2026 ATA多学科共识声明：门诊甲状腺手术

Introduction

This multidisciplinary consensus statement reflects the evolving landscape of ambulatory thyroid surgery over the past three decades, emphasizing its increasing adoption and nuanced factors influencing decisions between same-day discharge and overnight observation for patients with surgical thyroid disease.$^{1.2}$ While ambulatory thyroid surgery offers significant advantages and opportunities for improved patient satisfaction with resource conservation, achieving optimal outcomes remains the top priority in the decision-making process.

In the context of more widespread utilization of ambulatory thyroid surgery, this multidisciplinary consensus statement aims to update the 2013 publication on this topic from the American Thyroid Association (ATA), refining the eligibility criteria for safe ambulatory thyroid surgery based on recent data.$^{3}$ This statement also outlines evidence-based perioperative considerations that are essential for optimizing the safety and efficiency of these procedures.

Ambulatory thyroid surgery, defined as the discharge of patients on the same day as their operation, aligns with the International Association for Ambulatory Surgery's definition of an outpatient procedure.$^{4}$ Notably, patients who stay overnight under a 23-hour observation protocol without formal hospital admission are not considered part of this outpatient category. The decision regarding a patient's recovery location is influenced by multiple factors, including patient preferences, surgeon expertise, facility policies, and insurer requirements. However, ensuring patient safety remains the overarching priority in these decisions. Since the last iteration of this work, multiple studies have continued examination of this question, including several systematic reviews.$^{5-9}$

A notable driver of the shift toward same-day discharge has been regulation by the Center for Medicare and Medicaid and an outpatient basis, except for certain Current Procedural Terminology codes (60254—total or subtotal thyroidectomy for malignancy performed with a radical neck dissection, 60270—thyroidectomy including a substernal component, performed via a sternal split or transthoracic approach, 60271—thyroidectomy including a substernal component, performed without a sternal split).$^{10}$ The COVID-19 pandemic further accelerated this transition, pushing surgeons and facilities to adopt same-day protocols to manage strained health care resources.$^{11}$ Data from the American College of Surgeons National Surgical Quality Improvement Program showed a significant increase in the rate of outpatient thyroid lobectomy and total thyroidectomy during 2020, with ambulatory thyroid lobectomy for thyroid cancer rising from 43.2% to 57.9% between 2016 and 2020.$^{12}$ However, this rate decreased slightly in 2021 as the pressure of the pandemic to discharge patients eased.

Ambulatory thyroidectomy presents several advantages. For patients, recovering at home offers the comfort of

familiar surroundings, family support, and the flexibility to choose their food and beverages, enhancing overall satisfaction.$^{13}$ In addition, avoiding an overnight stay reduces the risk of hospital-acquired infections, falls, and medication administration errors. Studies have shown increased patient contentment with ambulatory procedures and a potential reduction in out-of-pocket expenses due to lower facility fees.$^{3,5,14,15}$ Rosen et al. highlighted that an overnight stay following thyroidectomy costs an average of $2367 more per patient.$^{16}$ AlEssa et al. showed that patients who were discharged home the same day after their procedure saved approximately 15.5% of health care costs compared with those admitted overnight.$^{17}$ From the perspective of surgeons and facilities, ambulatory procedures help conserve hospital resources, allowing more critical patients to access inpatient beds and enabling better utilization of health care capacities.

Despite these advantages, ambulatory thyroid surgery is not suitable for all patients or procedures. Although thyroid surgery carries an overall low risk of complications, more complex procedures, such as neck dissections and surgery for large goiters, increase the likelihood of adverse events and may necessitate an overnight hospital stay for close monitoring. In addition, an overnight stay may be recommended for children or those with functional or cognitive impairments who may require additional postoperative supervision to ensure safe recovery and adherence to discharge instructions.

A significant challenge in determining the appropriateness of ambulatory thyroid surgery lies in recognizing that research data and reported outcomes may not be universally applicable across diverse patient populations, surgeons, or health care facilities. With this context, it is important to ensure that key criteria, such as appropriate patient selection and proximity to the treatment institution or nearest emergency room facility, are thoughtfully applied to support safe implementation. In addition, the presence of clear preoperative, intraoperative, and postoperative protocols, as well as the experience and volume of the surgical team and facility, plays a pivotal role in the success of ambulatory thyroid surgery. Close collaboration among nursing staff, surgeons, and anesthesiologists is important at every stage of the patient's care, from selection and surgical planning to intraoperative management and postoperative monitoring. Effective teamwork ensures comprehensive patient assessment, timely identification of potential risks, and rapid intervention when needed, ultimately optimizing patient safety, recovery, and overall surgical outcomes.

The primary goal of this updated ATA statement is to provide objective, evidence-based guidance for surgeons, health care providers, and their multidisciplinary teams in safely performing ambulatory thyroid surgery and determining the patients, procedures, and facilities that are best suited for this approach (Fig. 1). While these recommendations are largely informed by data from health care systems with different resource availability, care pathways, and regulatory frameworks, each facility's regional health care infrastructure,

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

3


FIG. 1. Considerations for safe outpatient thyroidectomy.

cultural expectations, and local policies should be carefully considered when applying these recommendations globally. This document serves as a comprehensive resource to support informed decision-making and optimize patient outcomes while maintaining high standards of safety and care. This statement was endorsed by ThyCa: Thyroid Cancer Survivors' Association, the Graves' Disease and Thyroid Foundation, the American Head and Neck Society, and the American Association of Endocrine Surgeons (AAES). Table 1 includes a summary of key studies that underpin the findings and recommendations of this statement.

Methods

A writing group convened by the Surgical Affairs Committee of the ATA was tasked with updating the 2013 publication, with the goal of outlining best-practice recommendations for safe ambulatory thyroid surgery based on recent data in adult and pediatric patients. The author panel was carefully selected to represent a diverse range of disciplines, including endocrine surgery, otolaryngology—head and neck surgery, general surgery, pediatric surgery, endocrinology, and anesthesiaiology. The panel was developed to include both community-based and academic practitioners to ensure a balanced representation of opinions and practice patterns in this statement.

The writing group first developed an outline defining the scope and key clinical domains to be addressed. The objective

was to formulate recommendations that were evidence-based whenever sufficient data were available. A comprehensive literature review was performed focusing on relevant articles published after 2012, marking the endpoint of the previous statement's review. The literature used as the basis for the review was obtained by PubMed and Google Scholar searches using the following terms: outpatient thyroidectomy, ambulatory care, same-day thyroid surgery, outpatient thyroidectomy criteria, anesthesia for outpatient thyroidectomy, and ("Thyroidectomy"[Mesh]) AND "Ambulatory Surgical Procedures"[Mesh]. The majority of articles were published from 2012 through February of 2025, with the exception of select earlier publications recognized as seminal contributions on the topic.

A draft of each section was generated and subsequently discussed during a series of structured virtual meetings and email correspondences. Areas of controversy or limited evidence were explicitly reviewed. Consensus was achieved through group discussion rather than formal quantitative voting. The statement was refined until no substantive objections remained among the writing group. When disagreements arose, they were resolved through further discussion, review of supporting evidence, and modification of language to reflect shared agreement. In situations where high-quality evidence was lacking, statements were based on expert opinion and framed accordingly. Once this iterative process was complete, a draft was circulated to the full writing panel for further commentary and refinement.

TABLE 1. SUMMARY OF RECENT PUBLICATIONS ON AMBULATORY THYROID SURGERY

|Study|Year|Study design|Sample size (% same-day)|Brief summary of findings| |---|---|---|---|---| |Nakanishi et $al.^{7}$|2024|Systematic review and single-arm meta-analysis|N/A|The authors found low pooled complication rates with same-day thyroidectomy: neck hematoma: 0.7%; RLN injury: 1.5%; hypocalcemia: 0.7%; and readmission: 1.2%.| |Noel et $al.^{9}$|2021|Population-based retrospective cohort study|81,199 (8442)|This study examined ambulatory thyroidectomy in Ontario (1993–2017), finding it safe with low complication rates (neck hematoma 0.8% same-day vs. 1.3% inpatient) but low utilization (only 17.8% same-day discharges). Same-day discharge was associated with increased emergency room visits and readmissions.| |Hu et $al.^{8}$|2019|Analysis of ACS-NSQIP database|10,502 (2776)|This study evaluated the safety of same-day discharge versus one or two days postoperatively after thyroid surgery. A propensity-matched analysis showed that same-day discharge after thyroid surgery did not increase complications or readmissions, supporting its safety in well-selected patients.| |Meltzer et $al.^{125}$|2016|Propensity-matched retrospective cohort study|4708 (2354)|A propensity score-matched study within the California Kaiser health system found no differences in complications, emergency room visits, or readmissions between outpatient and inpatient thyroidectomy, supporting same-day discharge in selected patients.| |Compton et $al.^{74}$|2020|Retrospective chart review with national database analysis|99 (60) in community practice. Additional analysis of 12,755 cases from the Healthcare Cost and Utilization Project database for comparison|This study assessed the safety of ambulatory total thyroidectomy in a community otolaryngology practice. Two-thirds of cases were planned as ambulatory cases, with 8% requiring unplanned admission. Complication rates were low, and readmission rates were 1.5% and 3% for the ambulatory and inpatient cohorts, respectively. This supports the feasibility of ambulatory thyroidectomy in appropriately selected patients outside of academic centers.| |Lee et $al.^{6}$|2018|Systematic review and meta-analysis|N/A|Based on 10 nonrandomized observational studies, outpatient thyroidectomy had a lower risk of complications and no difference in readmission compared with inpatient thyroidectomy. The authors concluded that outpatient thyroidectomy may be safe, but studies were limited by high risk of bias.| |Hsu et $al.^{124}$|2023|Cross-sectional survey study|N/A|This study found significant variation in same-day discharge practices after total thyroidectomy among endocrine surgery fellowship programs, with a bimodal distribution driven largely by surgeon preference. There was little consensus on observation times, discharge criteria, or postoperative protocols. The findings highlight that ambulatory thyroid surgery remains inconsistent and is largely shaped by institutional culture rather than standardized guidelines.|

(continued)

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

5

TABLE 1. (CONTINUED)

|Study|Year|Study design|Sample size (% same-day)|Brief summary of findings| |---|---|---|---|---| |Mathur et $al.^{164}$|2018|Systematic review|9163|This study found that postoperative PTH levels have moderate predictive value for hypocalcemia, with median accuracy, sensitivity, and specificity of 86%, 85%, and 86% for absolute thresholds. Percent change in PTH performed slightly better (89%, 88%, 90%), but variability in methods and false-negative rates up to 54% limit reliability.| |Mallick et $al.^{68}$|2018|Retrospective cohort study|41 (39)|This study of Graves' disease patients found 95% of those planned for ambulatory total thyroidectomy were discharged the same day. Complications included transient hypocalcemia (12%), RLN palsy (9.7%), and hematoma (4.9%). Thirty-day emergency room visits and readmissions were 9.7% and 7%. Therefore, even with optimally selected patients and experienced surgical teams with well-trained ancillary staff, unanticipated admissions for surgical or medical management of complications may occur.| |Wilhelm et $al.^{96}$|2023|Retrospective cohort study|5446 (2118)|This study of thyroid cancer patients found that routine intraoperative nerve monitoring significantly reduced vocal cord dysfunction (short-term: 2.4% vs. 4.4%; long-term: 2.2% vs. 3.7%) and hypoparathyroidism, while increasing same-day discharge rates. These benefits were not seen with selective intraoperative nerve monitoring use.|

ACS-NSQIP, American College of Surgeons National Surgical Quality Improvement Program; PTH, parathyroid hormone; RLN, recurrent laryngeal nerve.

To incorporate the patient perspective, we sought review, feedback, and endorsement from ThyCa: Thyroid Cancer Survivors' Association and the Graves' Disease and Thyroid Foundation. Prior to the peer review process, the finalized consensus statement was submitted to the following groups for feedback and endorsement: AAES, American Head and Neck Society, and the ATA. Comments received from the ATA membership during a public comment period were considered and addressed, as appropriate, in the final draft submitted for publication.

Discussion

Preoperative considerations for eligibility

The decision to pursue ambulatory thyroid surgery centers around appropriate patient selection to optimize surgical outcomes and ensure high levels of patient satisfaction. When making this decision, consideration should be given to the patient's specific thyroid pathology, medical history and comorbidities, living situation, and proximity to the hospital, in addition to the willingness of the patient to undergo same-day surgery (Fig. 2). Of note, this decision-making process may differ significantly depending on whether surgery is scheduled at a free-standing outpatient surgery center or a hospital, where planned ambulatory surgery can be more readily converted to an overnight stay if necessary. The goal of appropriate patient selection and education is to reduce unplanned

hospital transfers, emergency department visits, readmissions, cost, and resource utilization while prioritizing patient safety, comfort, and satisfaction.

