 111 (93.2) | 208 (92) | 0.869 | -0.048 (-0.121, -0.007) |
| BMI* (mean, SD) | 30.7 (+/-7.7) | 31.4 (+/-8.2) | 0.496 | -0.0879 (-1.86, 1.68) |
| ASA* class 3 (n, %) | 45 (37.5) | 74 (32.7) | 0.505 | 0.122 (0.24, 0.236) |
| CCI* (mean, SD) | 1.4 (+/-1.7) | 1.5 (+/-1.6) | 0.781 | -0.0606 (-0.42, 0.30) |
| Outcomes (n, %) |
| Unplanned admission | 1 (0.83) | 2 (0.88) | 0.158 | -0.0052 (-0.026, 0.014) |
| Hematoma | 2 (1.67) | 2 (0.88) | 0.562 | 0.0732 (0.044, 0.096) |
| 30-day ED encounters | 7 (5.8) | 16 (7.1) | 0.636 | -0.0502 (-0.106, 0.001) |
RLN injury,
transient / permanent | 2 (1.67) / 0 (0) | 13 (5.8) / 1 (0.44) | 0.035 / 0.318 | -0.2264 (-0.268, -0.192) /
-0.1328 (-0.141, -0.124) |
| Hypocalcemia, transient / permanent | 13 (10.8) / 0 (0) | 42 (18.6) / 0 (0) | 0.032 / 1.0 | 0.2098 (-0.301, -0.151) /
0 (0.00, 0.00 |
*AC = anticoagulation; AP = antiplatelet; ASA = American Society of Anesthesiologists; BMI = body mass index; CCI – Charlson Comorbidity Index score; CI = confidence interval; ED = emergency department; SMD = standardized mean difference
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