The American Journal of Surgery xxx (2018) 1e6

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The American Journal of Surgery

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Risk of major complications following thyroidectomy and

parathyroidectomy: Utility of the NSQIP surgical risk calculator
Joseph Margolick, Sam M. Wiseman*
Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: The primary objective of this study was to determine rates of reoperation, ED visits, and
Received 17 November 2017 hospital readmission after thyroid and parathyroid surgery at a tertiary hospital. A secondary objective
Received in revised form was to determine if scores from the American College of Surgeons Surgical Risk Calculator (ACS SRC)
27 December 2017
predicted these events.
Accepted 2 January 2018
Methods: We retrospectively reviewed the records of patients undergoing parathyroid and thyroid
surgery between 2011 and 2014. Patients who underwent an unplanned reoperation, returned to the ED,
Keywords:
or were readmitted to hospital were evaluated using the ACS SRC.
Hospital readmission
Unplanned reoperation
Results: 436 patients underwent thyroid and parathyroid operations. Rates of re-operations, ED visits
Surgical risk calculator and hospital readmissions after thyroid and parathyroid surgery were: 3.4%, 0.6% and 3.0% and 2.2%, 0%
Emergency department visits and 1.4%, respectively. 71% of patients who experienced post-operative complications scored below
Hypocalcemia average on the ACS SRC, 17% scored above average and 12% scored average risk.
Thyroid surgery Conclusions: The SRC did not predict re-operation, ED visits, or hospital readmission after thyroid or
parathyroid operations.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction
In the late 19th century, through improvements in surgical
technique and perioperative care, surgical pioneer Theodor Kocher
helped reduce the mortality rate after thyroid operations from over
40% to approximately 1%.1 Nowadays, even though perioperative
mortality after thyroidectomy has remained low, at less than
0.15%,2,3 unplanned emergency department (ED) visits and hospital
readmissions continue to frustrate both patients and surgeons
alike. Unplanned hospital readmissions after thyroid surgery can
cost greater than 6000 United States Dollars (USD) per patient, and
Emergency Department (ED) visit and readmission rates are
currently used as quality indicators by many healthcare centers.4e6
The National Surgical Quality Improvement Program (NSQIP) is
a data collection program that provides risk-adjusted, 30-day post-
operative, surgical outcomes measures in order to improve quality
of surgical care.2,7 Study data from NSQIP reported a 30 post-
operative day hospital readmission rate after thyroidectomy that
was 2.9%.2 Other retrospective studies have documented
* Corresponding author. Department of Surgery, University of British Columbia &
St Paul's Hospital, C303-1081 Burrard Street, Vancouver, BC V5Z 1Y6, Canada.
E-mail address: smwiseman@providencehealth.bc.ca (S.M. Wiseman).
readmission rates that ranged between 2.8% and 4.7%, with rates of
post-operative ED visits that ranged from 8% to 11%.8,9 In elderly
patients the rate of hospital readmission following thyroid opera-
tions has even been reported to be as high as 8%.6 Risk factors for
hospital readmission after thyroid operations have been studied,
and include: male gender, African American race, obesity,
increasing length of index hospitalization, inpatient procedures,
and post-operative hypocalcemia.6,8,10e13
In an attempt to predict and reduce perioperative complications
in surgical patients, the American College of Surgeons (ACS) has
developed a Surgical Risk Calculator (SRC) using data accrued from
over 3.2 million operations collected in the NSQIP database.14 The
ACS SRC allows 20 patient characteristics to be easily entered on-
line, and may even be carried out in the surgeon's office with the
patient present. A statistical model then predicts a percentage
chance of complications for an individual patient, for a specific
operation, and compares their individual risk to the overall average
general population risk.14 This tool allows physicians to anticipate
procedure related complications independent of hospital settings,
and engages patients in a shared decision making process. How-
ever, attempts at external validation of the ACS SRC have been
somewhat inconsistent.7
The primary objective of our study was to review patient data

https://doi.org/10.1016/j.amjsurg.2018.01.006
0002-9610/© 2018 Elsevier Inc. All rights reserved.