Thyroid pathology. Surgeons must consider the indication for thyroidectomy when assessing the suitability and likelihood of success of ambulatory surgery. Patients undergoing thyroid lobectomy for nodular disease or low-risk thyroid cancer face no risk of postoperative hypoparathyroidism and have a smaller operative field, which results in an overall lower risk of neck hematoma or airway compromise due to recurrent laryngeal nerve (RLN) injury.$^{24.25}$ These are favorable characteristics for pursuing successful ambulatory thyroid surgery. However, some patients with presumed low-risk thyroid cancer initially planned for thyroid lobectomy or total thyroidectomy may present with intraoperative findings necessitating more extensive surgery, including central neck dissection. Surgeons should account for this possibility and may prioritize facilities equipped to perform intraoperative frozen section analysis, if utilized in their practice, which can guide surgical decisions in real time. Such considerations are particularly important when deciding which patients are more suitable candidates for ambulatory thyroid surgery without the option for overnight admission.

Graves' disease can be associated with large goiters, increased gland vascularity, and perithyroidal inflammation,

6

NOURELDINE & SEIB ET AL.


FIG. 2. Procedural, clinical, and social characteristics that warrant careful attention and evaluation by an experienced thyroid surgeon to determine, on a case-by-case basis, whether ambulatory thyroid surgery can be safely performed. $^{a}$If increased risk of recurrent laryngeal nerve injury or hypoparathyroidism. $^{b}$Excluding ASA 81 mg. $^{c}$If total/completion thyroidectomy planned.

which may necessitate more extensive dissection and increase the risk of both transient and permanent hypoparathyroidism.$^{26,27}$ As a result, patient selection is of the utmost importance when electing to proceed with ambulatory thyroid surgery in this population. Large or substernal goiters are also associated with an increased risk of bleeding and RLN injury.$^{26}$ Therefore, anticipated challenging cases due to gland size or degree of substernal extension are considered relative contraindications to ambulatory thyroid surgery. Patients with Hashimoto's thyroiditis undergoing total thyroidectomy are at an increased risk of both transient and permanent hypocalcemia, which should be accounted for when considering same-day thyroidectomy in this population.$^{28}$ When planning thyroid surgery in a reoperative field, whether due to previous thyroid, parathyroid, airway, or anterior approach spinal operations, consideration should be given to the anticipated risks of nerve injury and hypoparathyroidism when determining the feasibility of same-day discharge.

Comorbidities. Comorbid conditions that increase the risk of perioperative complications or predict the need for overnight monitoring should be carefully considered when determining a patient's candidacy for ambulatory thyroid surgery. General literature evaluating patient selection for ambulatory surgery suggests that the following factors should be considered in the decision-making process: American Society of Anesthesiologists Physical Status (ASA-PS) class, morbid obesity, obstructive sleep apnea (OSA), cardiac disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, end-stage renal disease (ESRD), history of stroke, chronic opioid use, and history of malignant hyperthermia.$^{29}$ Although ASA-PS class III patients (indicating severe systemic disease) have a higher risk of unplanned readmissions

following outpatient thyroid surgery,$^{30}$ select patients in this group who have been properly evaluated and optimized pre-operatively may safely undergo ambulatory thyroid surgery, at the discretion of the surgeon and anesthesia team.$^{31}$ Nevertheless, these factors must be considered when selecting the facility for these procedures, reviewing the availability of overnight stay options and relevant specialists for consultation to manage any potential complications that occur because of their comorbid conditions.

Due to the concerns about perioperative airway management and hematoma formation in patients undergoing thyroid surgery, comorbidities that increase the risk of pulmonary or bleeding complications are considered relative contraindications to ambulatory thyroid surgery. This includes severe OSA, poorly controlled COPD, uncontrolled hypertension, ESRD, use of antiplatelet or anticoagulation medications, and morbid obesity. Patients with a known or presumptive diagnosis of OSA based on preoperative screening are at higher risk of postoperative hypoxemia and pulmonary or cardiac complications.$^{32,33}$ Therefore, prior to surgery, the anesthesiologist and surgeon should discuss whether ambulatory surgery is safe, considering the severity of OSA, the patient's ability to comply with positive airway pressure therapy, the likelihood of needing postoperative opioids, and the adequacy of postoperative observation parameters.$^{29,34}$ Patients on anti-platelet medications, oral anticoagulants, or injectable anticoagulants are at higher risk of neck hematoma, even when these medications are appropriately discontinued preperatively based on their half-lives.$^{35,36}$ Oltmann et al.$^{35}$ showed that postoperative hematoma rates in patients receiving 325 mg aspirin (0.8%) or clopidogrel (2.2%) were notably higher than patients not receiving antiplatelet therapy (0.5%) or receiving <325 mg of aspirin (0.1%, p = .04). Therefore, strong consideration for overnight observation is recommended

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

7

for this population (excluding patients on low-dose aspirin).$^{37,38}$ Patients with morbid obesity are at an increased risk of OSA and neck hematoma, and the presence of excess subcutaneous fat may delay the recognition of a hematoma.$^{39}$ Decisions about the need for overnight observation rather than same-day discharge following thyroid surgery in this patient group should be made on a case-by-case basis.

Age. Patients in older age groups are eligible for ambulatory thyroid surgery.$^{40}$ In fact, older adults are more susceptible to postoperative delirium and tend to have worse outcomes when complications arise. Therefore, ambulatory surgery may offer notable clinical benefits in this population. Same-day surgery may facilitate early mobilization and return to baseline function, which could help reduce the risk of venous thromboembolism and pulmonary complications and maximize the chance of maintaining preoperative mobility.$^{41}$ In addition, avoiding hospital admission may reduce the risk of nosocomial infections and exposure to multidrug-resistant organisms, which can be particularly severe in this patient population. Frailty is more important than age alone in risk stratifying patients for ambulatory thyroid surgery and can be assessed routinely in the clinic setting to determine suitability for ambulatory thyroid surgery.$^{42,43}$

Ambulatory thyroid surgery in the pediatric population continues to be an emerging concept. While the number of published case series has increased, data on overall outcomes and safety in children are more limited than in adults.$^{44.45}$ Several studies suggest that thyroid surgery, including lobectomy and total thyroidectomy, can be performed safely on an ambulatory basis in well-selected pediatric patients. Factors such as the age of the child and the surgical team's expertise and volume play a key role in determining the feasibility and safety of this approach.$^{45-48}$ Based on expert opinion, children younger than 12 may not be ideal candidates for ambulatory thyroid surgery. Accordingly, most pediatric thyroid surgeries are still performed with overnight hospitalization, especially for those under 12 years of age. The increased risks associated with neck hematoma leading to airway obstruction (due to both the smaller pediatric airway and potential for less clear communication by children about symptoms of distress) and hypocalcemia are notable concerns in this population and make ambulatory surgery more challenging.

Moreover, obtaining informed consent and making decisions about perioperative care in the pediatric population involves securing parental permission and, when appropriate, the child's assent. The American Academy of Pediatrics emphasizes that children should participate in decision-making, commensurate with their level of development and ability to understand the medical situation, and provide assent to care whenever reasonable.$^{49}$ Children may be anxious, frightened, or not fully able to comprehend the implications of the surgery. Therefore, it is crucial to consider the child's emotional and psychological state when considering ambulatory surgery and provide support through counseling and age-appropriate information.$^{50-52}$ Given the current data and documented experience, individualized patient selection remains the most appropriate approach for determining candidacy for ambulatory thyroid surgery in children.

Preoperative patient education. Ambulatory thyroid surgery has consistently demonstrated high levels of patient

satisfaction in multiple studies, with patients valuing autonomy, comfort, and cost savings associated with recovering in their home environment.$^{13,53-55}$ Appropriate patient education and counseling on anticipated recovery and potential complications is essential for the success of ambulatory thyroid surgery. This process requires adequate patient health literacy (HL), defined as the ability to comprehend and use medical information to make informed medical decisions.$^{56}$ It is estimated that approximately 33% of the U.S. population has low HL.$^{57}$ Moreover, awareness of HL on both sides of the physician-patient relationship is often lacking, which can exacerbate inherent barriers to care. As a result, HL should be taken into account when evaluating the safety of ambulatory thyroid surgery.$^{58}$ If a significant lack of HL is demonstrated during patient counseling about ambulatory thyroid surgery, such as poor recall or understanding of postoperative instructions, or if screening suggests limited HL, it may be appropriate to reassess the discharge plan.

A randomized controlled trial demonstrated that patients who underwent ambulatory thyroid surgery in China had increased anxiety after the procedure despite equivalent rates of complications to those who had inpatient surgery, although baseline measures of anxiety were not taken.$^{59}$ This observation, along with the understanding that patients may have difficulty retaining new information as they recover from anesthesia at the time of discharge from ambulatory surgery, underscores the value of introducing patient education early in the care pathway, ideally at the time of initial office consultation. Early engagement allows patients to learn about the perioperative process, ask questions, and familiarize themselves with what to expect. Offering educational materials, including written instructions, early on can help support preparedness. It is helpful to review with patients and caretakers' potential key events, such as symptomatic hypocalcemia and neck hematoma, that may require timely medical attention. Providing clear, actionable guidance on how to recognize and respond to these situations can contribute to patient safety and improve overall outcomes.

Availability of a willing caregiver and proximity to the hospital. During the preoperative evaluation, it is essential to identify a willing and responsible adult who can stay with the patient for 24-48 hours after surgery.$^{14,60-62}$ This caregiver should ideally be present during the discharge process to hear postoperative instructions, ensure adherence to medication schedules (including calcium, calcitriol, and thyroid replacement therapy), and respond to communication from the surgical team as needed.$^{26}$ The caregiver should be looking out for the potential complications, understand whom to contact, and know where to seek emergency care based on detailed instructions provided both before and after surgery.$^{60}$ Although early studies recommended limiting ambulatory thyroid surgery to patients living within a one-hour driving distance of the surgery center, more recent research has deemphasized this restriction, provided that caregivers have reliable telephone access to the surgical team.$^{30,44,62-64}$ For patients living farther from the surgical center, identifying a nearby and reliable acute care facility, preferably in coordination with the referring physician, can be a practical solution to ensure safe care. Ideally, patients should be

8

NOURELDINE & SEIB ET AL.

within 60–90 minutes of a hospital capable of taking care of any life-threatening complication for the first 24 hours after surgery. If no suitable local facility can be identified, or if the patient is unwilling or unable to stay near the surgical center on the first postoperative day, an overnight hospital stay may be indicated for select $patients.^{15,62}$

Special consideration should also be given to patients whose postoperative environment limits access to immediate medical evaluation or continuous supervision. This includes incarcerated individuals, for whom same-day discharge may pose logistical and safety challenges related to transportation, monitoring, and timely access to emergent care. In such select cases, overnight observation may be appropriate despite otherwise meeting clinical criteria for ambulatory thyroid surgery.

Preoperative optimization of thyroid and related disorders. Preoperative optimization of hyperthyroidism and vitamin D deficiency is important to the success of ambulatory thyroid surgery. Hyperthyroidism, or thyrotoxicosis, increases the risk of complications such as atrial fibrillation, ventricular dysfunction, and heart failure, which are associated with increased morbidity and mortality in patients undergoing thyroidectomy.$^{65}$ The 2016 ATA Guidelines for the Management of Hyperthyroidism and Other Causes of Thyrotoxicosis and the AAES Thyroid Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults recommend rendering hyperthyroid patients euthyroid preoperatively using antithyroid drugs.$^{66,67}$ Beta-blockers should also be used as needed to achieve a target heart rate below 90 beats per minute.$^{66,67}$

For patients with Graves' disease, potassium iodide (SSKI or Lugol's iodine) may be considered to reduce thyroidity vascularity and intraoperative blood loss.$^{66.67}$ Published data show that ambulatory surgery for Graves' disease or hyperthyroidism can be performed with acceptable outcomes.$^{68}$. However, it is important to note that even with optimally selected patients and experienced surgical teams with well-trained ancillary staff, unanticipated admissions for surgical or medical management of complications occur.$^{9.68.69}$ Therefore, pathways for further patient evaluation and admission should be available when same-day surgery is planned.

