Application of optimized postoperative drainage pressure combined with parathyroid function monitoring in enhanced recovery after surgery for thyroid cancer: A prospective randomized controlled study

Abstract

Background: Postoperative drainage management and hypocalcemia monitoring are critical factors influencing enhanced recovery after surgery (ERAS) following thyroidectomy. This study aimed to evaluate the effects of different drainage pressures on postoperative drainage volume and hospitalization duration, and to explore the predictive value of parathyroid hormone (PTH) levels for hypocalcemia. The goal was to develop a multidimensional ERAS strategy for thyroid cancer patients.

Methods: This prospective randomized controlled trial enrolled 211 patients undergoing thyroidectomy. Participants were randomly allocated into three groups based on drainage pressure. Postoperative drainage volume, hospitalization duration, and complications were recorded. For patients undergoing total thyroidectomy, PTH and serum calcium levels were measured postoperatively. The optimal PTH cut-off value was determined using receiver operating characteristic curve analysis.

Results: The low-pressure group exhibited significantly reduced postoperative drainage volume on day 1 (6.54 ± 9.53 mL) compared to the medium- and highpressure groups (34.07 ± 19.05 mL and 32.41 ± 20.72 mL). Drainage removal time (1.06 ± 0.23 days) and hospitalization duration (1.26 ± 0.47 days) were also shorter in the low-pressure group. A postoperative 2-h PTH level ≤ 6.985 pg/mL effectively predicted hypocalcemia (sensitivity 79.4%, specificity 91.0%). The combined ERAS protocol further reduced hospitalization duration and significantly lowered postoperative Visual Analog Scale scores (0.85 ± 0.75) without increasing complication rates.

Conclusion: Low-pressure drainage reduces postoperative drainage volume and accelerates recovery in thyroid cancer patients. A 2-h postoperative PTH level ≤ 6.985 pg/mL serves as a reliable predictor for hypocalcemia. The combined strategy of optimized drainage pressure and PTH monitoring provides a safe and effective ERAS pathway for thyroid surgery.

Keywords

enhanced recovery after surgery (ERAS) / hypocalcemia / parathyroid hormone / postoperative drainage pressure / thyroid cancer

References

[1] Pizzato M , Li M , Vignat J . The epidemiological landscape of thyroid cancer worldwide: GLOBOCAN estimates for incidence and mortality rates in 2020. Lancet Diabetes Endocrinol. 2022; 10 (4): 264- 272.

[2] Filetti S , Durante C , Hartl D . Thyroid cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol Off J Eur Soc Med Oncol. 2019; 30 (12): 1856- 1883.

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

[4] Chorath K , Luu N , Go BC , Moreira A , Rajasekaran K . ERAS protocols for thyroid and parathyroid surgery: a systematic review and metaanalysis. Otolaryngol——Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2022; 166 (3): 425- 433.

[5] Lee JS , Lee JS , Yun HJ . No change in complications following thyroidectomy despite increase in thyroid cancer surgeries: a metaregression analysis. Yonsei Med J. 2024; 65 (6): 348- 355.

[6] Zhang X , An C , Liu J , Li Z , Tang P , Xu Z . Prevention and treatment of life-threatening bleeding after thyroid surgery. Med Sci Monit Int Med J Exp Clin Res. 2015; 21: 3682- 3689.

[7] Woo SH , Kim JP , Park JJ . Comparison of natural drainage group and negative drainage groups after total thyroidectomy: prospective randomized controlled study. Yonsei Med J. 2013; 54 (1): 204- 208.

[8] An C , Jin Z , Zhao B , Liu Y , Lv Q . Observation on enhanced recovery after surgery without drainage in thyroid cancer. J Cancer Control Treat. 2020; 33 (12):

[9] Edafe O , Antakia R , Laskar N , Uttley L , Balasubramanian SP . Systematic review and meta-analysis of predictors of post-thyroi dectomy hypocalcaemia. Br J Surg. 2014; 101 (4): 307- 320.

[10] Toniato A , Boschin IM , Piotto A , Pelizzo M , Sartori P . Thyroidectomy and parathyroid hormone: tracing hypocalcemia-prone patients. Am J Surg. 2008; 196 (2): 285- 288.

[11] Yan D , Zhang B , Xu Z , Tang P . Analysis of risk factors for hypocalcemia after total thyroidectomy. Chin J Endocr Surg. 2015 (3): 238- 241.

