De la tiroidectomía a la tiroidectomía costo-efectiva. El concepto de minimalismo en cirugía tiroidea

Álvaro Sanabria

Resumen


La tiroidectomía constituye el procedimiento endocrino y la cirugía cervical más frecuente que realizan los cirujanos generales. Desde hace varios años, se ha evaluado la utilidad de muchos de los pasos que se realizan durante el procedimiento quirúrgico. El uso u omisión de cada uno de ellos puede aumentar o disminuir la efectividad y los costos del procedimiento global. En ese sentido, si fuera posible mantener los altos estándares de resultados del procedimiento quirúrgico, eliminado el uso de recursos que no han demostrado efectividad, sería posible lograr un impacto importante sobre la atención y distribuir mejor los recursos en otras intervenciones. El presente manuscrito muestra el proceso llevado a cabo por el autor desde hace más de 10 años, con el fin de depurar la intervención de la tiroidectomía en términos de emplear solo los pasos que se muestren efectivos, costo-efectivos y que puedan ser aplicables al contexto del sistema de salud colombiano, buscando un uso racional de los recursos quirúrgicos y una mayor calidad del servicio médico para el paciente y la familia, esto con el ánimo de desarrollar el concepto de cirugía tiroidea minimalista.

 

From thyroidectomy to cost-effective thyroidectomy. The concept of minimalism in surgery

Abstract

Thyroidectomy is both the most frequent endocrine procedure and cervical surgery performed by general surgeons. The usefulness of many of the steps performed during the surgical procedure has been evaluated for several years. The use or omission of each of these steps may increase or decrease the effectiveness and costs of the overall procedure. In that regard, if the high standards of thyroidectomy results could be maintained when resources not proven to be effective are eliminated, that could have a significant impact on care and those resources could be directed to other interventions. The author of this paper describes the process undertaken by him for longer than 10 years, in order to refine thyroidectomy intervention in terms of using only those steps that are effective, cost-effective and that may be applicable within the context of the colombian health system. We seek a rational use of surgical resources and greater comfort for the patient and family, aiming at framing the concept of minimalistic thyroid surgery.


Palabras clave


tiroidectomía, medicina basada en la evidencia, análisis costo-eficiencia, minimalismo, thyroidectomy, evidence-based medicine, cost-efficiency analysis, minimalism

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Referencias


Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996; 312 (7023): 71- 2.

Sanabria A, Dominguez LC, Vega V, Osorio C, Duarte D. Routine postoperative administration of vitamin D and calcium after total thyroidectomy: a meta-analysis. Int J Surg. 2011; 9 (1): 46- 51.

Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT. Recurrent laryngeal nerve monitoring versus identification alone on post- thyroidectomy true vocal fold palsy: a meta-analysis. Laryngoscope. 2011; 121 (5): 1009- 17.

4. Ecker T, Carvalho AL, Choe JH, Walosek G, Preuss KJ. Hemostasis in thyroid surgery: harmonic scalpel versus other techniques--a meta-analysis. Otolaryngol Head Neck Surg. 2010; 143 (1): 17- 25.

Sanabria A, Carvalho AL, Silver CE, Rinaldo A, Shaha AR, Kowalski LP, et al. Routine drainage after thyroid surgery--a meta-analysis. J Surg Oncol. 2007; 96 (3): 273- 80.

Chatterjee A, Payette MJ, Demas CP, Finlayson SR. Opportunity cost: a systematic application to surgery. Surgery. 2009; 146 (1): 18-22.

Palmer S, Raftery J. Economic Notes: opportunity cost. BMJ. 1999; 318 (7197): 1551- 2.

Diccionario de la Lengua Española. Madrid, España: Real Academia de la Lengua Española.

Okten AI. Minimalism in Art, Medical Science and Neurosurgery. Turk Neurosurg. 2016.

Patiño J. Reflexiones sobre el estado actual y el futuro de la cirugia. Rev Col Cirugia. 2002; 17 (3): 133- 45.

Callahan D. Minimalist ethics. Hastings Cent Rep. 1981; 11 (5): 19- 25.

Almou M, Alaoui M, Mokhtari M, el Alaoui M, Mansouri A. [Differentiated cancer of the thyroid. Prognostic factors and therapeutic attitude]. Acta Chir Belg. 1989; 89 (5): 271- 5.