Hypocalcemia is the most common complication following total thyroidectomy. When considering both inpatient and outpatient thyroidectomy, biochemical hypocalcemia occurs in approximately 28% of patients and severe, symptomatic hypocalcemia occurs in 6% of patients.$^{22,70}$ Preoperative correction of vitamin D deficiency can help reduce the risk of symptomatic hypocalcemia. The 2018 ATA statement on postoperative hypoparathyroidism provides guidance for treating vitamin D deficiency, recommending a Food and Drug Administration-approved regimen of 50,000 International Units (IU) of vitamin D3 (cholecalciferol) weekly or 6000 IU daily for 8 weeks for severe (<10 ng/mL), moderate (10 to <20 ng/mL), or mild (20–30 ng/mL) vitamin D deficiency.$^{71}$ The recent 2024 Endocrine Society guidelines recommend daily vitamin D supplementation over the larger weekly doses to minimize the risk of elevated inactive vitamin D levels and enhance efficacy.$^{72}$

Operative planning and intraoperative considerations

The choice of facility is a critical consideration for ambulatory thyroid surgery. While freestanding ambulatory surgical

centers offer efficiency, cost-effectiveness, and streamlined care, thyroid surgery may present unique challenges that necessitate additional resources for optimal patient outcomes.$^{73}$ Thyroid surgery may require more extensive dissection based on intraoperative findings, intraoperative frozen section analysis results, or management of complex anatomy. In addition, the potential for airway compromise, postoperative hematoma formation, or hypocalcemia necessitates having resources readily available to manage these complications promptly.$^{74}$ Hospitals provide access to intensive monitoring, overnight observation if needed, and immediate access to specialists, such as (1) intensivists and high-acuity nursing care for assistance in postoperative management and surveillance, (2) anesthesiologists experienced in airway management, and (3) pathologists to guide intraoperative decision-making. These resources allow for greater flexibility in patient management and overnight admission as a backup plan if unexpected complications occur. Compton et al. showed that while most ambulatory thyroid surgeries proceeded without incident, 6% required unplanned hospital admission and 3% required readmission after discharge,$^{74}$ highlighting the importance of surgeon judgment in selecting patients for thyroidectomy in this setting. Ultimately, surgeons performing ambulatory thyroid surgery must ensure that the chosen facility has the capacity for all procedures necessary for optimal surgical outcomes, including real-time nerve monitoring or rapid frozen section evaluation if utilized in their practice, and for postoperative monitoring protocols to safely discharge patients on the same day. Moreover, surgeons pursuing ambulatory thyroid surgery are encouraged to evaluate their own outcomes. This includes monitoring rates of unplanned readmissions, emergency department visits, and complications such as hematoma and hypocalcemia. Tracking and benchmarking these metrics over time can identify areas for improvement, support protocol refinement, and ensure that ambulatory thyroidectomy remains a safe practice tailored to their specific patient population and institutional resources.

Thyroidectomy is most commonly performed under general endotracheal anesthesia (GETA), while regional anesthesia (RA) with monitored anesthesia care is used less frequently. Regardless of the chosen technique, the primary anesthesia goals include safe performance of the operation and adequate control of postoperative nausea and vomiting (PONV) as well as pain.$^{75}$ Acute elevations in venous pressures caused by retching and vomiting should be avoided, as they can increase the risk of bleeding at the surgical site. Similarly, uncontrolled hypertension due to pain should be mitigated, particularly during the immediate postoperative period. Instituting standardized protocols, such as Enhanced Recovery After Surgery (ERAS), can help achieve these goals.$^{19}$ Recent meta-analyses have shown that ERAS pathways significantly reduce hospital stays and costs without increasing readmission rates or complications in thyroid and parathyroid surgeries.$^{76,77}$ Key components of ERAS pathways in thyroid surgery include a focus on preadmission education, PONV prophylaxis, fluid management, and multimodal pain management.$^{76}$

Thyroid surgery under GETA allows for intraoperative laryngeal nerve monitoring via an electromyography endotracheal tube. Many agents used in general anesthesia, such as volatile anesthesia, nitrous oxide, and opioids, have pro-

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

9

emetic properties. This side effect must be considered when tailoring the anesthetic to be used for ambulatory thyroid surgery. Volatile anesthetics, in a dose-dependent manner, are the leading cause of PONV, especially in the early postoperative period.$^{78}$ To address this, the ASA recommends multimodal prophylaxis in patients with one or more risk factors for PONV.$^{79}$ Ondansetron, scopolamine transdermal patches, and dexamethasone are commonly used due to their efficacy, safety profile, and cost-effectiveness, although newer class antiemetic combination therapies are also emerging.$^{14,80}$ Propofol, known for its antiemetic properties, is another valuable option in multimodal therapy. For high-risk patients, avoiding volatile anesthetics altogether by using a total intravenous anesthesia technique with propofol may be advisable and has proved safe in thyroid surgery.$^{81,82}$ Another important goal of GETA is smooth emergence. This can be achieved by administering intravenous dexmedetomidine or lidocaine to attenuate coughing. The administration of intravenous lidocaine during thyroidectomy may also reduce postoperative pain and PONV.$^{83}$ Deep extubation, where the endotracheal tube is removed while the patient remains in a deep plane of anesthesia but is spontaneously breathing, can reduce sympathetic activity and prevent emergence hypertension that usually accompanies extubation. However, this technique is contraindicated in patients with a difficult airway, obesity, or a high aspiration risk.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), increasingly used for management of type 2 diabetes and obesity, delay gastric emptying through effects on gastrointestinal motility. This may lead to increased residual gastric contents despite adherence to standard fasting guidelines, potentially raising the risk of aspiration at induction of anesthesia. Therefore, recent consensus guidelines from the ASA suggest an individualized approach to perioperative GLP-1 RA management.$^{84}$ For patients at higher risk of delayed gastric emptying or aspiration, a modified preoperative diet or withholding these medications approximately one week before elective procedures may be considered. Including point-of-care gastric ultrasound may be helpful. For daily dosing, holding on the day of surgery has been suggested.$^{85}$

The drive to reduce opioid use in postoperative pain management has led to an emerging interest in nonopioid analgesic regimens. In a randomized clinical trial of patients undergoing ambulatory thyroid and parathyroid surgery, a patient-centered opt-in strategy for postoperative opioid prescriptions significantly reduced the number of opioids prescribed and consumed without increasing postoperative pain or worsening health-related quality of life. No patients who declined opioids required rescue prescriptions, demonstrating that selective, on-demand opioid use is safe and effective after thyroid and parathyroid surgery.$^{86}$ Moreover, regional techniques are increasingly used alongside general anesthesia to enhance postoperative pain control and reduce narcotic requirements after thyroid surgery, both of which may facilitate ambulatory thyroid surgery.$^{87,88}$ The superficial location of the cervical plexus at the posterior border of the sternocleidomastoid muscle makes it amenable to blockade by RA.$^{89}$ Ultrasound guidance allows for real-time visualization of local anesthetic spread in the correct fascial planes, but landmark techniques can be performed by the surgeon with minimal risk. Inadvertent deep injection can result in brachial

plexus, phrenic, or other local nerve blocks, potentially leading to patient distress or respiratory complications, so care should be taken to avoid this. A recent updated meta-analysis evaluating the analgesic effects of bilateral superficial cervical plexus block found that it significantly reduced opioid consumption, prolonged analgesia, resulted in lower visual analog pain scale scores in the first 24 hours postoperatively, and decreased PONV.$^{90}$ Therefore, use of regional adjuncts, to include cervical plexus blocks, surgical wound infiltration, avoiding cervical hyperextension, and using smaller endotracheal tubes, may be beneficial for patients planned for same-day discharge.$^{87}$ An opioid-free anesthetic approach that combines RA with nonopioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and ketamine, as part of a multimodal analgesic regimen, has shown promising results. Contrary to reported concerns about increased risk of bleeding,$^{91}$ multiple studies have shown that NSAIDs do not significantly increase the risk of postoperative hematoma and can be safely used to assist with pain control after thyroidectomy.$^{92}$ These strategies improve recovery outcomes following thyroid surgery by minimizing opioid-related side effects and enhancing patient comfort.$^{93}$

Technical considerations. Intraoperative neuromonitoring (IONM) using an endotracheal tube-based system is widely employed by thyroid surgeons to monitor the laryngeal nerves intraoperatively.$^{94}$ IONM can predict nerve integrity by eliciting a laryngeal response through direct stimulation of the RLN or vagus nerve. While the literature provides mixed evidence regarding the effect of IONM on the risk of laryngeal nerve injury,$^{23,95}$ the use of IONM has been associated with a higher rate of same-day discharge.$^{96,97}$ The ability to confirm neural integrity during surgery may inform discharge planning, given the potential for aspiration after unilateral RLN injury and the potential severe respiratory consequences of bilateral nerve injury. If unilateral nerve injury is suspected intraoperatively, a thorough evaluation of respiratory status and swallowing function should be performed prior to discharge. In cases of bilateral laryngeal nerve injury, airway management requires careful consideration and inpatient evaluation. This includes assessing the decision to extubate, performing flexible laryngoscopy to assess vocal fold function, and determining the need for reintubation, tracheostomy, or whether close postoperative airway monitoring is necessary.

Achieving hemostasis intraoperatively is of paramount importance to facilitate safe ambulatory thyroidectomy, given the potentially life-threatening consequences of a postoperative neck hematoma. Traditionally, hemostasis has been achieved using a clamp and tie technique, surgical clips, or electrocautery. However, vessel-sealing devices have been widely adopted in recent years, providing a safe and more efficient method for achieving a hemostatic surgical bed.$^{98-100}$ Multiple observational studies and a meta-analysis have shown that the use of vessel-sealing devices is associated with a decreased risk of neck hematoma without increasing the risk of RLN injury or hypocalcemia.$^{101-106}$ These data suggest consideration should be given to using these devices to minimize the risk of perioperative bleeding. However, a 2007 prospective randomized controlled trial and a recent systematic review and meta-analysis showed no significant differences in the incidence of hematoma requiring operative

10

NOURELDINE & SEIB ET AL.

intervention among patients managed with conventional hemostatic techniques versus vessel-sealing devices.$^{107,108}$ Regardless of the techniques used, at the conclusion of surgery, careful inspection of the thyroid bed and strap muscles is essential to identify and address any sources of bleeding. This process often includes irrigation with sterile water or saline to clear clots and facilitate the identification of active bleeding sites. In addition, this can be accomplished by increasing the venous pressure in the neck for a brief period either by utilizing a Valsalva maneuver (up to 30–40 cm H₂O) or by repositioning the patient in the Trendelenburg position.$^{109}$ Both maneuvers should be limited to under one minute to reduce the risk of complications such as pneumothorax or increased intracranial pressure. Meticulous inspection and control of the operative field are the most critical components for achieving hemostasis.

Multiple randomized controlled trials have shown that the use of drains during thyroidectomy does not reduce the risk of postoperative hematoma and seromas.$^{110-112}$ This observation holds true even in cases of significant intraoperative bleeding, large goiters, or the addition of a central neck dissection. Therefore, appropriate utilization of adjuncts, such as surgical drains or hemostatic agents, remains at the discretion of the treating surgeon.

Recommendations related to wound closure are based on theoretical benefits and expert opinion. At the conclusion of the procedure, suturing the right and left sternohyoid muscles, with or without the sternothyroid, in the midline helps prevent the adhesion of skin and subcutaneous tissues to the trachea.$^{113}$ However, it is important to note that airway obstruction associated with postoperative bleeding is often related to venous and lymphatic outflow obstruction.$^{114}$ Therefore, many surgeons will leave the inferior portion of this closure open to potentially allow blood egress superficially in case of a central neck hematoma.$^{115}$

Postoperative hypocalcemia is the most common cause of prolonged hospitalization following thyroid surgery, making prudent parathyroid management essential.$^{71}$ Hypoparathyroidism following thyroid surgery occurs from disruption of the parathyroid arterial blood supply or venous drainage, direct mechanical or thermal injury, or intentional or inadvertent removal.$^{116}$ Intraoperative preservation of the parathyroid glands with intact vascular supply, typically from the inferior thyroid artery, should be a priority during thyroid surgery. This requires meticulous dissection and at least 3–5 mm of separation between vessel sealing devices and parathyroid glands to avoid thermal injury.$^{117,118}$ At the conclusion of dissection, all identified parathyroid glands should be evaluated for devascularization, and the thyroid specimen should be examined for adherent or intracapsular parathyroids. Parathyroid autotransplantation to maximize the preservation of functional parathyroid tissue should be performed for any incidentally resected parathyroid glands and considered for parathyroids with evidence of inadequate blood supply, recognizing that discoloration may not be a good marker of long-term impaired function and that an in situ functional parathyroid gland is preferable to an autograft with respect to short-term calcium homeostasis.$^{71,119}$ Parathyroid autotransplantation does not preclude ambulatory management, provided the other parathyroid glands were identified, preserved, and appeared viable at the conclusion of the case

or early postoperative parathyroid hormone (PTH) levels are adequate.

