Abstract
Background:
Enhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions.
Methods:
We collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance.
Results:
Enhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay.
Conclusion:
This study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.
Introduction
Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to optimize the perioperative period to reduce complications and improve recovery for patients undergoing surgery. Enhanced Recovery After Surgery pathways have become the standard of care and improved outcomes in numerous surgical specialties.1–3 A small number of studies have evaluated ERAS protocol implementation in thyroid and parathyroid surgery.
A systematic review and meta-analysis of 7 studies found that the most common elements reported in ERAS protocols for thyroid and parathyroid surgery include preadmission education, perioperative nutritional care, pain management, and postoperative wound and drain care.4 Patients enrolled in ERAS protocols had reduced hospital length of stay (LOS), reduced costs, and lower risk of intensive care unit admission.5 No difference in postoperative complications (specifically vocal cord paralysis, persistent hoarseness, bleeding, infections, reoperation, and postoperative hypocalcemia) and readmission rates were reported between ERAS and control patients. Prior studies have also demonstrated reduced opioid use by implementing ERAS protocols for thyroid and parathyroid surgery.6,7
More recently, there has been a push toward same-day discharge for thyroid/parathyroid surgeries, especially after the onset of the COVID-19 pandemic.8 Our institution’s ERAS protocol was designed with same-day discharge In mind, with a particular focus on pain control and postoperative nausea and vomiting (PONV) prevention. We sought to evaluate whether an institutional ERAS protocol could significantly impact the frequency of PONV, post-anesthesia care unit (PACU) LOS, and opioid consumption, as well as the rate of unanticipated postoperative admissions.
Methods
This study was determined to be exempt from approval by the Yale Institutional Review Board (#2000031364), and the requirement for written informed consent was waived. The ERAS protocol at Yale New Haven Hospital was initiated in August 2021 and was rolled out in stages between August 2021 and March 2022. As stakeholder buy-in was attained, the following interventions were initiated: (1) risk-based multi-modal PONV prevention and preoperative acetaminophen administration, (2) the addition of preoperative celecoxib, and (3) the addition of superficial cervical plexus blocks. With increased stakeholder buy-in, we were able to implement the ERAS protocol in its entirety, shown in Figure 1 and described as follows. Patients received preoperative acetaminophen, 1,000 mg, and celecoxib, 200 mg, orally in the holding area. A risk-based approach to PONV prevention was implemented. Patients with no risk factors for PONV received dexamethasone; patients with 1 to 2 risk factors received dexamethasone, 10 mg, and ondansetron, 4 mg; and patients with 3 to 4 risk factors received dexamethasone, 10 mg, ondansetron, 4 mg, and a third prophylactic antiemetic chosen by the anesthesiologist (droperidol, 0.625 mg, dimenhydrinate, 12.5 mg or 25 mg, diphenhydramine, 12.5 mg or 25 mg, or scopolamine patch). In addition, total intravenous anesthesia was encouraged at the anesthesiologist’s discretion.
Figure 1.
Enhanced Recovery After Surgery protocol at Yale New Haven Hospital. PO, per os; PONV, postoperative nausea and vomiting; PPx, prophylaxis.
Our data collection was carried out in 2 phases, as described in the following section.
We first analyzed data for all thyroidectomies and parathyroidectomies performed by endocrine surgeons between June 2020 and July 2021 (“control group”) and for all such procedures between March 2022 and November 2022 (“performance group”). We included all patients who underwent thyroid lobectomies and total thyroidectomies regardless of preoperative diagnosis, excluding modified radical neck dissections. We included all patients who underwent either minimally invasive or subtotal parathyroidectomies for primary hyperparathyroidism. Patients with secondary and tertiary hyperparathyroidism were excluded because they are not considered candidates for the ERAS pathway, given a higher risk of prolonged postoperative hypocalcemia and inpatient hospital stay. The inclusion criteria were based on a Care Signature Pathway developed by a multidisciplinary team at Yale New Haven Hospital, included in Figure 2.
