Why quantity and quality matter for thyroid surgery

Andrew J. Bauer, MD

Volume and experience are the keys to success when it comes to pediatric thyroid surgeries, according to a new report.

The study, published in the Journal of Pediatric Surgery, found that pediatric thyroid surgeries-which are not all that common-have better outcomes when performed at facilities that do a lot of them.¹

The study, conducted at the Children’s Hospital of Philadelphia (CHOP), reviewed nearly 500 cases of children who underwent thyroid surgeries at CHOP between 2009 and 2017. Researchers assessed diagnoses, surgical techniques used, and surgical complications that followed the procedures. Most children who had surgical thyroid interventions had papillary or follicular thyroid cancer, followed by benign nodules, Graves disease, medullary thyroid cancer, and multiple medullary carcinoma of the thyroid.

The team found very low complication rates among the patients at CHOP-0.4% with persistent recurrent laryngeal nerve deficit at six months and 0.6% with persistent hypoparathyroidism six months after thyroidectomy. The study concluded it was the high volume and practiced expertise of the surgical teams at CHOP-a high-volume center when it comes to thyroid surgeries-that contributed to this success.

Right place, right surgeon matters

Andrew J. Bauer, MD, an endocrinologist, medical director of the Pediatric Thyroid Center at CHOP, and one of the co-authors of the study, says where a surgery is performed and by whom appears key to a good outcome.

“Having the right surgeon perform the surgery is the most important first step in treating patients with thyroid nodules and thyroid cancer, as well as for patients that select thyroidectomy for definitive treatment of Graves disease,” says Bauer. “Because disease-specific mortality for thyroid disease in children and adolescents is low, reducing the risk of treatment-associated complications is critical to optimize long-term outcomes and quality of life.”

Bauer says there really is no secret treatment plan to optimize treatment outcomes during these types of surgeries. “It comes down to basics, to building a comprehensive, multidisciplinary team invested in improving the lives of pediatric patients with thyroid disease,” he says. “Having a highly skilled thyroid surgeon is critical, but the surgeon is one member of the team. The greater the knowledge and experience of the team, the more accurate and complete the evaluation and plan, and the lower the rate of complications.”

Multiple studies have reported an increased rate of surgical complications associated with thyroid surgeries in children and teenagers, and national databases indicate a 2-fold higher rate of complications for pediatric versus adult patients undergoing the same operations, Bauer says. Research has also shown a 2-fold higher risk of complications in surgeries conducted by low-volume surgeons compared with high-volume surgeons, or those who do more than 30 pediatric thyroid surgeries per year, he adds.

The study was performed at CHOP because the facility has invested a lot of time and effort to build an internationally recognized pediatric thyroid center, Bauer notes.

“This retrospective review was undertaken to analyze return on investment, to determine if our surgical complication rates were lower than published data. The results are unequivocal, showing a 0.4% risk of permanent, unilateral recurrent laryngeal nerve damage and 0.6% rate of permanent hypoparathyroidism based on 464 thyroid surgeries conducted by 2 surgeons over 8 years [at CHOP],” he says. “This is great news for our patients and confirms that creation of high-volume pediatric thyroid centers is an important and worthwhile endeavor in our efforts to improve the evaluation and management of children and adolescents with thyroid disease.”

Bauer says despite the successes at CHOP, the facility will continue to work toward even greater improvement.

“There are an increasing number of pediatric thyroid centers, but still too few to adequately care for the increasing number of children and adolescents with thyroid nodules, thyroid cancer, and Graves disease,” Bauer says. “Each center may be organizing their team differently, but our hope is that this data, as well as other reports being published from pediatric thyroid centers, serve as an example that we can reduce complications through regionalization of care, via referral to high-volume pediatric thyroid centers.”

To aid in this goal, Bauer says CHOP’s Pediatric Thyroid Center is spearheading a Child and Adolescent Thyroid Consortium with the goal of creating a community of centers that work together to share protocols and data in an effort to improve the

References:

1. Baumgarten HD, Bauer AJ, Isaza A, Mostoufi-Moab S, Kazahaya K, Adzick NS. Surgical management of pediatric thyroid disease: complication rates after thyroidectomy at the Children’s Hospital of Philadelphia high-volume Pediatric Thyroid Center. J Pediatr Surg. February 28, 2019. Epub ahead of print.