[12] Tecilazich F , Formenti AM , Frara S , Giubbini R , Giustina A . Treatment of hypoparathyroidism. Best Pract Res Clin Endocrinol Metabol. 2018; 32 (6): 955- 964.

[13] Ezzat WF , Fathey H , Fawaz S , El-Ashri A , Youssef T , Othman HB . Intraoperative parathyroid hormone as an indicator for parathyroid gland preservation in thyroid surgery. Swiss Med Wkly. 2011; 141: w13299.

[14] Mattoo S , Agarwal A , Mayilvaganan S . Role of postoperative intact serum PTH as an early predictor of severe post-thyroidectomy hypocalcemia: a prospective study. J Endocrinol Investig. 2021; 44 (9): 1961- 1970.

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

[16] Shaha AR , Jaffe BM . Selective use of drains in thyroid surgery. J Surg Oncol. 1993; 52 (4): 241- 243.

[17] Hurtado-López LM , López-Romero S , Rizzo-Fuentes C , Zaldívar-Ramírez FR , Cervantes-Sánchez C . Selective use of drains in thyroid surgery. Head Neck. 2001; 23 (3): 189- 193.

[18] Neary PM , O'Connor OJ , Shafiq A . The impact of routine open nonsuction drainage on fluid accumulation after thyroid surgery: a prospective randomised clinical trial. World J Surg Oncol. 2012; 10 (1): 72.

[19] Li L , Liu W , Tao H . Efficacy and safety of negative pressure versus natural drainage after thyroid surgery: a systematic review and meta-analysis. Medicine (Baltim). 2018; 97 (31): e11576.

[20] Park I , Her N , Choe JH , Kim JS , Kim JH . Management of chyle leakage after thyroidectomy, cervical lymph node dissection, in patients with thyroid cancer. Head Neck. 2018; 40 (1): 7- 15.

[21] Sanabria A , Carvalho AL , Silver CE . Routine drainage after thyroid surgery——a meta-analysis. J Surg Oncol. 2007; 96 (3): 273- 280.

[22] Kennedy SA , Irvine RA , Westerberg BD , Zhang H . Meta-analysis: prophylactic drainage and bleeding complications in thyroid surgery. J Otolaryngol-Head Neck Surg J Oto-Rhino-Laryngol Chir CervicoFaciale. 2008; 37 (6): 768- 773.

[23] Kristoffersson A , Sandzén B , Järhult J . Drainage in uncomplicated thyroid and parathyroid surgery. Br J Surg. 1986; 73 (2): 121- 122.

[24] Wang Z , Qi P , Zhang L . Is routine drainage necessary after thyroid surgery? A randomized controlled trial study. Front Endocrinol. 2023; 14: 1148832.

[25] Rajinikanth J , Paul MJ , Abraham DT , Ben Selvan CK , Nair A . Surgical audit of inadvertent parathyroidectomy during total thyroidectomy: incidence, risk factors, and outcome. Medscape J Med. 2009; 11 (1): 29.

[26] Rejnmark L , Sikjaer T , Underbjerg L , Mosekilde L . PTH replacement therapy of hypoparathyroidism. Osteoporos Int J Establ Result Coop Eur Found Osteoporos Natl Osteoporos Found USA. 2013; 24 (5): 1529- 1536.

[27] Corvilain J , Manderlier T , Struyven J . Metabolism of human PTH by the kidney and the liver. Horm Metab Res Horm Stoffwech-selforschung Horm Metab. 1977; 9 (3): 239- 242.

[28] Grodski S , Lundgren CI , Sidhu S , Sywak M , Delbridge L . Postoperative PTH measurement facilitates day 1 discharge after total thyroidectomy. Clin Endocrinol. 2009; 70 (2): 322- 325.

[29] Reddy AC , Chand G , Sabaretnam M . Prospective evaluation of intra-operative quick parathyroid hormone assay as an early predictor of post thyroidectomy hypocalcaemia. Int J Surg Lond Engl. 2016; 34: 103- 108.

[30] Markey DW , McGowan J , Hanks JB . The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients. Am Surg. 2000;66(6):533-538. discussion 538-539.

[31] Yip L , Carty SE , Holder-Murray JM . A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery. Surgery. 2021; 169 (1): 197- 201.

[32] Zheng L , Zhang S . Application and evaluation of a care plan for enhanced recovery after thyroidectomy. Inq J Med Care Organ Provis Financ. 2022; 59: 00469580221090404.

RIGHTS & PERMISSIONS

The Author(s). Eye & ENT Research published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.