Figure 2.
Care Signature Pathway to evaluate Enhanced Recovery After Surgery and same day discharge candidates. ERAS, Enhanced Recovery After Surgery; PACU PTH, postanesthesia care unit parathyroid hormone.
These data sets included demographic variables, clinical characteristics, and details related to the surgical admission (primary procedure, date/time of admission, date of surgery, date/time of discharge, inpatient/outpatient indicator, and an indicator of whether outpatients were converted to inpatient). We excluded patients who were admitted one day or more before their surgery. The demographic variables are included in Tables I and II.
Table 1.
Demographic Variables for Control and Performance Groups
| Variables | Control (n = 479) | Performance (n = 166) | P value |
|---|---|---|---|
|
| |||
| Age, mean (SD), y | 56.2 (14.9) | 57.0 (14.6) | .56 |
| Sex, n (%) | |||
| Male | 117 (24.5) | 28 (17.0) | .047 |
| Female | 361 (75.5) | 137 (83.0) | |
| Race, n (%) | |||
| White | 338 (72.2) | 126 (77.3) | .65 |
| African-American | 64 (13.7) | 19 (11.7) | |
| Hispanic/Latino | 47 (10.0) | 13 (8.0) | |
| Other | 19 (4.1) | 5 (3.1) | |
| BMI, mean (SD) | 30.6 (7.5) | 29.1 (6.2) | .021 |
| ASA score, n (%) | |||
| 1 | 6 (1.3) | 0 (0.0) | .33 |
| 2 | 242 (50.5) | 80 (48.2) | |
| 3 | 227 (47.4) | 83 (50.0) | |
| 4 | 4 (0.8) | 3 (1.8) | |
| Smoking, n (%) | |||
| Yes (current) | 39 (8.1) | 7 (4.2) | .090 |
| No (former/never) | 440 (91.9) | 159 (95.8) | |
| History of opioid use, n (%) | |||
| Yes | 32 (6.7) | 11 (6.6) | .98 |
| No | 447 (93.3) | 155 (93.4) | |
ASA, American Society of Anesthesiologists; BMI, body mass index.
Table II.
Demographic variables for 3-group comparison
| Control (N = 479) | ERAS 0–2 (N = 94) | ERAS 3–4 (N = 72) | P value | |
|---|---|---|---|---|
|
| ||||
| Age, mean (SD), y | 56.2 (14.9) | 56.4 (14.7) | 57.8 (14.5) | .71 |
| Sex, n (%) | ||||
| Male | 117 (24.5) | 17 (18.3) | 11 (15.3) | .12 |
| Female | 361 (75.5) | 76 (81.7) | 61 (84.7) | |
| Race, n (%) | ||||
| White | 338 (72.2) | 73 (77.7) | 53 (76.8) | .64 |
| African-American | 64 (13.7) | 12 (12.8) | 7 (10.1) | |
| Hispanic/Latino | 47 (10.0) | 8 (8.5) | 5 (7.2) | |
| Other | 19 (4.1) | 1 (1.1) | 4 (5.8) | |
| BMI, mean (SD) | 30.6 (7.5) | 30.5 (6.8) | 27.3 (4.7) | .0013 |
| ASA score, n (%) | ||||
| 1 | 6 (1.3) | 0 (0.0) | 0 (0.0) | .56 |
| 2 | 242 (50.5) | 44 (46.8) | 36 (50.0) | |
| 3 | 227 (47.4) | 49 (52.1) | 34 (47.2) | |
| 4 | 4 (0.8) | 1 (1.1) | 2 (2.8) | |
| Smoking, n (%) | ||||
| Yes (current) | 39 (8.1) | 4 (4.3) | 3 (4.2) | .24 |
| No (former/never) | 440 (91.9) | 90 (95.7) | 69 (95.8) | |
| History of opioid use, n (%) | ||||
| Yes | 32 (6.7) | 7 (7.4) | 4 (5.6) | .89 |
| No | 447 (93.3) | 87 (92.6) | 68 (94.4) | |
ASA, American Society of Anesthesiologists; BMI, body mass index; ERAS, Enhanced Recovery After Surgery.