Shaha AR, Jaffe BM. Selective use of drains in thyroid surgery. J Surg Oncol. 1993; 52 (4): 241- 3.

Jeng LB, Chen MF. The use of a small feeding tube for suction drainage after thyroidectomy. Changgeng Yi Xue Za Zhi. 1994; 17 (3): 235- 8.

Karayacin K, Besim H, Ercan F, Hamamci O, Korkmaz A. Thyroidectomy with and without drains. East Afr Med J. 1997; 74 (7): 431- 2.

Ardito G, Revelli L, Guidi ML, Murazio M, Lucci C, Modugno P, et al. [Drainage in thyroid surgery]. Ann Ital Chir. 1999; 70 (4): 511-6.

Williams J, Toews D, Prince M. Survey of the use of suction drains in head and neck surgery and analysis of their biomechanical properties. J Otolaryngol. 2003; 32 (1):16- 22.

Ruark DS, Abdel-Misih RZ. Thyroid and parathyroid surgery without drains. Head Neck. 1992; 14 (4): 285- 7.

Ariyanayagam DC, Naraynsingh V, Busby D, Sieunarine K, Raju G, Jankey N. Thyroid surgery without drainage: 15 years of clinical experience. J R Coll Surg Edinb. 1993; 38 (2): 69- 70.

Wax MK, Valiulis AP, Hurst MK. Drains in thyroid and parathyroid surgery. Are they necessary? Arch Otolaryngol Head Neck Surg. 1995; 121 (9): 981- 3.

Daou R. Thyroidectomy without drainage. Chirurgie. 1997; 122 (7): 408- 10.

Defechereux T, Hamoir E, Nguyen Dang D, Meurisse M. Drainage in thyroid surgery. Is it always a must?. Ann Chir. 1997; 51 (6): 647- 52.

Tabaqchali MA, Hanson JM, Proud G. Drains for thyroidectomy/parathyroidectomy: fact or fiction? Ann R Coll Surg Engl. 1999;81(5):302-5.

Pothier DD. The use of drains following thyroid and parathyroid surgery: a meta-analysis. J Laryngol Otol. 2005; 119 (9): 669- 71.

Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta- analyses. Lancet. 1999; 354 (9193): 1896- 900.

Samraj K, Gurusamy KS. Wound drains following thyroid surgery. Cochrane Database Syst Rev. 2007; (4): CD006099.

Kennedy SA, Irvine RA, Westerberg BD, Zhang H. Meta-analysis: prophylactic drainage and bleeding complications in thyroid surgery. J Otolaryngol Head Neck Surg. 2008; 37 (6): 768- 73.

Tian J, Li L, Liu P, Wang X. Comparison of drain versus no-drain thyroidectomy: a meta-analysis. Eur Arch Otorhinolaryngol. 2017; 274 (1): 567- 77.

Lee SW, Choi EC, Lee YM, Lee JY, Kim SC, Koh YW. Is lack of placement of drains after thyroidectomy with central neck dissection safe? A prospective, randomized study. Laryngoscope. 2006; 116 (9): 1632- 5.

Abboud B, Sleilaty G, Tannoury J, Daher R, Abadjian G, Ghorra C. Cervical neck dissection without drains in well-differentiated thyroid carcinoma. Am Surg. 2011; 77 (12): 1624- 8.

Mekel M, Stephen AE, Gaz RD, Randolph GW, Richer S, Perry ZH, et al. Surgical drains can be safely avoided in lateral neck dissections for papillary thyroid cancer. Am J Surg. 2010; 199 (4): 485- 90.

Falk SA, Birken EA, Baran DT. Temporary postthyroidectomy hypocalcemia. Arch Otolaryngol Head Neck Surg. 1988; 114 (2): 168- 74.

Auguste LJ, Attie JN. Completion thyroidectomy for initially misdiagnosed thyroid cancer. Otolaryngol Clin.North Am. 1990; 23 (3): 429- 39.

Chia SH, Weisman RA, Tieu D, Kelly C, Dillmann WH, Orloff LA. Prospective study of perioperative factors predicting hypocalcemia after thyroid and parathyroid surgery. Arch.Otolaryngol.Head Neck Surg. 2006; 132 (1): 41- 5.

Pisaniello D, Parmeggiani D, Piatto A, Avenia N, d’Ajello M, Monacelli M, et al. Which therapy to prevent post-thyroidectomy hypocalcemia? G.Chir. 2005; 26 (10): 357- 61.