Please cite this article in press as: Margolick J, Wiseman SM, Risk of major complications following thyroidectomy and parathyroidectomy:
Utility of the NSQIP surgical risk calculator, The American Journal of Surgery (2018), https://doi.org/10.1016/j.amjsurg.2018.01.006
2 J. Margolick, S.M. Wiseman / The American Journal of Surgery xxx (2018) 1e6
from our high volume, tertiary care, endocrine surgical center in
order to ascertain our own rates of reoperation, postoperative ED
visits, and hospital readmission following thyroid and parathyroid
operations. Additionally, the ACS SRC represents a potential strat-
egy for identifying individuals who are at increased risk for
developing these adverse post-operative events. Therefore, a sec-
ondary study objective was to determine if “above average” scores
on the ACS SRC were associated with reoperations, ED visits and
hospital readmissions after thyroid and/or parathyroid operations.
2. Methods
All patients undergoing thyroid operations (total thyroidectomy
or thyroid lobectomy), and parathyroid operations (solitary or
multiple parathyroid gland resection) between January 5th, 2011
and December 31st, 2014 were identified. All operations were
carried out by surgeons with either Endocrine Surgery, or Head and
Neck Surgery, subspecialty fellowship training. This study was
carried out with approval of our research ethics board.
The study patient population was identified through retro-
spective chart review, and composed of all patients who had un-
dergone an unplanned re-operation, returned to the ED, or been
readmitted to hospital within 30 days of their index operation.
Clinical and patient characteristics collected from patient records
included: age, gender, body mass index (BMI), indications for sur-
gery, type of surgery, emergency or elective procedure status,
presence of dyspnea, renal failure, congestive heart failure (CHF),
disseminated malignancy, dialysis, liver failure, diabetes, American
Society of Anesthesia (ASA) score, functional status, hypertension,
steroid usage, smoking status, anticoagulant utilization, antiplate-
let medication usage, operating surgeon as well as the nature of the
complications that were encountered. The principle outcome
measures were rates of re-operation, ED visits, and hospital read-
missions. For cases in which at least one of these 3 postoperative
complications occurred, patient characteristics were then inputted
into the ACS SRC (https://riskcalculator.facs.org/RiskCalculator) to
determine if they fell within the “above average” risk category for
major complications.
3. Results
Four hundred and thirty-six patients were identified who un-
derwent thyroid and parathyroid operations during the study
period. 298 patients underwent a thyroid operation, and 138 pa-
tients underwent a parathyroid operation. Rates of re-operations,
ED visits and hospital readmissions after thyroid surgery were:
3.4%, 0.6% and 3.0%, respectively (Fig. 1). Rates of re-operation, ED
visits and hospital readmission after parathyroid surgery were:
2.2%, 0% and 1.4%, respectively (Fig. 2). Seventy-seven percent of
Fig. 1. Adverse events after thyroidectomy in study population.
Please cite this article in press as: Margolick J, Wiseman SM, Risk of major complications following thyroidectomy and parathyroidectomy:
Utility of the NSQIP surgical risk calculator, The American Journal of Surgery (2018), https://doi.org/10.1016/j.amjsurg.2018.01.006
patients who presented to the emergency department within 30
days of their index operation were ultimately admitted to hospital
for a least one night.
Seventy-five percent of reoperations were due to hemorrhage
during the index hospital admission, with the remainder due to
incision complications, one cricothyroid membrane fistula, one to
evaluate dysphagia, and one case for airway management due to
bilateral recurrent laryngeal nerve injury (Fig. 3). Eighty percent of
reoperations occurred the same day as the index operation, while
the remaining 20% of patients who required a reoperation were
discharged home and then returned to the ED for evaluation. Thirty
percent of hospital readmissions and 33% of ED visits were sec-
ondary to hypocalcemia, or early postoperative hypoparathyroid-
ism, and 20% of hospital readmissions and 33% of ED visits were
related to incision complications. Twenty percent of hospital
readmissions and 33% of ED visits were due to bleeding related
complications. Finally, 30% percent of hospital readmissions were
due to other issues such as a cardiac arrhythmia unrelated to hy-
pocalcemia and dysphagia (See Figs. 4 and 5). The adverse post-
operative events that led to reoperations, ED visits, and hospital
readmissions are summarized, by procedure type, in Table 1.