Postoperative considerations

The initial postoperative period following outpatient thyroidectomy is critical to ensuring patient safety and optimizing recovery. A comprehensive approach that includes careful monitoring, appropriate pain and symptom management, patient education, and clear discharge criteria is essential. A structured and evidence-based protocol should guide postoperative care and monitoring for hematoma formation, airway compromise, and hypocalcemia.

Proper surgical dressing allows for early recognition of postthyroidectomy hematoma formation. While some surgical procedures benefit from the use of pressure dressings to the surgical site, this practice is not recommended following most types of thyroid surgery. Pressure dressings do not significantly reduce the risk of postoperative bleeding and may, in fact, delay the identification of hematoma formation.$^{120}$For this reason, it is preferable to use minimal dressings, such as a small adhesive bandage, steri-strips, or topical skin adhesive, to allow direct visualization of the surgical field. This practice facilitates early detection of swelling, bruising, or other signs of hematoma formation, which can be life-threatening if not addressed promptly.

PONVs are common concerns after thyroid surgery, as excessive retching can increase venous pressure and contribute to the risk of hematoma formation.$^{121}$ To minimize this risk, prophylactic antiemetic therapy should be administered as part of the routine perioperative management, as discussed above.$^{14,80}$ Lozenges and cough suppressants should be encouraged if the patient develops a cough. In addition to nausea and cough control, careful blood pressure management is essential. Hypertension in the immediate postoperative period, particularly when systolic blood pressure exceeds 180 mmHg, has been associated with an increased risk of postoperative bleeding.$^{114,122,123}$ Patients with a history of hypertension should have their blood pressure closely monitored perioperatively, and appropriate antihypertensives should be given as needed to maintain normotension. Adequate blood pressure control is required prior to same-day discharge. In addition, persistently elevated systolic blood pressures may be an early indicator for hematoma that should prompt an assessment by the surgical team.

Postoperative monitoring and establishing safe discharge criteria. Strict and well-defined discharge criteria are of paramount importance to ensure safe ambulatory thyroid surgery. Many centers require a minimum time period of observation prior to discharge. However, even in high-volume centers, this observation period can vary significantly, with 30% of participating institutions in one survey not reporting a minimum postoperative observation time and the remaining 70% reporting ranges from <2 to >6 hours.$^{124}$ Based on the available evidence, there is no consensus on a minimum amount of time to observe thyroidectomy patients prior to discharge. Nonetheless, hematoma formation is a rare but life-threatening complication that may arise after thyroid surgery and usually occurs within the first 6-8 hours following surgery,$^{125}$ making this period a key window for observation.

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

11

To standardize the discharge process, well-defined criteria should be utilized to confirm that patients are stable and ready for home recovery (Fig. 3). Different discharge scoring systems have been applied and adapted at individual institutions, but in general, the key elements that must be ruled out prior to discharge include (1) any signs of bleeding, such as neck swelling, discoloration, or increased tension/tenderness at the incision; (2) symptoms or evidence of airway compromise, such as stridor, hoarseness, neck tightness, or difficulty breathing; and (3) symptoms of hypocalcemia, including perioral tingling, numbness, or muscle cramps, which is relevant for patients who undergo total or completion thyroidectomy, as well as central neck dissection. Other essential criteria include the absence of nausea and vomiting, the ability to tolerate oral intake, adequate blood pressure control, and the establishment of a clear postoperative care plan. To further enhance patient safety, a standardized discharge instruction sheet outlining the signs and symptoms that require urgent medical attention should be provided to both patients and caregivers, with clear contact information for the on-call surgical team.

Patient education and anticipated recovery course. A well-informed patient is more likely to have a smooth and uneventful recovery from ambulatory thyroid surgery. Before discharge, patients should receive detailed instructions on what to expect in the days following surgery. Mild throat discomfort, transient voice changes, and localized swelling are common and should not be cause for alarm. However, patients should be made aware of warning signs that necessitate immediate medical evaluation, including

progressive or rapid neck swelling, difficulty breathing, severe hoarseness, persistent nausea/vomiting, or intractable symptoms of hypocalcemia. Clear education must be provided on how to manage these problems, which may include contacting the surgeon or their coverage, going to the emergency department, or calling 911 (or the relevant regional number for emergency assistance). Providing patients with a 24-hour emergency contact number is required to ensure that they have access to guidance should they develop concerns at home. If patients are sent to the emergency department for evaluation of a possible neck hematoma, the emergency physician should be made aware of the potential need for and technique of bedside wound opening if the patient is rapidly deteriorating. Intubation is protective but secondary to decompressing the hematoma and may be challenging with a truly emergent airway obstruction due to cervical hematoma.

Management of complications

Vocal fold dysfunction. RLN paralysis includes both transient and permanent dysfunction. While permanent RLN injury is relatively rare, transient paralysis occurs in 5–11% of patients undergoing thyroidectomy and resolves within a defined timeframe, typically within 6–12 months of surgery.$^{18,20,126}$ Injury to the RLN may be noted intraoperatively, whether from a visualized nerve transaction or from loss of signal if using IONM. However, even in the absence of a detected intraoperative injury, all patients should undergo clinical evaluation of the airway, voice, and swallowing prior to same-day discharge. If a nerve injury is suspected, flexible laryngoscopy can be performed to assess for vocal fold paralysis. In certain patients, transcutaneous laryngeal


No evidence of neck hematoma or airway compromise

after observation during critical window*


Plan for calcium supplementation provided

with no active symptoms of hypocalcemia


Pain adequately managed

prioritizing acetaminophen and NSAIDs


Tolerating oral intake

of liquids and medications


Symptoms controlled

including PONV and hypertension


Comprehension of instructions for management of complications

number to contact and nearest facility in case of emergency

*no universal minimum, but structured observation protocol recommended. PONV, postoperative nausea and vomiting; NSAIDs, non-steroidal anti-inflammatory drugs.

FIG. 3. Criteria for safe same-day discharge after thyroidectomy.

12

NOURELDINE & SEIB ET AL.

ultrasound can be considered a screening tool for selecting cases for flexible laryngoscopy.$^{127,128}$ Once confirmed on laryngoscopy or if suspected based on IONM signal loss and postoperative clinical assessment, a formal swallow evaluation should be conducted. Patients deemed at low risk for aspiration by the surgeon or a speech-language pathologist may be considered for same-day discharge, although patients should be advised that their symptoms may worsen as vocal fold swelling subsides and earlier follow-up should be considered. In contrast, patients demonstrating clear clinical evidence of aspiration or significant airway compromise should be considered for extended observation or inpatient management. Close follow-up should be considered for all patients with confirmed or suspected vocal fold paralysis. Prompt referral to a laryngologist or otolaryngologist who specializes in airway rehabilitation should be considered.

Neck hematoma. The incidence of hematoma following thyroid surgery ranges from 0.4% to 1.5% in studies of overall patients undergoing thyroidectomy.$^{7,129}$ The results from recent retrospective cohort studies reporting rates of neck hematoma after same-day thyroid surgery are listed in Table 2. A recent meta-analysis of 31 studies comprising 74,328 patients undergoing same-day and 23-hour stay thyroidectomy by Nakanishi et al. reported a postoperative hematoma rate of 0.4% overall and 0.7% among patients undergoing same-day surgery.$^{7}$ Postoperative hematoma occurs typically within the first 6 hours after thyroidectomy. In a single-institution study of 5156 thyroid operations, Liu et al. found that 64% of neck hematomas occurred within 6 hours of surgery and 89% within 12 hours.$^{130}$ Similarly, Lang et al. reported that 72.7% of patients experiencing a neck hematoma and requiring reoperation occurred within 6 hours.$^{131}$ Campbell et al. described a more delayed time course in a multi-institutional case-control study of patients developing post-thyroidectomy hematomas, with 47% occurring within 6 hours and 79% within 24 hours.$^{132}$ Patient factors associated with an increased risk of neck hematoma include male sex, hypertension, obesity, antiplatelet or anticoagulation therapy, chronic steroid use, Graves' disease, and larger goiters/nodules.$^{38,105,129,130,132-134}$ Procedural factors associated with an increased risk of hematoma include reoperative or more extensive surgery,$^{36,129,132}$ while the use of an energy device for hemostasis has been associated with decreased hematoma rate.$^{104,105}$ All these factors should be considered when deciding to proceed with ambulatory thyroidectomy. The development of a postoperative hematoma is associated with an increased risk of other perioperative complications, including RLN injury, wound complications, hypocalcemia, pulmonary morbidity, longer length of stay, and readmission.$^{105}$

Given the potentially lethal outcome of a neck hematoma occurring in an outpatient setting, an important component of planning for safe same-day thyroidectomy is to (1) select patients who are at lower risk of developing a neck hematoma and would be able to obtain urgent medical care in an outpatient setting if this rare but life-threatening complication were to occur; (2) develop care pathways that mitigate the risk of hematoma development; (3) provide sufficient

|Study|Publication year|Study type|Study setting|Data collection (years)|Number of patients, N|Same-day discharge N (%)|Total thyroidectomy N (%)|Hematoma among those discharged same day N (%)| |---|---|---|---|---|---|---|---|---| |Rajeev et $al.^{184}$|2014|Retrospective cohort study|Single institution in United Kingdom|2000–2011|802|163 (20.3%)|NR|0| |de Boisanger et $al.^{185}$|2015|Retrospective cohort study|Two hospitals in|2010–2013|106|106 (100%)|0|0| |Yakhlef et $al.^{186}$|2017|Retrospective cohort study|Scotland|2009–2013|130|128 (98.5%)|0|1 (0.1)| |Hu et $al.^{8}$|2020|Retrospective cohort study|ACS NSQIP Targeted Thyroidectomy|2016–2017|2776|2776 (100%)|716 (25.8%)|23 (1.2)| |Jeppesen et $al.^{187}$|2020|Retrospective cohort study|Participant Use File Single hospital in Denmark|2014–2019|137|124 (90.5%)|0|0| |AIEssa et $al.^{17}$|2021|Retrospective cohort study|Two tertiary hospitals in Saudi Arabia|2017–2019|76|76 (100%)|50 (65.8%)|0| |Chereau et $al.^{188}$|2021|Retrospective cohort study|Single center in France|2018–2020|529|523 (98.9%)|16 (3.0%)|2 (0.4)| |Noel et $al.^{9}$|2021|Retrospective cohort study|Population-based study in Ontario, Canada|1993–2017|8442|8442 (100%)|1648 (19.5%)|64 (0.8%)|

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

13

postoperative monitoring for early identification of bleeding; and (4) have protocols for the management of both inpatient and outpatient neck hematomas (Table 3). Patient selection, risk mitigation, and postoperative monitoring have been addressed in previous sections. Guidelines for the evaluation and management of neck hematoma after thyroid surgery were recently reported in a systematic review and multidisciplinary consensus guidelines by the British Association of Endocrine and Thyroid Surgeons and the British Association Otolaryngology Head and Neck Surgery and provide a helpful framework for institutional protocol development.$^{135}$

For patients undergoing ambulatory thyroid surgery, the evaluation and management of a postoperative neck hematoma after discharge is more challenging due to the lack of immediate medical supervision. As a result, patient education and early detection are essential, with swift emergency action needed if a hematoma is suspected. Although there are no data on patient outcomes when a hematoma develops after hospital discharge, anticipating and preparing for this rare complication is a key component of ambulatory thyroid surgery. Patients need to be informed of the symptoms of a hematoma, including swelling, tightness, dysphagia, difficulty breathing, and voice changes. It should be emphasized that any signs of respiratory distress or neck swelling require immediate attention and should prompt a call to emergency services (911 or the relevant regional number) or presentation to the nearest facility with the capability to manage a neck hematoma rather than waiting to contact the surgeon.