The primary outcomes in this analysis were the LOS in hours and whether patients originally booked for outpatient procedures were converted to inpatient (“unanticipated admissions”). We compared LOS between the control and performance groups using a Wilcoxon signed rank test. We compared the proportion of unanticipated admissions between the 2 groups using χ2 analysis. To provide effect size measurements, we performed univariable negative binomial regression for LOS and univariable logistic regression for the proportion of unanticipated admissions. We also assessed the confounding of the demographic and clinical characteristics on LOS using multivariable negative binomial regression and on the proportion of unanticipated admissions using multivariable logistic regression.
We then subdivided the performance group into 2 groups based on compliance with the 4 main ERAS interventions. Those with 0 to 2 interventions were classified as “low compliance,” and those with 3 to 4 interventions were classified as “high compliance.” These 2 groups were then compared to the control group. The primary outcomes in this analysis were the PACU LOS in hours, average daily pain (0–10 scale), postoperative morphine milligram equivalents (MME), and postoperative antiemetic use.
We compared PACU LOS, average daily pain scores, and postoperative MME using the analysis of variance. We compared the proportion with postoperative antiemetic use between the 2 groups using χ2 analysis. To provide effect size measurements, we performed univariable Poisson regression on PACU LOS, univariable linear regression on average daily pain and postoperative MME, and univariable logistic regression on the proportion of antiemetic use.
Results
There were 675 patients who underwent thyroid or parathyroid surgery at our institution during the study period. After excluding patients who did not meet our inclusion criteria (by admission status, preoperative diagnosis, etc), 479 control group patients and 166 performance group patients were included for analysis.
We compared demographic variables between the control and performance group patients, and, with the exception of body mass index, there were no significant differences in demographic variables between the 2 groups. This was borne out in a further subgroup analysis comparing the control group with both low-compliance and high-compliance ERAS patients. We similarly evaluated the distribution of preoperative diagnoses and procedure types between groups, shown in Table III.
Table III.
Preoperative diagnoses and procedure types for 3-group comparison
| Control (N = 479) | ERAS 0–2 (N = 94) | ERAS 3–4 (N = 72) | P value | |
|---|---|---|---|---|
|
| ||||
| Preoperative diagnosis, n (%) | ||||
| Graves’ | 23 (4.8) | 6 (6.4) | 5 (6.9) | .011 |
| MNG | 58 (12.1) | 8 (8.5) | 0 (0.0) | |
| Multiple diagnoses | 22 (4.6) | 5 (5.3) | 2 (2.8) | |
| Parathyroid carcinoma | 2 (0.4) | 0 (0.0) | 0 (0.0) | |
| PHPT | 208 (43.5) | 36 (38.3) | 44 (61.1) | |
| THPT | 1 (0.2) | 0 (0.0) | 0 (0.0) | |
| Thyroid cancer | 68 (14.2) | 21 (22.3) | 14 (19.4) | |
| Thyroid cyst | 0 (0.0) | 1 (1.1) | 1 (1.4) | |
| Thyroid nodule | 96 (20.1) | 17 (18.1) | 6 (8.3) | |
| Procedure, n (%) | ||||
| Minimally invasive parathyroidectomy | 128 (26.7) | 26 (27.7) | 39 (54.2) | < .001 |
| Multiple procedures | 23 (4.8) | 3 (3.2) | 6 (8.3) | |
| Partial thyroidectomy | 109 (22.8) | 35 (37.2) | 15 (20.8) | |
| Re-do parathyroid surgery | 15 (3.1) | 1 (1.1) | 0 (0.0) | |
| Re-do thyroid surgery | 20 (4.2) | 4 (4.3) | 2 (2.8) | |
| Subtotal parathyroidectomy | 63 (13.2) | 7 (7.4) | 2 (2.8) | |
| Total thyroidectomy | 93 (19.4) | 16 (17.0) | 5 (6.9) | |
| Total thyroidectomy with CND | 28 (5.8) | 2 (2.1) | 3 (4.2) | |
CND, central neck dissection; ERAS, Enhanced Recovery After Surgery; MNG, multinodular goiter; PHPT, primary hyperparathyroidism; THPT, tertiary hyperparathyroidism.