Only 17% of patients that experienced a post-operative compli-
cation that required either a reoperation, ED visit, or hospital
readmission scored above average risk on the ACS SRC for major
complications. The majority of patients (71%) actually scored below
average risk, and 12% of patients scored in the average risk category
(Fig. 6). Only 20% of patients who were readmitted to hospital
scored above average on the ACS SRC for risk of readmission, the
remaining 80% of readmitted patients scored below average risk for
readmission. Finally, 25% of patients who required a reoperation
scored above average on the ACS SRC for risk of reoperation, while
19% scored average risk and 56% scored below average risk for
reoperation. In patients who either underwent an unplanned
reoperation, visited the ED or were readmitted to hospital we
considered an above average score on the ACS SRC as accurately
predicting a complication and therefore representing a true posi-
tive event, while an average or below average score on the ACS SRC
was considered a false negative event. We therefore calculated the
sensitivity for the ACS SRC to be 16.6% for major complications, 25%
for reoperations and 20% for readmission to hospital.
4. Discussion
At our center 3% of patients were readmitted to hospital within
30 days of their thyroid operation. This is similar to reports based
on NSQIP data that found a readmission rate of 2.9% after thyroid
operations.2 Our study also found that hypocalcemia was the chief
complaint in nearly a third of all patients readmitted to hospital or
who visited the ED. Early post-operative hypoparathyroidism, that
presents with hypocalcemia, has been reported to occur in up to a
Fig. 2. Adverse events after parathyroidectomy in study population.
 J. Margolick, S.M. Wiseman / The American Journal of Surgery xxx (2018) 1e6 3

Fig. 3. Reasons for unplanned reoperations.

quarter of total thyroidectomy patients.15 Reducing patient risk of Fig. 5. Reasons for Emergency Department visits.

post-operative hypoparathyroidism is critical in order to reduce

hospital ED visits and readmissions. A retrospective review of
received routine post-operative calcium and vitamin D supple-
11,120 total thyroidectomy patients found that over half of post-
mentation, which was significantly less common (OR 0.39, CI
operative hospital readmissions were due to hypocalcemia.16 Many
0.26e0.59) than in patients who did not receive routine supple-
surgeons who perform thyroid operations routinely administer oral
mentation (25.9% hypocalcemia rate).15 Similarly, Youngwirth et al.
calcium and vitamin D supplementation to all total thyroidectomy
found that a standardized post-operative calcium and vitamin D
patients in order to facilitate hospital discharge, and reduce their
supplementation protocol significantly decreased their risk of
risk of hypocalcemia. The utility of this practice has been well
symptomatic post-thyroidectomy hypocalcemia from 17% to 7%
studied. In a review of 9 randomized controlled trials (RCTs) that
(p ¼ .005), and significantly reduced ED visit frequency from 8% to
included 2285 patients, Alhefdhi et al. found that postoperative
1.8% (p ¼ .008).13 In another systematic review and meta-analysis of
hypocalcemia occurred in 6.8% of thyroidectomy patients who
8 RCTs Antakia et al. also found that routine calcium and vitamin D
supplementation was associated with significantly decreased post-
operative hypocalcemia when compared to no supplementation
(OR 0.34; p ¼ .007), and supplementation with calcium alone (OR
0.66; p ¼ .04).10 Other risk factors for postoperative hypocalcemia
after thyroidectomy that have been studied include: lower preop-
erative calcium levels, female gender, young age, thyroid cancer
diagnosis, Grave's disease diagnosis, removal of 2 or more para-
thyroid glands, more extensive surgery, and operative time longer
than 120 min.17e21 A retrospective cohort analysis showed that
transient hypocalcemia developed in 29.8%, 33.6%, 52.9% and 100%
of patients undergoing total thyroidectomy, total thyroidectomy
with unilateral central neck dissection (CND), total thyroidectomy
with bilateral CND, and total thyroidectomy with bilateral CND and
lateral neck dissection, respectively (p < .001). A similar trend was
seen for permanent hypocalcemia, but was not statistically signif-
icant.20 Meticulous surgical technique with in situ identification
and preservation of the parathyroid glands, and their blood supply,
can also decrease postoperative hypocalcemia risk as some studies
have found that the only independent risk factor for permanent
postoperative hypoparathyroidism was inadvertent and unrecog-
nized parathyroid tissue removal as highlighted in the pathology
report.21
At our center most surgeons routinely administer oral calcium
and vitamin D to all total thyroidectomy patients for a minimum of
three weeks. Additionally, serum ionized calcium levels are usually
monitored the morning after surgery, and patients are kept in
hospital if their level is not well controlled. Interestingly, in our
Fig. 4. Reasons for unplanned hospital readmissions.