Postoperative hypoparathyroidism. The goal of managing potential or confirmed hypoparathyroidism is to prevent the symptoms and complications associated with hypocalcemia, which is most likely to occur after hospital discharge. Symptoms can range from mild to severe, with early signs of hypocalcemia typically appearing before more life-threatening complications develop. Safe ambulatory thyroid surgery requires recognition of patients at high risk of hypocalcemia and providing thorough patient education on symptom recognition, preventive strategies, and appropriate management to alleviate symptoms and avoid the progression to severe hypocalcemia.

The short observation period after ambulatory thyroid surgery limits opportunities for serial measurement of serum calcium or PTH levels, increasing the risk of undetected or progressive hypocalcemia, which typically peaks 48–72 hours after surgery. The lack of delayed lab testing emphasizes the need for alternative management approaches, such as prophylactic supplementation and patient education, to ensure safety in outpatient care settings. Routine prophylactic oral calcium supplementation, with or without calcitriol/vitamin D, is a cost-effective approach to prevent postthyroidectomy hypocalcemia that expedites hospital discharge and reduces hypocalcemia rates.$^{71,136-138}$ Oral calcium carbonate is commonly prescribed at 500–1250 mg, two to three times daily. This reduces hypocalcemia incidence to approximately 10%.$^{139}$ Adding calcitriol (0.5–1.0 µg/day) enhances calcium absorption and effectiveness, although it increases cost and carries a risk of over supplementation. Careful biochemical

monitoring is essential to avoid hypercalcemia and renal injury. Routine supplementation may not be necessary for all patients but provides a bridge for transient parathyroid dysfunction and is generally well-tolerated.

An approach that is especially relevant to ambulatory thyroid surgery is the use of intraoperative or early postoperative PTH levels to guide decisions about discharge and supplementation protocols.140-155 However, variations exist in the timing of PTH assessment and the cutoff values for treatment, leading to institutional differences in protocols. The earliest reliable predictor of postoperative hypoparathyroidism is a serum PTH level taken either at the conclusion of the case or shortly following surgery.$^{71}$ A PTH level <15 pg/mL is strongly associated with impending hypocalcemia.141,142,144,146,149-152,154,156,157 Measuring intraoperative or postoperative PTH levels alone or combined with serum calcium levels can help determine whether a patient requires continued hospital monitoring, prophylactic calcium supplementation, or more aggressive interventions to prevent or treat hypocalcemia. Based on current evidence, the ATA Surgical Affairs Committee recommends that a postoperative PTH level of 15 pg/mL or higher at least 20 minutes after surgery generally eliminates the need for intensive serum calcium monitoring.$^{71}$ In contrast, a PTH level below 15 pg/mL suggests an elevated risk of hypoparathyroidism, warranting preemptive calcium and calciumiol supplementation and/or serial serum calcium monitoring. Both approaches still allow ambulatory or outpatient management in appropriately selected patients. Severe hypocalcemia can be associated with laryngospasm, arrhythmias, and seizures, so patients with intracitable symptoms and down-trending calcium need close inpatient monitoring that may require treatment with intravenous calcium gluconate. It is important to note that calcium carbonate requires an acidic environment for optimal absorption, making it better suited for patients without gastric acid suppression and to be taken with meals. Calcium citrate is preferred for those on proton pump inhibitors or with achlorhydria, such as following gastric sleeve or bypass surgery.$^{158,159}$ Moreover, patients with a history of Roux-en-Y gastric bypass surgery or other duodenal bypass/resection procedures are at an increased risk for postoperative hypocalcemia due to underlying malabsorptive issues. These patients may also exhibit elevated serum PTH levels, particularly in the setting of vitamin D deficiency following bariatric surgery, which can complicate management of postoperative hypoparathyroidism.$^{160,161}$ In such cases, liquid calcium formulations may enhance absorption and improve management.$^{162,163}$

A 2018 systematic review evaluating the association of a single postoperative PTH level with postthyroidectomy hypocalcemia found accuracy, sensitivity, and specificity were 86%, 85%, and 86%, respectively. However, the false-negative rate (patients who developed hypocalcemia despite a normal PTH level) was as high as 54%.$^{164}$ These findings highlight the importance of patient education about the signs and symptoms of hypocalcemia, so that outpatient supplementation can be escalated as needed and patients with intractable symptoms can be evaluated expeditiously to avoid progression to severe, symptomatic hypocalcemia requiring intravenous calcium therapy. This comprehensive

14

NOURELDINE & SEIB ET AL.

TABLE 3. EXAMPLE PROTOCOL FOR THE MANAGEMENT OF ACUTE POSTTHYROIDECTOMY NECK HEMATOMA

|Step|Action| |---|---| |Early identification|Monitor for swelling, visible bulging, tightness, and respiratory signs (e.g., stridor and hoarseness)| |Immediate assessment|Activate emergency, assess airway, and notify surgical team| |Airway management|Elevate bed, open wound if obstructed, prepare for intubation, and cricothyroidotomy as last resort| |Hematoma evacuation|OR transport, controlled evacuation, and bleeding control| |Postoperative monitoring|Frequent examinations, consider follow-up imaging if concerns for reaccumulation| |Prevention and patient education|Teach signs of hematoma, precautions, and reporting| |Adapted from liff et al.135|| |approach balances prevention, patient education, and targeted treatment.|present studies suggest that ambulatory thyroid surgery can be performed safely in select pediatric patients, further research to include large-scale studies needed to establish standardized, well-defined protocols and best practice guidelines.| |Areas of continued debate in ambulatory thyroid surgery|There has been recent promise for improved parathyroid identification during thyroid surgery through near-infrared autofluorescence (NIRAF) imaging and confirmation of intact blood supply with indocyanine green angiography (ICGA). Randomized clinical trials have shown that NIRAF increases rates of parathyroid identification, preservation, and temporary hypocalcemia, but there is limited data on its effect on permanent hypoparathyroidism.21,169,170 Similarly, NIRAF plus ICGA was shown to decrease the rate of transient symptomatic hypocalcemia and reduce needs for calcium supplementation after total thyroidectomy when compared with visual identification in a single-center randomized control trial, with a recent observational study suggesting that NIRAF plus ICGA is associated with decreased transient hypoparathyroidism and inadvertent parathyroid resection after total thyroidectomy with central neck dissection when compared with visual identification or NIRAF alone.171,172 Despite these promising data, it remains uncertain whether routine use of these adjuncts increases the likelihood of successful same day thyroidectomy is cost-effective when compared with the routine and selective supplementation protocols described above, or if selective use in patient populations at higher risk of hypocalcemia is an effective risk mitigation strategy. Further research on this topic is necessary to inform use of these technologies in the ambulatory setting.| |As ambulatory thyroid surgery continues to gain widespread acceptance, several areas remain worthy of ongoing discussion and require more in-depth research investigation. Topics of interest include the utility of hemostatic agents, the feasibility of ambulatory thyroidectomy in pediatric patients, the role of emerging technologies such as autofluorescence for parathyroid preservation, and protocols for safe same-day remote access thyroid surgery.|present studies suggest that ambulatory thyroid surgery can be performed safely in select pediatric patients, further research to include large-scale studies needed to establish standardized, well-defined protocols and best practice guidelines.| |The role of hemostatic agents in ambulatory thyroid surgery is debated, particularly regarding their efficacy, cost-effectiveness, and impact on postoperative outcomes. There are several commercially available agents that include cellulose, topical thrombin, and fibrin sealants. Proponents argue that these agents may reduce the risk of postoperative neck hematoma. However, critics highlight the significant cost associated with these agents, questioning whether their routine use provides a meaningful reduction in bleeding-related complications, particularly when meticulous surgical technique remains the primary determinant of hemonstasis. A meta-analysis evaluating a variety of these agents to conventional methods found no statistically significant difference in hematoma formation.165 While some studies of individual agents suggest that they may contribute to reduced operative time and blood loss, others have failed to show a clear advantage over conventional techniques to include sealing energy devices.166,167 Further high-quality studies are needed to determine whether their use justifies the financial burden, especially in the context of cost-conscious ambulatory care. At this time, individual surgeon preference and experience should dictate the most effective and safe method for achieving hemostasis to allow for safe same-day discharge.168|There has been recent promise for improved parathyroid identification during thyroid surgery through near-infrared autofluorescence (NIRAF) imaging and confirmation of intact blood supply with indocyanine green angiography (ICGA). Randomized clinical trials have shown that NIRAF increases rates of parathyroid identification, preservation, and temporary hypocalcemia, but there is limited data on its effect on permanent hypoparathyroidism.21,169,170 Similarly, NIRAF plus ICGA was shown to decrease the rate of transient symptomatic hypocalcemia and reduce needs for calcium supplementation after total thyroidectomy when compared with visual identification in a single-center randomized control trial, with a recent observational study suggesting that NIRAF plus ICGA is associated with decreased transient hypoparathyroidism and inadvertent parathyroid resection after total thyroidectomy with central neck dissection when compared with visual identification or NIRAF alone.171,172 Despite these promising data, it remains uncertain whether routine use of these adjuncts increases the likelihood of successful same day thyroidectomy is cost-effective when compared with the routine and selective supplementation protocols described above, or if selective use in patient populations at higher risk of hypocalcemia is an effective risk mitigation strategy. Further research on this topic is necessary to inform use of these technologies in the ambulatory setting.Lastly, there are limited data on outcomes of or criteria for safe ambulatory remote-access thyroidectomy. Extra-cervical, remote access thyroodectomy techniques include approaches via the breast, axilla, retroauricular, and oral vestibular locations. The ultimate goal of each of these surgical approaches is to improve postoperative cosmesis.173 Given that these approaches were developed and are more commonly performed in Asia, where postoperative length of stay tends to be longer, there is limited data on ambulatory remote access thyroodectomy. Multiple observational studies and meta-analyses suggest that complication rates from remote access thyroid surgery approximate those in traditional open thyroid surgery.174 In this context, same day discharge can be considered and has been advocated by some authors, most notably for transoral endoscopic thyroidectomy via a vestibular approach.175,176 Indeed, in the|

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

15

United States, most authors describe outpatient thyroidectomy during their initial experience with remote access thyroid surgery, with some same-day discharge.$^{177-183}$ To ensure safe adoption of ambulatory remote-access thyroid surgery in select patients, further focused research on this topic is warranted.

Summary

The feasibility of ambulatory thyroid surgery relies on careful patient selection, ensuring that candidates are at low risk for complications. Preoperative optimization plays a crucial role in minimizing perioperative risks. Anesthetic techniques should be tailored to prevent PONV and pain to support early recovery and discharge. Surgical technique and intraoperative management play a pivotal role in determining whether a patient can be safely discharged the same day, with an emphasis on meticulous hemostasis and management of the parathyroid glands to reduce the risk of significant postoperative hypocalcemia. Patient education and expectation management are important components of the preoperative process. Clear preoperative and postoperative instructions should be provided, ensuring that patients and their caregivers can recognize signs of potential complications, such as neck hematoma, airway compromise, or hypocalcemia, and understand when and how to seek medical attention. Finally, standardized discharge criteria and structured postoperative monitoring ensure patient safety in the ambulatory setting. A well-structured follow-up plan, including early postoperative evaluation and clear emergency contact guidance, helps to address any complications that may arise after discharge.

By implementing these evidence-based preoperative strategies, ambulatory thyroid surgery can be performed safely and effectively while minimizing the risk of complications. A multidisciplinary approach involving surgeons, anesthesiologists, and nursing teams is important to optimizing patient outcomes and ensuring a seamless transition to outpatient care. With proper patient selection, meticulous surgical technique, and comprehensive perioperative planning, ambulatory thyroid surgery can offer patients a safe, efficient, and cost-effective alternative to an overnight admission.

Acknowledgments

The authors would like to thank both Kelly C. Hoff, CAE, and Sharlene E. Cano, CAE, for their invaluable administrative support during this project.

Authors' Contributions

Conception and design: All authors. Collection and assembly of data: All authors. Data analysis and interpretation: All authors. Manuscript writing: All authors. Final approval of manuscript: All authors. Accountable for all aspects of the work: All authors.

Author Disclosure Statement

The authors of this statement do not have any direct conflicts of interest to disclose. Conflict of interest disclosures were reviewed and approved by the ATA Guidelines and

Statement Committee as well as the ATA Board. Dr. Zafereo is an Associate Editor at Thyroid; however, he was blinded to the peer review process. Author disclosure statements are listed below. Salem Noureldine, Carolyn Seib, Erin Jayne Buczek, Marianne David, Jagdish Dhingra, Ian Ganly, Benjamin James, Jacob Pieter Noordzij, Merry Sebelik, Pinar Jaclyn Smith, Meredith Sorensen, and Michael Starks. Nadia Khoury (consultant for Immunovant), Biren Modi (stock interest in Vertex Pharmaceuticals), Sareh Parangi (stock interests in MoreHealth and Novartis, research support from Harvard Medical School, and consultant for MoreHealth), Susan Pitt (commercial interest in Johnson & Johnson and consultant for a Head & Neck Panel), and Jonathon Russell (consulting for Baxter Healthcare) reported relationships that were deemed not relevant. Mark Zafereo reported research support from Merck, Eli Lilly, and Exelixis, which were considered relevant; accordingly, he abstained from voting on items where a potential conflict of interest existed.