The median total LOS in the control group was found to be 9.2 hours compared to 7.5 hours in the performance group (P < .0001). We then evaluated our incidence of unanticipated postoperative admissions in both the control and performance groups. There was no evidence of a statistically significant decrease in unanticipated admissions as a whole; however, we noted an interesting observation regarding admissions initiated in PACU at the patient’s request (for pain or nausea control). Although we had 5 such admissions in the control group, there were no patient-directed admissions in the performance (ERAS) group. The details are shown below in Tables IV and V.
Table IV.
Primary outcome measures in control and performance groups
| Control (N = 479) | Performance (N = 166) | P value | IRR/beta/OR (95% CI) | |
|---|---|---|---|---|
|
| ||||
| LOS, h, mean (SD) | 17.0 (12.1) | 11.9 (12.1) | < .0001 | 0.70 (0.62–0.79) |
| LOS, h, median (IQR) | 9.2 (6.5–26.8) | 7.5 (6.1–9.5) | .0001 | |
| Unanticipated admission | 16/356 = 4.5% | 10/165 = 6.1% | .44 | 1.37 (0.61–3.1) |
| Patient-requested admission | 10/356 = 2.8% | 0/165 = 0% | .030 | n/a |
| PACU LOS, mean (SD) | 122.8 (61.9) | 116.9 (54.5) | .34 | 0.95 (0.86–1.05) |
| Postoperative MME, mean (SD) | 24.8 (23.7) | 15.5 (12.4) | .0003 | −9.3 (−14.4 to −4.3) |
| Average daily MME, mean (SD) | 53.0 (28.0) | 36.9 (22.7) | < .0001 | −16.1 (−21.2 to −10.9) |
| Average daily pain, mean (SD) | 2.74 (1.90) | 2.17 (1.95) | .003 | −0.58 (−0.96 to −0.19) |
| Postoperative antiemetic, n (%) | 44 (13.3%) | 14 (9.2) | .20 | 0.66 (0.35–1.25) |
IRR, incidence rate ratio; LOS, length of stay; MME, morphine milligram equivalent; OR, odds ratio; PACU, postanesthesia care unit.
Table V.
Primary outcomes measures in 3-group comparison
| Control (N = 479) | ERAS 0–2 (N = 94) | ERAS 3–4 (N = 72) | P value | IRR/beta/OR (95% CI) for ERAS 0–2 versus control | IRR/beta/OR (95% CI) for ERAS 3–4 versus control | |
|---|---|---|---|---|---|---|
|
| ||||||
| LOS, h, mean (SD) | 17.0 (12.1) | 12.9 (13.8) | 10.6 (9.2) | < .0001 | 0.76 (0.65–0.89), P = .001 | 0.62 (0.52–0.74), P < .001 |
| LOS, h, median (IQR) | 9.2 (6.5–26.8) | 7.8 (6.6–9.8) | 6.7 (5.8–9.1) | .0001 | ||
| Unanticipated admission | 16/356 = 4.5% | 8/94=8.5% | 2/71 = 2.8% | .19 | 1.98 (0.82–4.77), P = .13 | 0.62 (0.14–2.74), P = .52 |
| Patient-requested admission | 10/356 = 2.8% | 0/94 = 0.0% | 0.71 = 0.0% | .094 | n/a | n/a |
| PACU to care complete min, mean (SD) | 122.8 (61.9) | 122.0 (54.3) | 110.6 (54.5) | .34 | 0.99 (0.97–1.02), P = .57 | 0.90 (0.88–0.92), P < .001 |
| Postoperative MME, mean (SD) | 24.8 (23.7) | 16.2 (13.3) | 14.4 (11.0) | .0015 | −8.6 (−14.8 to −2.4), P = .006 | −10.4 (−17.8 to −3.0), P =.006 |
| Average daily MME, mean (SD) | 53.0 (28.0) | 45.6 (19.9) | 25.6 (21.1) | < .0001 | −7.4 (−13.6 to −1.2), P = .019 | −27.4 (−34.3 to −20.4), P < .001 |