Please cite this article in press as: Margolick J, Wiseman SM, Risk of major complications following thyroidectomy and parathyroidectomy:
Utility of the NSQIP surgical risk calculator, The American Journal of Surgery (2018), https://doi.org/10.1016/j.amjsurg.2018.01.006
4 J. Margolick, S.M. Wiseman / The American Journal of Surgery xxx (2018) 1e6
Table 1
Adverse postoperative events listed by procedure.
Adverse Event Total Thyroidectomy Thyroidectomy with CND Thyroid Lobectomy
Reoperations 4 4
Hematoma Evacuation 3 3
Other 1 (Gastroscopy) 1 (Tracheostomy)
Hospital Readmissions 2 4
Hypocalcemia 1 2
Dysphagia 1 (Gastroscopy) 0 0
Other 0 2 (Hematoma; Pain)
ED visits 0 1
Hypocalcemia 0 1
Other 0 0
study, all the patients who returned to hospital (ED visits or hos-
pital readmission) with hypocalcemia were total thyroidectomy
patients who had been discharged with a prescription for calcium
and vitamin D supplements. One important unmeasured factor is
patient compliance with the postoperative supplementation pro-
tocol. Also, because pre-operative calcium and vitamin D deficiency
may predict postoperative hypocalcemia,17,22 it may be reasonable
to start the supplementation protocol preoperatively, especially in
patients with proven calcium and vitamin D deficiency. Finally,
debate still exists regarding optimal dosing, timing, duration and
formulation of calcium and vitamin D prophylaxis, and thus the
specific protocol utilized is currently determined by clinician
preference.
We identified post-operative hemorrhage as the most common
cause of unplanned reoperations. Hemorrhage is one of the most
dreaded complications after central neck surgery due to the po-
tential for rapid airway compromise secondary to tracheal
compression and oedema. The current literature estimates the
incidence of post-thyroidectomy hematoma ranges from 0.3% to
2.2%.23 A large retrospective American study identified: male sex,
partial thyroidectomy, coagulopathy, inflammatory thyroid condi-
tions, and chronic renal disease, as risk factors for post-
Fig. 6. Overall scores for study patient population calculated using the American
College of Surgeons Surgical Risk Calculator.