Bentrem DJ, Rademaker A, Angelos P. Evaluation of serum calcium levels in predicting hypoparathyroidism after total/near-total thyroidectomy or parathyroidectomy. Am Surg. 2001; 67 (3): 249- 51.

Noordzij JP, Lee SL, Bernet VJ, Payne RJ, Cohen SM, McLeod IK, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am.Coll.Surg. 2007; 205 (6): 748- 54.

Moore FD, Jr. Oral calcium supplements to enhance early hospital discharge after bilateral surgical treatment of the thyroid gland or exploration of the parathyroid glands. J Am Coll.Surg. 1994; 178 (1): 11- 6.

Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, Alesina PF, De CC, et al. Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy? Surgery. 2002; 132 (6): 1109- 12.

Roh JL, Park CI. Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy. Am J Surg. 2006; 192 (5): 675- 8.

Testa A, Fant V, De RA, Fiore GF, Grieco V, Castaldi P, et al. Calcitriol plus hydrochlorothiazide prevents transient post-thyroidectomy hypocalcemia. Horm. Metab Res. 2006; 38 (12): 821- 6.

Uruno T, Miyauchi A, Shimizu K, Tomoda C, Takamura Y, Ito Y, et al. A prophylactic infusion of calcium solution reduces the risk of symptomatic hypocalcemia in patients after total thyroidectomy. World J Surg. 2006; 30 (3): 304- 8.

Roh JL, Kim JM, Park CI. Central cervical nodal metastasis from papillary thyroid microcarcinoma: pattern and factors predictive of nodal metastasis. Ann.Surg.Oncol. 2008; 15 (9): 2482- 6.

Lee SH, Lee SS, Jin SM, Kim JH, Rho YS. Predictive factors for central compartment lymph node metastasis in thyroid papillary microcarcinoma. Laryngoscope. 2008; 118 (4): 659- 62.

Ito Y, Miyauchi A. Lateral and mediastinal lymph node dissection in differentiated thyroid carcinoma: indications, benefits, and risks. World J.Surg. 2007; 31 (5): 905- 15.

Wada N, Duh QY, Sugino K, Iwasaki H, Kameyama K, Mimura T, et al. Lymph node metastasis from

papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann.Surg. 2003; 237 (3): 399- 407.

Zetoune T, Keutgen X, Buitrago D, Aldailami H, Shao H, Mazumdar M, et al. Prophylactic central neck dissection and local recurrence in papillary thyroid cancer: a meta-analysis. Ann.Surg Oncol. 2010; 17 (12): 3287- 93.

Shen WT, Ogawa L, Ruan D, Suh I, Kebebew E, Duh QY, et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch Surg. 2010; 145 (3): 272- 5.

Chisholm EJ, Kulinskaya E, Tolley NS. Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. Laryngoscope. 2009; 119 (6): 1135- 9.

Palestini N, Borasi A, Cestino L, Freddi M, Odasso C, Robecchi A. Is central neck dissection a safe procedure in the treatment of papillary thyroid cancer? Our experience. Langenbecks Arch Surg. 2008; 393 (5): 693-8.

Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, et al. Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients. World J Surg. 2002; 26 (8): 879- 85.

Goncalves FJ, Kowalski LP. Surgical complications after thyroid surgery performed in a cancer hospital. Otolaryngol Head Neck Surg. 2005; 132 (3): 490-4.

Filho JG, Kowalski LP. Postoperative complications of thyroidectomy for differentiated thyroid carcinoma. Am J Otolaryngol. 2004; 25 (4): 225- 30.

Haugen BRM, Sawka AM, Alexander EK, Bible KC, Caturegli PD, Doherty G, et al. The ATA Guidelines on Management of Thyroid Nodules and Differentiated Thyroid Cancer Task Force Review and Recommendation on the Proposed Renaming of eFVPTC without Invasion to NIFTP. Thyroid. 2017.

Kowalski LP, Sanabria A, Vartanian JG, Lima RA, de Mendonca UB, dos Santos CR, et al. Total thyroidectomy with ultrasonic scalpel: a multicenter, randomized controlled trial. Head Neck. 2012; 34 (6): 805- 12.

Upadhyaya A, Hu T, Meng Z, Li X, He X, Tian W, et al. Harmonic versus LigaSure hemostasis technique in thyroid surgery: A meta-analysis. Biomed Rep. 2016; 5 (2): 221-7.

