More is better when it comes to surgeon experience and patient outcome in thyroid surgery

Total thyroidectomy is the most commonly performed endocrine surgical procedure worldwide, both for thyroid cancer and for benign thyroid disease (1). However, potential morbidity of this operation including postoperative hypoparathyroidism, recurrent laryngeal nerve and external branch of the superior laryngeal nerve injury may substantially limit patient quality of life afterwards. It has been repeatedly shown in the literature that surgical volume correlates with decreased prevalence of postoperative complications and shorter hospital stay in thyroid surgery (1-3). Al-Quarayshi et al. performed cross-sectional analysis of adult (≥18 years) inpatients in US community hospitals using the Nationwide Inpatient Sample for the years 2003 through 2009. A total of 77,863 patients were included. Surgeon volumes were stratified into low (1–3 thyroidectomies per year), intermediate (4–29 thyroidectomies per year), and high (≥30 thyroidectomies per year). Procedures performed by low-volume surgeons were associated with a higher risk of postoperative complications compared with high-volume surgeons [15.8% vs. 7.7%; OR, 1.55 (95% CI, 1.19–2.03); P=0.001]. Mean (SD) hospital cost was significantly associated with surgeon volume [high volume, $6,662.69 ($409.31); intermediate volume, $6,912.41 ($137.20); low volume, $10,396.21 ($345.17); P<0.001]. During the study period, if all operations performed by low-volume surgeons had been selectively referred to intermediate- or high-volume surgeons, savings of 11.2% or 12.2%, respectively, would have been incurred. On the basis of the cost growth rate, greater savings are forecasted for high-volume surgeons. With a conservative assumption of 150,000 thyroidectomies per year in the United States, referral of all patients to intermediate- or high-volume surgeons would produce savings of $2.08 or $3.11 billion, respectively, over a span of 14 years (2).