Please cite this article in press as: Margolick J, Wiseman SM, Risk of major complications following thyroidectomy and parathyroidectomy:
Utility of the NSQIP surgical risk calculator, The American Journal of Surgery (2018), https://doi.org/10.1016/j.amjsurg.2018.01.006
Parathyroid Adenoma Removal Subtotal Parathyroidectomy
4 2 1
3 2 0
1 (Cricothyroid Fistula Closure) 0 1 (Neck Abscess Drainage)
2 1 1
0 0 0
0 0
2 (Hematoma requiring 1 0
OR; Incision Edema)
1 0 0
0 0 0
1 (Bleeding From Incision) 0 0
thyroidectomy hemorrhage.24 In a large Japanese retrospective
review, multivariate analysis identified: older age, male sex, BMI
>25.0, Grave's disease, total thyroidectomy, neck dissection,
antithrombotic agents, and blood transfusion on the day of thy-
roidectomy as risk factors for post-thyroidectomy hemorrhage.23
Other studies have also identified elevated systolic blood pressure
in the immediate post-operative period as an important risk factor
for the development of post-thyroidectomy bleeding.25,26
Our rate of re-operation was high at 3.4%. Seventy-three percent
of re-operations were for hematoma evacuation, with the
remainder of the 4 re-operations being for: incision and drainage of
a neck infection, a tracheostomy, a gastroscopy, and a closure of a
cricothyroid membrane fistula. Our study identified “surgeon” as
the only identifiable risk factor for post-operative unplanned return
to the operating room (OR). Seventy-three percent of all hematoma
evacuations had their thyroidectomy performed by a single sur-
geon, and this surgeon accounted for 53% of all reoperations, while
the remaining 5 surgeons collectively accounted for the remaining
47% of reoperations.
An association between surgeon volume and patient outcomes
has become established in the current literature for many different
types of operations. Sosa et al. reported in a retrospective analysis
of all patients undergoing thyroidectomy in Maryland between
1991 and 1996, that surgery performed by the highest volume
surgeons (>100 cases during the 6 year study period) resulted in
the shortest lengths of hospital stay and the lowest overall
complication rates, independent of hospital volume.27 A retro-
spective analysis of nationwide data from the United States evalu-
ated 62,722 thyroid operations performed between 2003 and 2009,
and found that a greater total number of complications occurred
after operations were performed by low and intermediate volume
surgeons, compared to high volume surgeons.28 Other factors, such
as hospital volume and region were associated with higher
complication rates, but teaching hospital status, and rural versus
urban environments did not influence risk of developing compli-
cations.28 There is also evidence that suggests surgeon volume is
inversely related to postoperative hemorrhage risk after para-
thyroidectomy.29 However, a large retrospective review analysing
cases performed between 2008 and 2013 found no significant dif-
ference in outcomes after parathyroidectomy between high volume
(>40 operations per year) surgeons and low volume (<20 opera-
tions per year) surgeons.30 A retrospective review reported by
Adam et al., in 2017 identified a surgeon volume threshold of
greater than 25 thyroidectomies per year as being associated with
improved patient outcomes.31 Using this definition 5 of the 6 sur-
geons at our center who performed the thyroidectomies in the
current study were high volume surgeons, and one was a low
volume surgeon. Interestingly, the surgeon at our center who was
involved in the majority of reoperations was one of the high volume
surgeons.
 J. Margolick, S.M. Wiseman / The American Journal of Surgery xxx (2018) 1e6
Undoubtedly, surgeon experience is not the sole determinant of
complication rates after thyroid or parathyroid operations. There
are inherent risks to thyroid operations as contemporary rates of
complications after thyroid operations have been recorded to be as
high as 24%.28 Therefore, thyroidectomy should be offered to pa-
tients judiciously with ongoing discussions between the multidis-
ciplinary care team in order to allow for optimal perioperative
management, that is tailored to each individual patient. This holds
especially true when performing thyroid or parathyroid operations
in the outpatient setting.
One tool that can help individualize surgical treatment is the
ACS SRC. This online calculator, created by the ACS, is optimally
used as an adjunct for estimating perioperative risk. The ACS SRC
can inform clinical decision making specific to an individual patient
and help engage patients in a joint, informed decision making
process. The ACS SRC has also been used preoperatively to improve
high surgical risk patient outcomes. Kuy and Romero found that
surgical mortality at a VA Medical Center could be reduced from
0.9% to 0.3%, over a 14 month period, after implementing a Pre-
Operative Consultation Committee for evaluation of high risk sur-
gical patients that were identified using the ACS SRC32. However,
there have been debates regarding the SRC's validity due to design
limitations and inconsistency of external studies assessing its
accuracy.7
The ACS SRC quoted average risk of readmission and reoperation
as being 2.1% and 1.0% after total thyroidectomy, and 1.8% and 0.9%
after thyroid lobectomy, respectively. The ACS SRC quoted average
risk of readmission and reoperation after parathyroidectomy is 2.3%
and 0.6%, respectively. Our study suggested limited usefulness of
the ACS SRC in stratifying for operative risk in our patient popula-
tion because most thyroid and parathyroid patients (71%) that
returned to the ED, were readmitted to hospital, or underwent an
unplanned second operation actually scored below average risk,
while another 12% scored average risk of major complication.