Revelli L, Damiani G, Bianchi CB, Vanella S, Ricciardi W, Raffaelli M, et al. Complications in thyroid surgery. Harmonic Scalpel, Harmonic Focus versus Conventional Hemostasis: A meta-analysis. Int J Surg. 2016; 28 (Supl. 1):S22- 32.

Ren ZH, Xu JL, Fan TF, Ji T, Wu HJ, Zhang CP. The Harmonic Scalpel versus Conventional Hemostasis for Neck Dissection: A Meta-Analysis of the Randomized Controlled Trials. PLoS One. 2015; 10 (7): e0132476.

Contin P, Goossen K, Grummich K, Jensen K, Schmitz- Winnenthal H, Buchler MW, et al. ENERgized vessel sealing systems versus CONventional hemostasis techniques in thyroid surgery--the ENERCON systematic review and network meta-analysis. Langenbecks Arch Surg. 2013; 398 (8): 1039- 56.

Sanabria A, Ramirez A, Kowalski LP, Silver C, Shaha A, Owen R, et al. Neuromonitoring in Thyroidectomy. A Meta-Analysis of Effectiveness from Randomized Controlled Trials. Eur Arch Otorhinolaryngol. 2013; 270 (8): 2175- 89.

Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014; 188 (1): 152- 61.

Sanabria A RA. Análisis económico de la neuromonitoría rutinaria del nervio laríngeo recurrente en tiroidectomía total In: Endocrinologia ACd, ed. Congreso Nacional de Endocrinologia. Medellín, Colombia; 2012.

Dedivitis RA, Pfuetzenreiter EG, Jr., Castro MA, Denardin OV. Analysis of safety of short-stay thyroid surgery. Acta Otorhinolaryngol.Ital. 2009; 29 (6): 326- 30.

Mirnezami R, Sahai A, Symes A, Jeddy T. Day-case and short-stay surgery: the future for thyroidectomy? Int.J Clin.Pract. 2007; 61 (7): 1216- 22.

Sahai A, Symes A, Jeddy T. Short-stay thyroid surgery. Br.J Surg. 2005; 92 (1): 58- 9.

Marohn MR, LaCivita KA. Evaluation of total/near-total thyroidectomy in a short-stay hospitalization: safe and cost-effective. Surgery. 1995; 118 (6): 943- 7.

Mishra SK, Sharma AK, Thakur S. Outpatient and short-stay thyroid surgery. Head Neck. 1992; 14 (3): 247- 8.

Lo GP, Gates R, Gazetas P. Outpatient and short-stay thyroid surgery. Head Neck. 1991; 13 (2): 97- 101.

Snyder SK, Hamid KS, Roberson CR, Rai SS, Bossen AC, Luh JH, et al. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg. 2010; 210 (5): 575- 4.

Terris DJ, Moister B, Seybt MW, Gourin CG, Chin E. Outpatient thyroid surgery is safe and desirable. Otolaryngol.Head Neck Surg. 2007; 136 (4): 556- 9.

Spurgeon D. Outpatient thyroidectomy is safe in selected patients. BMJ. 2006; 333 (7569): 622.

Samson PS, Reyes FR, Saludares WN, Angeles RP, Francisco RA, Tagorda ER, Jr. Outpatient thyroidectomy. Am.J.Surg. 1997; 173 (6): 499- 503.

Cabrera E, Cifuentes P, Sanabria A, Dominguez LC. Tiroidectomía ambulatoria: análisis de minimización de costos en Colombia. Rev Col Cirugía. 2014; 29 (4): 319- 26.

Marshall DA, Douglas PR, Drummond MF, Torrance GW, Macleod S, Manti O, et al. Guidelines for conducting pharmaceutical budget impact analyses for submission to public drug plans in Canada. Pharmacoeconomics. 2008; 26 (6): 477- 95.

Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices--budget impact analysis. Value.Health. 2007; 10 (5): 336- 47.

Trueman P, Drummond M, Hutton J. Developing guidance for budget impact analysis. Pharmacoeconomics. 2001; 19 (6): 609- 21.

Sanabria A, Gomez X, Dominguez LC, Vega V, Osorio C. Tiroidectomia total basada en la evidencia, analisis de impacto presupuestario. Rev Col Cirugia. 2012; 27 (1): 30- 9.




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