Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis—European Society of Endocrine Surgeons (ESES) positional statement

Abstract

Introduction Continuous efforts in surgical speciality aim to improve outcome. Therefore, correlation of volume and outcome, developing subspecialization, and identification of reliable parameters to identify and measure quality in surgery gain increasing attention in the surgical community as well as in public health care systems, and by health care providers. The need to investigate these correlations in the area of endocrine surgery was identified by ESES, and thyroid surgery was chosen for this analysis of the prevalent literature with regard to outcome and volume. Materials and methods A literature search that is detailed below about correlation between volume and outcome in thyroid surgery was performed and assessed from an evidence-based perspective. Following presentation and live data discussion, a revised final positional statement was presented and consented by the ESES assembly. Results There is a lack of prospective randomized controlled studies for all items representing quality parameters of thyroid surgery using uniform definitions. Therefore, evidence levels are low and recommendation grades are based mainly on expert and peer evaluation of the prevalent data. Conclusion In thyroid surgery a volume and outcome relationship exists with respect to the prevalence of complications. Besides volume, cumulative experience is expected to improve outcomes. In accordance with global data, a case load of < 25 thyroidectomies per surgeon per year appears to identify a low-volume surgeon, while > 50 thyroidectomies per surgeon per year identify a high-volume surgeon. A center with a case load of > 100 thyroidectomies per year is considered high-volume. Thyroid cancer and autoimmune thyroid disease predict an increased risk of surgical morbidity and should be operated by high-volume surgeons. Oncological results of thyroid cancer surgery are significantly better when performed by high-volume surgeons.

The volume and outcome relationship for thyroidectomy in England

“…A recent positional statement by the European Society of Endocrine Surgeons also concluded that a surgeon volume-outcome effect exists for thyroid surgery [ 20 ]. They identify > 50 procedures per annum per surgeon as an appropriate threshold for high volume and < 25 procedures per annum per surgeon as an appropriate threshold for low volume.…”

The Ongoing Debate Regarding Completion Thyroidectomy Versus Primary Thyroid Surgery for Low and Intermediate Differentiated Thyroid Carcinoma: A Meta-Analysis

“…We included both prospective and retrospective studies; the included studies cannot control for various confounders that may affect the outcomes, including the original thyroid disease, the patient's age, comorbidities, and the extent of surgery, including central lymph nodes dissection [ 27 ]. Besides, a high-volume surgical team might affect the outcomes [ 28 ]. Also, the limitations include the significant observed heterogeneity and studies published only in the English language.…”

Differentiated Thyroid Cancer: A Health Economic Review

“…In part this may be caused by the increasing use of technology aimed to improve outcomes. The morbidity after thyroid surgery is low when performed by high-volume surgeons [ 50 , 51 ] and the real-world results suggest a gross underreporting of surgical morbidity [ 52 ]. Hypoparathyroidism, recurrent laryngeal nerve palsy, and post-operative haemorrhage reduce QoL and add cost to the overall treatment of thyroid cancer [ 52 ].…”