Similarly 56% of patients who required a reoperation scored below
average risk for reoperation and 80% of patients readmitted to
hospital scored below average risk for readmission. Overall the
sensitivity of the ACS SRC was 16.6% for predicting overall com-
plications, 25% for predicting reoperations and 20% for predicting
hospital readmissions. We specifically did not compare the ACS SCR
scores for patients who experienced reoperation, ED visits or hos-
pital readmission, to those who did not experience these compli-
cations because the ACS SRC is meant to be a universal risk
calculator that evaluates operative risk based upon the general
population, and not based on a specific surgical patient sub-
population. Also, because we do not know the rate of false posi-
tives in our study population (above average ACS SRC scores with
no complications) we are unable to calculate its specificity.
The ACS SRC is meant to evaluate risk in a hospital and provider
independent manner. However, the question remains as to what
proportion of perioperative risk is due to surgeon and/or hospital
provider factors, as opposed to patient factors. Perhaps in the future
the ACS SRC, or a new preoperative risk stratification tool, will be
able to incorporate the impact of specific surgeon and hospital
outcomes data. Centers that utilize the ACS NSQIP program for
quality improvement do have surgeon and center specific
morbidity and mortality data that could be incorporated into a
future more tailored SRC.
There are several limitations to our study, owing largely to its
retrospective and single center design. This cohort analysis relied
on retrospective chart review and is therefore subject to recall bias,
and depends upon the accuracy of documentation. Furthermore,
we may be underestimating our return to OR, hospital readmission,
and ED visit rates as only charts from our center were reviewed, and
therefore we do not know if patients visited other EDs or hospitals.
Please cite this article in press as: Margolick J, Wiseman SM, Risk of major complications following thyroidectomy and parathyroidectomy:
Utility of the NSQIP surgical risk calculator, The American Journal of Surgery (2018), https://doi.org/10.1016/j.amjsurg.2018.01.006
5
As well, a standardized supplementation protocol was not used at
our center with regards to postoperative prevention and manage-
ment of hypoparathyroidism.
5. Conclusions
In conclusion, we identified thyroidectomy and para-
thyroidectomy patients who required unplanned hospital read-
mission, ED visits and reoperations over a 3- year period at our
tertiary care academic center. Rates of ED visits were very low, at
only 0.6% for thyroidectomy patients and 1.4% for para-
thyroidectomy patients. Rates of hospital readmissions were
similar to rates identified by NSQIP being 3% for thyroidectomy.
Only 2 parathyroidectomy patients (1.4%) had an unplanned hos-
pital readmission. Our rates of reoperation were somewhat higher
than reported in most large retrospective studies at 3.4% for thy-
roidectomies and 2.2% for parathyroidectomies. However, this
appeared to be somewhat surgeon-dependent, as one specific
surgeon was responsible for over half of all reoperations. Finally, in
our study patient population if prospectively applied the ACS SRC
would not have been helpful in predicting unplanned hospital
readmission, ED visits and re-operation because 83% of the patients
that experienced these adverse events scored as either average or
below average risk of developing postoperative complications.
Future study of methods to improve thyroid and parathyroid pa-
tient outcomes by reducing their risk of reoperation, return to the
ED, and hospital readmission is important, and may require the
development of a more surgeon and center specific SRC tool.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors would like to acknowledge Dr. Shangmei Hou and
thank Mr. Stephen Parker for their administrative assistance that
facilitated conduct of this study.
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