| Average daily pain, mean (SD) | 2.74 (1.90) | 2.38 (2.13) | 1.89 (1.68) | .0045 | −0.36 (−0.84 to 0.11), P = .13 | −0.84 (−1.37 to −0.32), P = .002 |
| Postoperative antiemetic, n (%) | 44 (13.3) | 9 (10.6) | 5 (7.5) | .37 | 0.77 (0.36–1.65), P = .51 | 0.53 (0.20–1.38), P = .19 |
ERAS, Enhanced Recovery After Surgery; IRR, incidence rate ratio; LOS, length of stay; MME, morphine milligram equivalent; OR, odds ratio; PACU, postanesthesia care unit.
The second portion of the analysis focused on outcome measures in both the control and performance groups. We evaluated the following parameters in our outcomes analysis: (1) mean PACU stay duration (from patient delivery to PACU until completion of care); (2) postoperative MME use, which measured PACU opioid requirements; (3) average daily MME, which also included intra-operative pain medication administration; (4) daily pain score, which is the patient-reported pain score, averaged over the duration of their hospital stay; and (5) postoperative antiemetic use. We performed this analysis for the control and performance groups as a whole, followed by a sub-group analysis comparing the control group with low- and high-compliance ERAS patients.
We did not find a significant difference in PACU LOS between the control and low-compliance ERAS groups; however, there was a significant decrease in PACU LOS for the high-compliance ERAS group (those who received 3–4 interventions). There was, however, a statistically significant decrease in all the postoperative pain-related parameters in the performance group, especially with increasing ERAS compliance. The mean postoperative MME was 14.4, 16.2, and 24.8 among the high-compliance, low-compliance, and control groups, respectively, with a P value of .0015. The mean average daily MME was 25.6, 45.6, and 53 among the high-compliance, low-compliance, and control groups, respectively, with a P value < .0001. The mean average daily pain score was 1.89, 2.38, and 2.74 among the high-compliance, low-compliance, and control groups, respectively, with a P value of .0045. Finally, we did not note any statistically significant difference in the postoperative antiemetic requirement between groups. These results are similarly demonstrated in Tables IV and V.
Discussion
The ERAS protocols, since their introduction in 1997 by Henrik Kehlet,9,10 have proven to be significant in improving perioperative outcomes across various surgical specialties. Initially developed in the specialty of colorectal surgery, they have now been implemented in various surgical fields. The ERAS protocols for endocrine surgery are a relatively new development, and most have focused on inpatient surgery. Prior studies that have evaluated the impact of ERAS protocols on thyroid and parathyroid surgery have found an improvement in hospital LOS and hospital costs and a decrease in postoperative opioid consumption.