Funding Information

No funding information to declare.

References

1. Toumi A, DiGennaro C, Vahdat V, et al. Trends in thyroid surgery and guideline-concordant care in the United States, 2007-2018. Thyroid 2021:31(6):941-949.

2. Sun GH, DeMonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996–2006. Thyroid 2013;23(6):727–733.

3. Terris DJ, Snyder S, Carneiro-Pla D, et al.; American Thyroid Association Surgical Affairs Committee Writing Task Force. American thyroid association statement on outpatient thyroidectomy. Thyroid 2013;23(10):1193–1202.

4. Toftgaard C, Parmentier G. International terminology in ambulatory surgery and its worldwide practice. In: Day Surgery—Development and Practice. (Lemos P, Jarret P, Philip B., eds.) International Association for Ambulatory Surgery; 2006; pp. 35–60.

5. Philteos J, Baran E, Noel CW, et al. Feasibility and safety of outpatient thyroidectomy: A narrative scoping review. Front Endocrinol (Lausanne) 2021;12:717427.

6. Lee DJ, Chin CJ, Hong CJ, et al. Outpatient versus inpatient thyroidectomy: A systematic review and meta-analysis. Head Neck 2018;40(1):192–202.

7. Nakanishi H, Wang R, Miangul S, et al. Clinical outcomes of outpatient thyroidectomy: A systematic review and single-arm meta-analysis. Am J Surg 2024;236:115694.

8. Hu QL, Livhits MJ, Ko CY, et al. Same-day discharge is not associated with increased readmissions or complications after thyroid operations. Surgery 2020;167(1):117-123.

9. Noel CW, Griffiths R, Siu J, et al. A population-based analysis of outpatient thyroidectomy: Safe and under-utilized. Laryngoscope 2021;131(11):2625–2633.

10. Addendum E.-CPT Codes That Are Only Paid As Inpatient Procedures. Available from: https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/cms-1427-p adde.pdf.

11. Beninato T, Laird AM, Graves CE, et al. Impact of the COVID-19 pandemic on the practice of endocrine surgery. Am J Surg 2022;223(4):670-675.

12. Shariq OA, Bews KA, Etzioni DA, et al. Performance of general surgical procedures in outpatient settings before

16

NOURELDINE & SEIB ET AL.

and after onset of the COVID-19 pandemic. JAMA Netw Open 2023;6(3):e231198.

13. Sahmkow SI, Audet N, Nadeau S, et al. Outpatient thyroidectomy: Safety and patients' satisfaction. J Otolaryngol Head Neck Surg 2012;41 Suppl 1:S1–S12.

14. Snyder SK, Hamid KS, Roberson CR, et al. Outpatient thyroidectomy is safe and reasonable: Experience with more than 1,000 planned outpatient procedures. J Am Coll Surg 2010;210(5):575–582, 82-4.

15. Segel JM, Duke WS, White JR, et al. Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients. Surgery 2016;159(2):518–523.

16. Rosen P, Bailey L, Manickavel S, et al. Ambulatory surgery vs overnight observation for total thyroidectomy: Cost analysis and outcomes. OTO Open 2021;5(1).

17. AlEssa M, Al-Angari SS, Jomah M, et al. Safety and cost-effectiveness of outpatient thyroidectomy: A retrospective observational study. Saudi Med J 2021;42(2):189–195.

18. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg 2013;150(4):249–256.

19. 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(5):1545-1552.

20. Jeannon JP, Orabi AA, Bruch GA, et al. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: A systematic review. Int J Clin Pract 2009;63(4):624–629.

21. Dip F, Falco J, Verna S, et al. Randomized controlled trial comparing white light with near-infrared autofluorescence for parathyroid gland identification during total thyroidectomy. J Am Coll Surg 2019;228(5):744–751.

22. Kazaure HS, Zambeli-Ljepovic A, Oyekunle T, et al. Severe hypocalcemia after thyroidectomy: An analysis of 7366 patients. Ann Surg 2021;274(6):e1014–e21.

23. Marti JL, Holm T, Randolph G. Universal use of intraoperative nerve monitoring by recently fellowship-trained thyroid surgeons is common, associated with higher surgical volume, and impacts intraoperative decision-making. World J Surg 2016:40(2):337–343.

24. Doran HE, Wiseman SM, Palazzo FF, et al. Post-thyroid-ectomy bleeding: Analysis of risk factors from a national registry. Br J Surg 2021;108(7):851–857.

25. Gunn A, Oyekunle T, Stang M, et al. Recurrent laryngeal nerve injury after thyroid surgery: An analysis of 11,370 patients. J Surg Res 2020;255:42–49.

26. Butler D, Oltmann S. Is outpatient thyroid surgery for everyone? Clin Med Insights Ear Nose Throat 2017;10.

27. Edafe O, Antakia R, Laskar N, et al. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg 2014;101(4):307–320.

28. Guldvog I, Reitsma LC, Johnsen L, et al. Thyroidectomy versus medical management for euthyroid patients with hashimoto disease and persisting symptoms: A randomized trial. Ann Intern Med 2019;170(7):453–464.

29. Rajan N, Rosero EB, Joshi GP. Patient selection for adult ambulatory surgery: A narrative review. Anesth Analg 2021;133(6):1415–1430.

30. McLaughlin EJ, Brant JA, Bur AM, et al. Safety of outpatient thyroidectomy: Review of the American College of Surgeons national surgical quality improvement program. Laryngoscope 2018;128(5):1249–1254.

31. Ansell GL, Montgomery JE. Outcome of ASA III patients undergoing day case surgery. Br J Anaesth 2004;92(1): 71–74.

32. Kaw R, Pasupuleti V, Walker E, et al. Postoperative complications in patients with obstructive sleep apnea. Chest 2012;141(2):436-441.

33. Chan MTV, Wang CY, Seet E, et al.; Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) Study Investigators. Association of unrecognized obstructive sleep apnea with postoperative cardiovascular vascular events in patients undergoing major noncardiac surgery. JAMA 2019;321(18):1788–1798.

34. American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: An updated report by the American Society of Anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2014;120(2):268–286.

35. Öltmann SC, Alhefdhi AY, Rajaei MH, et al. Antiplatelet and anticoagulant medications significantly increase the risk of postoperative hematoma: Review of over 4500 thyroid and parathyroid procedures. Ann Surg Oncol 2016; 23(9):2874–2882.

36. Promberger R, Ott J, Kober F, et al. Risk factors for post-operative bleeding after thyroid surgery. Br J Surg 2012; 99(3):373–379.

37. Canu GL, Medas F, Cappellacci F, et al. Does the continu-ation of low-dose acetylsalicylic acid during the periopera-tive period of thyroidectomy increase the risk of cervical haematoma? A 1-year experience of two Italian centers. Front Surg 2022;9:1046561.

38. Tausanovic K, Zivaljevic V, Grujicic SS, et al. Case control study of risk factors for occurrence of postoperative hematoma after thyroid surgery: Ten year analysis of 6938 operations in a tertiary center in Serbia. World J Surg 2022;46(10):2416–2422.

39. Memeh K, Abou Azar S, Afolaranmi O, et al. Association of obesity and thyroidectomy-specific perioperative outcomes. World J Surg 2025;49(1):179–186.

40. Grubey JS, Raji Y, Duke WS, et al. Outpatient thyroidectomy is safe in the elderly and super-elderly. Laryngoscope 2018;128(1):290–294.

41. Raya-Benítez J, Heredia-Ciuró A, Calvache-Mateo A, et al. Effectiveness of non-instrumental early mobilization to reduce the incidence of deep vein thrombosis in hospitalized patients: A systematic review and meta-analysis. Int J Nurs Stud 2025;161:104917.

42. Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg 2018;153(2):160–168.

43. Chow WB, Rosenthal RA, Merkow RP, et al.; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons national surgical quality improvement program and the American Geriatrics Society. J Am Coll Surg 2012;215(4):453–466.

44. July O'Brien K, Naveed A, Patel S, et al. Same-day discharge for pediatric hemithyroidectomy patients: Evaluating safety and barriers to discharge. Otolaryngol Head Neck Surg 2024;171(2):538–545.

45. Dream S, Wang R, Lovell K, et al. Outpatient thyroidectomy in the pediatric population. Am J Surg 2020;219(6): 890–893.

46. Stack BC Jr, Twining C, Rastatter J, et al. Consensus statement by the American Association of Clinical Endocrinology

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

17

(AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on pediatric benign and malignant thyroid surgery. Head Neck 2021;43(4): 1027–1042.

47. Baumgarten HD, Bauer AJ, Isaza A, et al. 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 2019;54(10):1969–1975.

48. Youngwirth LM, Adam MA, Thomas SM, et al. Pediatric thyroid cancer patients referred to high-volume facilities have improved short-term outcomes. Surgery 2018;163(2): 361-366.

49. Katz AL, Webb SA, COMMITTEE ON BIOETHICS. Informed consent in decision-making in pediatric practice. Pediatrics 2016;138(2):e20161485.

50. Evans C, Bercades G, Ambler G, et al. Little journey: A phase III randomised controlled trial of a psychological preparation and education smartphone application for management of paediatric perioperative anxiety compared with standard care in children undergoing ambulatory surgery - study protocol. BMJ Open 2025;15(2):e090696.

51. Potthoff LM, Glotzbecker MP, O'Connell B, et al. SIMDiscovery: A simulation-based preparation program for adolescents undergoing spinal fusion surgery. Spine Deform 2021;9(5):1363–1370.

52. Cohen-Bearak A, Meyer EC, Mednick L, et al. Aligning family-clinician expectations during pediatric surgical informed consent: Development and implementation of an innovative communication skills workshop. J Contin Educ Health Prof 2021;41(4):279–285.

53. Mowschenson PM, Hodin RA. Outpatient thyroid and parathyroid surgery: A prospective study of feasibility, safety, and costs. Surgery 1995;118(6):1051–1053; discussion 3–4.

54. Samson PS, Reyes FR, Saludares WN, et al. Outpatient thyroidectomy. Am J Surg 1997;173(6):499–503.

55. Cozzaglio L, Monzani R, Zuccarelli A, et al. Quality of life and patient satisfaction in outpatient thyroid surgery. Updates Surg 2022;74(1):317-323.

56. Sørensen K, Van den Broucke S, Fullam J, et al.; (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80.

57. Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician 2015;92(2):118–124.

58. Bettis T, Lewis M, Wang R, et al. An evaluation of health literacy in patients undergoing surgical evaluation for thy-roid disease. J Surg Res 2024;295:81–88.

59. Zhang Z, Xia F, Wang W, et al. Ambulatory thyroidectomy is safe and beneficial in papillary thyroid carcinoma: Randomized controlled trial. Head Neck 2021;43(4):1116–1121.

60. Balentine CJ, Sippel RS. Outpatient thyroidectomy: Is it safe? Surg Oncol Clin N Am 2016;25(1):61–75.

61. Materazzi G, Dionigi G, Berti P, et al. One-day thyroid surgery: Retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period. Eur Surg Res 2007;39(3):182–188.

62. Terris DJ, Moister B, Seybt MW, et al. Outpatient thyroid surgery is safe and desirable. Otolaryngol Head Neck Surg 2007:136(4):556-559.

63. Champault A, Vons C, Zilberman S, et al. How to perform a thyroidectomy in an outpatient setting. Langenbecks Arch Surg 2009;394(5):897–902.

64. Sheikh Z, Lingamanaicker V, Irune E, et al. Introducing day case thyroid lobectomy at a tertiary head and neck centre. Ann R Coll Surg Engl 2021;103(7):499–503.

65. Terefe M, Belay Bizuneh Y, Addisu Nigatu Y, et al. Peri-operative management of the thyrotoxic patients: A systematic review. Ann Med Surg (Lond) 2022:81:104487.

66. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxosis. Thyroid 2016;26(10):1343–1421.