In the largest currently published study of ERAS outcomes in thyroid and parathyroid surgery, Yip et al found a 72% reduction in mean opioid consumption in the hospital for patients enrolled in ERAS (n = 654) compared to control patients (n = 464).6 Lide et al also found reduced opioid use with the implementation of an ERAS protocol for thyroid and parathyroid surgery, with a 56% reduction in MME and a 29% reduction in opioid prescriptions.11 Afonso et al reported that ERAS implementation for thyroidectomies led to a 9.7% decrease in patients requiring PONV rescue medication but no change in postoperative opioid consumption.12 Zheng and Zhang found that implementation of an ERAS protocol for thyroidectomies resulted in reduced pain scores, LOS, and hospitalization costs in the ERAS group, with no difference in postoperative complications, including PONV.13
Our institution has made significant changes to our postoperative admission practices over the last few years, a process accelerated by the COVID-19 pandemic. Our current practice is same-day discharge for most thyroid lobectomies and total thyroidectomies and patients with primary hyperparathyroidism (regardless of the extent of exploration). Patients who do not meet the criteria for discharge are observed in-house overnight. With the increase in same-day discharges from PACU, it has become even more essential to implement pathways to decrease PONV, as well as improve pain control and limit postoperative opioid use.14
Our initial experience with the staged roll-out of an ERAS pathway for thyroid and parathyroid surgery demonstrated decreased total LOS during the ERAS protocol implementation period. Although this is a statistically significant decrease in stay, the clinical and financial implications of this finding will be the subject of future research. The average PACU LOS was also significantly less in our higher compliance ERAS patients (3–4 interventions), whereas it was unchanged in our lower compliance ERAS patients (1–2 interventions). Although unanticipated admissions account for some of the longer durations of stay in the hospital, there has still been an improvement in this parameter with the initiation of ERAS. Although the total number of unanticipated admissions is not significantly different between groups, there were no patient-requested admissions for postoperative pain or nausea in the performance group. The pathway includes risk-based nausea prevention, preoperative multimodal oral analgesics (acetaminophen and celecoxib), and a superficial cervical plexus block. We also demonstrated a significant decrease in mean postoperative MME, mean average daily MME, and mean average daily pain scores, especially with the high compliance ERAS patients, showing a clear benefit even during the early stages of this process. There was no significant difference in postoperative antiemetic requirements.
Study limitations
Some of the limitations of this study include the retrospective nature of our data. Although we denote a specific period as the beginning of our ERAS pathway rollout, not all our interventions were started simultaneously. This implies a period of overlap for a few months where certain interventions were performed, and others had not yet been initiated. Enhanced Recovery After Surgery protocols are also patient- and provider-dependent to ensure compliance, which cannot always be accurately assessed and may impact data analysis.
Although some of these parameters have not yet approached statistical significance, they denote the progress usually seen with an initial roll-out of a multidisciplinary, multi-step pathway with multiple stakeholders and individual steps. Our aim is to reevaluate these exact parameters at regular intervals as our institution attains a higher level of compliance with all steps in the ERAS pathway.
Further steps for us include a prospective trial to identify the specific benefit afforded by the superficial cervical plexus block alone versus the rest of the ERAS pathway and to identify patient satisfaction with the ERAS protocols as evaluated by patient surveys in the PACU and 24 hours post-procedure.
In conclusion, our early institutional experience with an ERAS pathway for endocrine surgery has shown improvements in a number of postoperative patient-related parameters. The multimodal analgesia, focus on PONV prophylaxis, and patient education have resulted in a decrease in total LOS and PACU LOS with increasing levels of compliance with ERAS interventions, as well as postoperative MME and pain scores in our patients. Although these interventions may have to be rolled out in stages to ensure compliance, we believe that institutional ERAS pathways can help improve patient satisfaction and expedite the recovery process, especially for those patients who are candidates for ambulatory procedures and same-day discharge.
Funding/Support
This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit areas.
Biographies
Miguel Herrera (Mexico City, Mexico): Could you please tell me what are the benefits to the patient for same-day discharge? Is this mostly insurance-driven? In many parts of the world, where there are no insurance pressures, patients often spend overnight with high satisfaction.
Dr Nikita Machado: We are not trying to send everybody home the same day. I do not think that is realistic. There are many factors that indicate if a patient should stay or go home, but a majority of our patients would prefer to recover at home with their loved ones in a familiar setting, as opposed to having to stay in the hospital. The cost burden is another thing. The cost of health care in this country is unnecessarily expensive, and anything we can do to mitigate that is appreciated. We are always careful with this approach, and if there are patients who should stay overnight, they do so without hesitation.