67. Patel ĶN, Yip L, Lubitz CC, et al. The American Association of Endocrine Surgeons guidelines for the definitive surgical management of thyroid disease in adults. Ann Surg 2020;271(3):e21-e93.

68. Mallick R, Asban A, Chung S, et al. To admit or not to admit? Experience with outpatient thyroidectomy for Graves' disease in a high-volume tertiary care center. Am J Surg 2018;216(5):985–989.

69. Zhang FG, Ow TJ, Lin J, et al. Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery. Head Neck 2024;46(5):1094-1102.

70. McMurran AEL, Blundell R, Kim V. Predictors of post-thyroidectomy hypocalcaemia: A systematic and narrative review. J Laryngol Otol 2020;134(6):541–552.

71. Orloff LA, Wiseman SM, Bernet VJ, et al. American Thyroid Association statement on postoperative hypoparathyroidism: Diagnosis, prevention, and management in adults. Thyroid 2018;28(7):830–841.

72. Demay MB, Pittas AG, Bikle DD, et al. Vitamin D for the prevention of disease: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2024;109(8):1907–1947.

73. Okocha O, Gerlach RM, Sweitzer B. Preoperative evaluation for ambulatory anesthesia: What, when, and how? Anesthesiol Clin 2019;37(2):195–213.

74. Compton RA, Simmonds JC, Dhingra JK. Total thyroidectomy as an ambulatory procedure in community practice. OTO Open 2020;4(3).

75. Murray B, Tandon S, Dempsey G. Ambulatory thyroidectomy: An anesthesiologist's perspective. Local Reg Anesth 2017;10:31–39.

76. Chorath K, Luu N, Go BC, et al. ERAS protocols for thyroid and parathyroid surgery: A systematic review and meta-analysis. Otolaryngol Head Neck Surg 2022;166(3): 425–433.

77. Machado N, Mortlock R, Maduka R, et al. Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward. Surgery 2024; 175(1):114-120.

78. Apfel CC, Kranke P, Katz MH, et al. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: A randomized controlled trial of factorial design. Br J Anaesth 2002;88(5):659–668.

79. Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2020;131(2):411–448.

80. Wang JJ, Ho ST, Lee SC, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in females undergoing thyroidectomy: A dose-ranging study. Anesth Analg 2000:91(6):1404–1407.

81. Wang D, Sun Y, Zhu YJ, et al. Comparison of opioid-free and opioid-inclusive propofol anaesthesia for thyroid and parathyroid surgery: A randomised controlled trial. Anaesthesia 2024;79(10):1072–1080.

18

NOURELDINE & SEIB ET AL.

82. Jo JY, Kim YJ, Choi SS, et al. A prospective randomized comparison of postoperative pain and complications after thyroidectomy under different anesthetic techniques: Volatile anesthesia versus total intravenous anesthesia. Pain Res Manag 2021;2021:8876906.

83. Choi GJ, Kang H, Ahn EJ, et al. Clinical efficacy of intravenous lidocaine for thyroidectomy: A prospective, randomized, double-blind, placebo-controlled trial. World J Surg 2016;40(12):2941–2947.

84. Joshi GP, Abdelmalak BB, Weigel WA, et al. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. Anesthesiology 2024;140(2):346–348.

85. Kindel TL, Wang AY, Wadhwa A, et al.; Society of American Gastrointestinal and Endoscopic Surgeons. Multisociety clinical practice guidance for the safe use of glucagonlike peptide-1 receptor agonists in the perioperative period. Clin Gastroenterol Hepatol 2025;23(12):2083–2085.

86. Zhu CY, Schumm MA, Hu TX, et al. Patient-centered decision-making for postoperative narcotic-free endocrine surgery: A randomized clinical trial. JAMA Surg 2021; 156(11):e214287.

87. Sanabria A, Betancourt C, Chiesa-Estomba C, et al. Locoregional strategies to decrease postoperative pain and neck discomfort after open thyroidectomy: A scoping review. Head Neck 2023;45(7):1841–1855.

88. Betancourt C, Sanabria A. Post-thyroidectomy pain relief is enhanced by wound infiltration. A systematic review of randomized controlled trials. Surgeon 2024;22(3):e133-e40.

89. Betancourt C, Sanabria A. Post-thyroidectomy bilateral cervical plexus block relieves pain: A systematic review. Eur Arch Otorhinolaryngol 2024;281(7):3765–3778.

90. Wilson L, Malhotra R, Mayhew D, et al. The analgesic effects of bilateral superficial cervical plexus block in thyroid surgery: A systematic review and meta-analysis. Indian J Anaesth 2023;67(7):579–589.

91. Dinis I, Pacheco Pereira CS, Ferros C, et al. Risk factors for cervical hematoma after thyroid surgery at a Portuguese hospital: A retrospective study. Cureus 2024;16(11):e72928.

92. Bongiovanni T, Lancaster E, Ledesma Y, et al. Systematic review and meta-analysis of the association between non-steroidal anti-inflammatory drugs and operative bleeding in the perioperative period. J Am Coll Surg 2021;232(5): 765–790.e1.

93. Liu Z, Bi C, Li X, et al. The efficacy and safety of opioid-free anesthesia combined with ultrasound-guided intermediate cervical plexus block vs. opioid-based anesthesia in thyroid surgery-a randomized controlled trial. J Anesth 2023;37(6):914–922.

94. Wojtczak B, Sutkowska-Stępień K, Glód M, et al. Current knowledge on the use of neuromonitoring in thyroid surgery. Biomedicines 2024;12(3):675.

95. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136(6):1310-1322.

96. Wilhelm A, Conroy PC, Calthorpe L, et al. Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery. BMC Surg 2023;23(1):215.

97. Ma C, Dodoo C, Alkhalili E. Analyzing the ATA state-ment on outpatient thyroidectomy using the NSQIP data-base. Am J Surg 2020;220(6):1405–1409.

98. Siperstein AE, Berber E, Morkoyun E. The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery. Arch Surg 2002;137(2):137–142.

99. Dionigi G, Wu CW, Kim HY, et al. Safety of energy based devices for hemostasis in thyroid surgery. Gland Surg 2016;5(5):490-494.

100. Konturek A, Szpyra B, Stopa-Barczyńska M, et al. Energy-based devices for hemostasis in thyroid surgery. Gland Surg 2020;9(Suppl 2):S153–S158.

101. Liu CH, Wang CC, Wu CW, et al. Comparison of surgical complications rates between LigaSure small jaw and clamp-and-tie hemostatic technique in 1,000 neuro-monitored thyroidectomies. Front Endocrinol (Lausanne) 2021;12:638608.

102. Zhang L, Li N, Yang X, et al. A meta-analysis comparing the outcomes of LigaSure small jaw versus clamp-and-tie technique or harmonic focus scalpel in thyroidectomy. Medicine (Baltimore) 2017;96(11):e6141.

103. Nemeth ZH, Kong K, Hwang R, et al. Vessel sealant devices in thyroidectomies: An ACS-NSQIP study. South Med J 2022;115(5):304–309.

104. Siu JM, McCarty JC, Gadkaree S, et al. Association of vessel-sealant devices vs conventional hemostasis with postoperative neck hematoma after thyroid operations. JAMA Surg 2019;154(11):e193146.

105. Mahoney RC, Vossler JD, Woodruff SL, et al. Predictors and consequences of hematoma after thyroidectomy: An American College of Surgeons national surgical quality improvement program database analysis. J Surg Res 2021; 260:481–487.

106. Grøndal AYK, Høgsbro M, Pryds K, et al. Intra- and post-operative complications using LigaSure™ small jaw in patients undergoing thyroidectomy: A register-based study. Eur Arch Otorhinolaryngol 2021;278(11):4491–4500.

107. Hua N, Quimby AE, Johnson-Obaseki S. Comparing hematoma incidence between hemostatic devices in total thyroidectomy: A systematic review and meta-analysis. Otolaryngol Head Neck Surg 2019;161(5):770-778.

108. Saint Marc O, Cogliandolo A, Piquard A, et al. LigaSure vs clamp-and-tie technique to achieve hemostasis in total thyroidectomy for benign multinodular goiter: A prospective randomized study. Arch Surg 2007;142(2):150–156; discussion 157.

109. Ezzy M, Alameer E. Predictors and preventive strategies of bleeding after thyroid surgery. Cureus 2023;15(10): e47575.

110. Sanabria A, Carvalho AL, Silver CE, et al. Routine drain-age after thyroid surgery-a meta-analysis. J Surg Oncol 2007;96(3):273-280.

111. Debry C, Renou G, Fingerhut A. Drainage after thyroid surgery: A prospective randomized study. J Laryngol Otol 1999;113(1):49–51.

112. Schietroma M, Pessia B, Bianchi Z, et al. Thyroid surgery: To drain or not to drain, that is the problem - A randomized clinical trial. ORL J Otorhinolaryngol Relat Spec 2017;79(4):202-211.

113. Richer SL, Wenig BL. Changes in surgical anatomy fol-lowing thyroidectomy. Otolaryngol Clin North Am 2008; 41(6):1069–1078, vii.

114. Harding J, Sebag F, Sierra M, et al. Thyroid surgery: Post-operative hematoma-prevention and treatment. Langenbecks Arch Surg 2006;391(3):169–173.

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

19

115. Terris D. Novel surgical maneuvers in modern thyroid surgery. Oper Tech Otolaryngol-Head Neck Surg 2009;20(1): 23–28.

116. Anastasiou OE, Yavropoulou MP, Papavramidis TS, et al. Secretary capacity of the parathyroid glands after total thyroidectomy in normocalcemic subjects. J Clin Endocrinol Metab 2012;97(7):2341–2346.

117. Jiang H, Shen H, Jiang D, et al. Evaluating the safety of the harmonic scalpel around the recurrent laryngeal nerve. ANZ J Surg 2010;80(11):822–826.

118. Tirelli G, Camilot D, Bonini P, et al. Harmonic scalpel and electrothermal bipolar vessel sealing system in head and neck surgery: A prospective study on tissue heating and histological damage on nerves. Ann Otol Rhinol Laryngol 2015;124(11): 852–858.

119. Stack BC Jr, Bimston DN, Bodenner DL, et al. American association of clinical endocrinologists and american college of endocrinology disease state clinical review: Postoperative hypoparathyroidism-definitions and management. Endocr Pract 2015;21(6):674-685.

120. Piromchai P, Vatanasapt P, Reechaipichitkul W, et al. Is the routine pressure dressing after thyroidectomy necessary? A prospective randomized controlled study. BMC Ear Nose Throat Disord 2008;8:1.

121. Qiu L, Cai J, Mei A, et al. Predictors of postoperative nausea and vomiting after same-day surgery: A retrospective study. Clin Ther 2023;45(3):210–217.

122. Rosenbaum MA, Haridas M, McHenry CR. Life-threatening neck hematoma complicating thyroid and parathyroid surgery. Am J Surg 2008;195(3):339–343; discussion 343.

123. Burkey SH, van Heerden JA, Thompson GB, et al. Reexploration for symptomatic hematomas after cervical exploration. Surgery 2001;130(6):914–920.

124. Hsu S, Melucci AD, Dave YA, et al. Outpatient endocrine surgery practice patterns are highly variable among US endocrine surgery fellowship programs. Surgery 2023; 173(1):76-83.

125. Meltzer C, Klau M, Gurushanthaiah D, et al. Safety of outpatient thyroid and parathyroid surgery: A propensity score-matched study. Otolaryngol Head Neck Surg 2016; 154(5):789–796.

126. Joliat GR, Guarnero V, Demartines N, et al. Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment. Medicine (Baltimore) 2017;96(17):e6674.

127. Rossi L, Papini P, De Palma A, et al. Surgeon-performed transcutaneous laryngeal ultrasound for vocal cord assessment after total thyroidectomy: A prospective study: Original article. Langenbecks Arch Surg 2024;409(1):183.

128. Kandil E, Deniwar A, Noureldine SI, et al. Assessment of vocal fold function using transcutaneous laryngeal ultrasonography and flexible laryngoscopy. JAMA Otolaryngol Head Neck Surg 2016;142(1):74–78.

129. Liu J, Sun W, Dong W, et al. Risk factors for post-thyroidectomy Haemorrhage: A meta-analysis. Eur J Endocrinol 2017;176(5):591–602.

130. Liu J, Li Z, Liu S, et al. Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution study based on 5156 cases from the past 2 years. Head Neck 2016;38(2):216–219.

131. Lang BH, Yih PC, Lo CY. A review of risk factors and timing for postoperative hematoma after thyroidectomy: Is outpatient thyroidectomy really safe? World J Surg 2012; 36(10):2497-2502.