Bradford Mitchell (Dover, DE): I am particularly interested in postoperative nausea and vomiting and the impact that has on postoperative bleeding and the need for reoperation. Did both of your groups have a superficial cervical block, or was it just the Enhanced Recovery After Surgery group that had the cervical block? Did any of your patients in the control group end up with general anesthesia?
Dr Machado: No patient in our control group had the superficial cervical plexus block. Only the patients in the Enhanced Recovery After Surgery pathway had it. That is a limitation to this study unless you have anesthesiologists in your center who are willing to do it or the surgeon does it.
Sareh Parangi (Boston, MA): I do find that patients have a lot more complications in the hospital. I had one patient who had a broken arm from falling in the hospital. So, I do think there is something to be said about safety with same-day discharge. My question pertains to your anesthesia group. Did you find high compliance with your anesthesiologists in giving the block, or were they resistant and wanted to do what they wanted?
Dr Machado: This is one of the limitations, as I mentioned before. This protocol is always going to be met with some resistance. We had some anesthesiologists who were much more interested in doing the blocks than others. We hope that this study and our data help change their minds and we can use this evidence to change practice patterns.
Footnotes
Conflict of interest/Disclosure
The authors have no conflicts of interests or disclosures to report.
References
- 1.Angelico R, Romano F, Riccetti C, et al. The Enhanced Recovery after Surgery (ERAS) pathway is a safe journey for kidney transplant recipients during the “extended criteria donor” era. Pathogens. 2022;11:1193. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Li J, Zhu H, Liao R. Enhanced recovery after surgery (ERAS) pathway for primary hip and knee arthroplasty: study protocol for a randomized controlled trial. Trials. 2019;20:599. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29:434–440. [DOI] [PubMed] [Google Scholar]
- 4.Chorath K, Luu N, Go BC, Moreira A, Rajasekaran K. ERAS protocols for thyroid and parathyroid surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2022;166:425–433. [DOI] [PubMed] [Google Scholar]
- 5.Kulkarni RP, Ituarte PHG, Gunderson D, Yeh MW. Clinical pathways improve hospital resource use in endocrine surgery. J Am Coll Surg. 2011;212:35–41. [DOI] [PubMed] [Google Scholar]
- 6.Yip L, Carty SE, Holder-Murray JM, et al. A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery. Surgery. 2021;169: 197–201. [DOI] [PubMed] [Google Scholar]
- 7.Wang L, Zhang X, Hu F, et al. Impact of enhanced recovery after surgery program for hungry bone syndrome in patients on maintenance hemodialysis undergoing parathyroidectomy for secondary hyperparathyroidism. Ann Surg Treat Res. 2022;103:264. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Memeh K, Angelos P. Ambulatory endocrine surgery. In: Singer MC, Terris DJ, eds. Innovations in Modern Endocrine Surgery. New York (NY): Springer Nature; 2021:271–282. [Google Scholar]
- 9.Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–641. [DOI] [PubMed] [Google Scholar]
- 10.Kehlet H Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–617. [DOI] [PubMed] [Google Scholar]
- 11.Lide RC, Creighton EW, Yeh J, et al. Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol. Head Neck. 2021;43:1545–1552. [DOI] [PubMed] [Google Scholar]
- 12.Afonso AM, McCormick PJ, Assel MJ, et al. Enhanced recovery programs in an ambulatory surgical oncology center. Anesth Analg. 2021;133:1391–1401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Zheng L, Zhang S. Application and evaluation of a care plan for enhanced recovery after thyroidectomy. Inquiry. 2022;59:469580221090404. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Militsakh O, Lydiatt W, Lydiatt D, et al. Development of multimodal analgesia pathways in outpatient thyroid and parathyroid surgery and association with postoperative opioid prescription patterns. JAMA Otolaryngology Head Neck Surg. 2018;144:1023–1029. [DOI] [PMC free article] [PubMed] [Google Scholar]