132. Campbell MJ, McCoy KL, Shen WT, et al. A multi-institutional international study of risk factors for hematoma after thyroidectomy. Surgery 2013;154(6):1283–1289; discussion 9–91.

133. Suzuki S, Yasunaga H, Matsui H, et al. Factors associated with neck hematoma after thyroidectomy: A retrospective analysis using a japanese inpatient database. Medicine (Baltimore) 2016;95(7):e2812.

134. Samona S, Hagglund K, Edhayan E. Case cohort study of risk factors for post-thyroidectomy hemorrhage. Am J Surg 2016;211(3):537–540.

135. Iliff HA, El-Boghdadly K, Ahmad I, et al. Management of haematoma after thyroid surgery: Systematic review and multidisciplinary consensus guidelines from the difficult airway society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia 2022; 77(1):82–95.

136. Wang TS, Cheung K, Roman SA, et al. To supplement or not to supplement: A cost-utility analysis of calcium and vitamin D repletion in patients after thyroidectomy. Ann Surg Oncol 2011;18(5):1293–1299.

137. Nelson KL, Hinson AM, Lawson BR, et al. Postoperative calcium management in same-day discharge thyroid and parathyroid surgery. Otolaryngol Head Neck Surg 2016; 154(5):854-860.

138. Singer MC, Bhakta D, Seybt MW, et al. Calcium management after thyroidectomy: A simple and cost-effective method. Otolaryngol Head Neck Surg 2012; 146(3):362-365.

139. Roh JL, Park JY, Park CI. Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid carcinoma undergoing total thyroidectomy plus central neck dissection. Cancer 2009;115(2):251–258.

140. Scurry WC Jr, Beus KS, Hollenbeak CS, et al. Perioperative parathyroid hormone assay for diagnosis and management of postthyroidectomy hypocalcemia. Laryngoscope 2005; 115(8):1362-1366.

141. McLeod IK, Arciero C, Noordzij JP, et al. The use of rapid parathyroid hormone assay in predicting postoperative hypocalcemia after total or completion thyroidectomy. Thyroid 2006;16(3):259–265.

142. Chia SH, Weisman RA, Tieu D, et al. Prospective study of perioperative factors predicting hypocalcemia after thyroid and parathyroid surgery. Arch Otolaryngol Head Neck Surg 2006;132(1):41–45.

143. Di Fabio F, Casella C, Bugari G, et al. Identification of patients at low risk for thyroidectomy-related hypocalcemia by intraoperative quick PTH. World J Surg 2006; 30(8):1428–1433.

144. Roh JL, Park CI. Intraoperative parathyroid hormone assay for management of patients undergoing total thyroidectomy. Head Neck 2006;28(11):990–997.

145. Noureldine SI, Genther DJ, Lopez M, et al. Early predictors of hypocalcemia after total thyroidectomy: An analysis of 304 patients using a short-stay monitoring protocol. JAMA Otolaryngol Head Neck Surg 2014;140(11): 1006–1013.

146. Sywak MS, Palazzo FF, Yeh M, et al. Parathyroid hormone assay predicts hypocalcaemia after total thyroidectomy. ANZ J Surg 2007;77(8):667–670.

147. Noordzij JP, Lee SL, Bernet VJ, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid

20

NOURELDINE & SEIB ET AL.

hormone: An analysis of pooled individual patient data from nine observational studies. J Am Coll Surg 2007; 205(6):748–754.

148. Alía P, Moreno P, Rigo R, et al. Postresection parathyroid hormone and parathyroid hormone decline accurately predict hypocalcemia after thyroidectomy. Am J Clin Pathol 2007;127(4):592–597.

149. Barczyński M, Cichoń S, Konturek A. Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery? Langenbecks Arch Surg 2007;392(6):693–698.

150. Grodski S, Serpell J. Evidence for the role of perioperative PTH measurement after total thyroidectomy as a predictor of hypocalcemia. World J Surg 2008;32(7):1367–1373.

151. Selberherr A, Scheuba C, Riss P, et al. Postoperative hypoparathyroidism after thyroidectomy: Efficient and cost-effective diagnosis and treatment. Surgery 2015;157(2): 349–353.

152. Rutledge J, Siegel E, Belcher R, et al. Barriers to same-day discharge of patients undergoing total and completion thyroidectomy. Otolaryngol Head Neck Surg 2014;150(5): 770–774.

153. Islam S, Al Maqbali T, Howe D, et al. Hypocalcaemia following total thyroidectomy: Early post-operative parathyroid hormone assay as a risk stratification and management tool. J Laryngol Otol 2014;128(3):274–278.

154. Youngwirth L, Benavidez J, Sippel R, et al. Parathyroid hormone deficiency after total thyroidectomy: Incidence and time. J Surg Res 2010;163(1):69–71.

155. Lee DR, Hinson AM, Siegel ER, et al. Comparison of intraoperative versus postoperative parathyroid hormone levels to predict hypocalcemia earlier after total thyroidectomy. Otolaryngol Head Neck Surg 2015;153(3):343–349.

156. Richards ML, Bingener-Casey J, Pierce D, et al. Intraoperative parathyroid hormone assay: An accurate predictor of symptomatic hypocalcemia following thyroidectomy. Arch Surg 2003;138(6):632–635; discussion 5–6.

157. Gupta S, Chaudhary P, Durga CK, et al. Validation of intra-operative parathyroid hormone and its decline as early predictors of hypoparathyroidism after total thyroidectomy: A prospective cohort study. Int J Surg 2015;18:150–153.

158. Gonzalez-Campoy JM, St Jeor ST, Castorino K, et al.; American College of Endocrinology and the Obesity Society. Clinical practice guidelines for healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults: Cosponsored by the American Association of Clinical Endocrinologists/the American College of Endocrinology and the Obesity Society. Endocr Pract 2013;19 Suppl 3:1–82.

159. Hany M, Wuyts S, Abouelnasr AA, et al. Comparison of calcium citrate and calcium carbonate absorption in patients with a Roux-en-Y gastric bypass, sleeve gastrectomy, and one-anastomosis gastric bypass: A double-blind, randomized cross-over trial. Surg Obes Relat Dis 2025;21(4):471–481.

160. Hewitt S, Søvik TT, Aasheim ET, et al. Secondary hyperparathyroidism, vitamin D sufficiency, and serum calcium 5 years after gastric bypass and duodenal switch. Obes Surg 2013;23(3):384–390.

161. Karefylakis C, Näslund I, Edholm D, et al. Vitamin D status 10 years after primary gastric bypass: Gravely high prevalence of hypovitaminosis D and raised PTH levels. Obes Surg 2014;24(3):343–348.

162. Pietras SM, Holick MF. Refractory hypocalcemia following near-total thyroidectomy in a patient with a prior Roux-en-Y gastric bypass. Obes Surg 2009;19(4):524–526.

163. Durr ML, Saunders JR, Califano JA, et al. Severe hypocalcemia complicating thyroid surgery after Roux-en-Y gastric bypass procedure. Arch Otolaryngol Head Neck Surg 2009;135(5):507-510.

164. Mathur A, Nagarajan N, Kahan S, et al. Association of parathyroid hormone level with postthyroidectomy hypocalemia: A systematic review. JAMA Surg 2018;153(1):69–76.

165. Khadra H, Bakeer M, Hauch A, et al. Hemostatic agent use in thyroid surgery: A meta-analysis. Gland Surg 2018; 7(Suppl 1):S34-Ss41.

166. Guler M, Maralcan G, Kul S, et al. The efficacy of Ankaferd blood stopper for the management of bleeding following total thyroidectomy. J Invest Surg 2011;24(5):205–210.

167. Testini M, Marzaioli R, Lissidini G, et al. The effectiveness of FloSeal matrix hemostatic agent in thyroid surgery: A prospective, randomized, control study. Langenbecks Arch Surg 2009:394(5):837-842.

168. Dream S, Wang TS. Implementation of vessel-sealing devices in thyroid surgery. JAMA Surg 2019;154(11):e193159.

169. Benmiloud F, Godiris-Petit G, Gras R, et al. Association of autofluorescence-based detection of the parathyroid glands during total thyroidectomy with postoperative hypocalcemia risk: Results of the PARAFLUO multicenter randomized clinical trial. JAMA Surg 2020;155(2):106–112.

170. Bergenfelz A, Barczynski M, Heie A, et al. Impact of auto-fluorescence for detection of parathyroid glands during thyroidectomy on postoperative parathyroid hormone levels: Parallel multicentre randomized clinical trial. Br J Surg 2023;110(12):1824–1833.

171. Rossi L, Vasquez MC, Pieroni E, et al. Indocyanine green fluorescence and near-infrared autofluorescence may improve post-thyroidectomy parathyroid function. Surgery 2023; 173(1):124–131.

172. Di Lorenzo S, Carrillo Lizarazo JL, Dionigi G, et al. Impact of near-infrared fluorescence imaging plus indocyanine green fluorescence on postoperative hypoparathyroidism rates after total thyroidectomy and central neck lymph node dissection. Br J Surg 2024;111(2):znae022.

173. Tae K, Ji YB, Song CM, et al. Robotic and endoscopic thyroid surgery: Evolution and advances. Clin Exp Otorhinolaryngol 2019;12(1):1–11.

174. Anuwong A, Ketwong K, Jitpratoom P, et al. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. JAMA Surg 2018;153(1):21–27.

175. Van Den Heede K, Brusselaers N, Gaujoux S, et al. Feasibility and safety of ambulatory transoral endoscopic thyroidectomy via vestibular approach (TOETVA). World J Surg 2022:46(11):2678–2686.

176. Sun H, Chu Y, Zhang G, et al. The ambulatory transoral endoscopic thyroidectomy vestibular approach is safe and economical for patients with thyroid nodules. Front Endocrinol (Lausanne) 2023;14:1116280.

177. Russell JO, Clark J, Noureldine SI, et al. Transoral thyroidectomy and parathyroidectomy - A North American series of robotic and endoscopic transoral approaches to the central neck. Oral Oncol 2017;71:75–80.

178. Inabnet WB 3rd, Suh H, Fernandez-Ranvier G. Trans- oral endoscopic thyroidectomy vestibular approach with intraoperative nerve monitoring. Surg Endosc 2017; 31(7):3030.

AMERICAN THYROID ASSOCIATION STATEMENT ON AMBULATORY THYROIDECTOMY

21

179. Kandil E, Akkera M, Shalaby H, et al. A single surgeon's 10-year experience in remote-access thyroid and parathy-roid surgery. Am Surg 2021;87(4):638-644.

180. Hussein M, Issa PP, LaForteza A, et al. Evaluating the efficacy and safety of robotic versus conventional completion thyroidectomy: A 10-year experience. Surg Innov 2024; 31(5):478-483.

181. Lang BH, Wong CK, Tsang JS, et al. A systematic review and meta-analysis comparing surgically-related complications between robotic-assisted thyroidectomy and conventional open thyroidectomy. Ann Surg Oncol 2014;21(3): 850–861.

182. Russell JO, Razavi CR, Garstka ME, et al. Remote-access thyroidectomy: A multi-institutional North American experience with transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. J Am Coll Surg 2019; 228(4):516–522.

183. de Vries LH, Aykan D, Lodewijk L, et al. Outcomes of minimally invasive thyroid surgery - A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2021;12: 719397.

184. Rajeev P, Sutaria R, Ezzat T, et al. Changing trends in thyroid and parathyroid surgery over the decade: is same-day discharge feasible in the United Kingdom? World J Surg. 2014;38(11):2825–2830; doi: 10.1007/s00268-014-2673-1

185. de Boisanger L, Blackwell N, Magos T, et al. Day case hemithyroidectomy is safe and feasible: experience in Scotland. Scott Med J. 2015;60(4):239–243; doi: 10.1177/0036933015584260

186. Yakhlef H, Marboeuf Y, Piquard A, et al. Outpatient hemi-thyroidectomy: A retrospective feasibility analysis. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134(4): 225–228; doi: 10.1016/j.anorl.2017.02.001

187. Jeppesen K, Skjøt-Arkil H, Moos C, et al. Outpatient hemithyroidectomy for benign thyroid disease. Dan Med J. 2020;67(10).

Address correspondence to: Salem I. Noureldine, MD Department of Surgery Section of Endocrine Surgery University School of Medicine and Health Sciences 2150 Pennsylvania Ave NW Suite 6B-423 Washington, DC 20037 USA

E-mail: snoureldine@gwu.edu