Response to the letter to the editor: Thyroid surgery volume – A statement issued by the Brazilian Head and Neck Surgery Society (SBCCP)

DOES BRAZIL HAVE ENOUGH HIGH-VOLUME HEAD AND NECK SURGEONS?

TO THE EDITOR:

We read with great interest the letter by Matos and cols. (¹) regarding our position statement published in 2022 (²). As rightly observed, the sentence pointed out in the letter reflects our opinion in the position statement, which is why the sentence was not supported by a reference. Our opinion, in turn, was based on arguments presented in the section where the sentence was inserted, which was supported by references (e.g., a consensus by the American Thyroid Association [ATA]). The ATA consensus, based on two strong pieces of evidence, states that "Surgeon experience likely influences the risks of thyroidectomy, with higher volume surgeons having lower complication rates (232,233)" (³). The importance of high surgical volume in the outcomes of patients with thyroid disease is also endorsed in several publications (⁴-⁶) and incorporated into the recommendations of various guidelines and statements issued by important groups (⁷). Considering that Brazil is a vast country, high-volume head and neck surgeons (i.e., 792 active members of the Brazilian Society of Head and Neck Surgery, according to data presented in the letter,) are mainly based in large cities and referral centers. For example, from 22,780 thyroid procedures performed within the private health care system, more than 16,000 (>70%) were carried out in only five Brazilian states: São Paulo, Rio de Janeiro, Minas Gerais, Pernambuco, and Santa Catarina (⁸). Thus, it is essential to consider that many of these procedures might have been performed either by less experienced head and neck surgeons, by surgeons who could not keep up with the minimum number since they left residency, or by general surgeons. Furthermore, a recent study analyzing public institutions in Brazil showed that 556 institutions performed 15,331 thyroidectomies in 2019. The institutions were then stratified according to the surgical volume into three categories: low volume (100 thyroidectomies/year), intermediate volume (10-100 thyroidectomies/year), and high volume (>100 thyroidectomies/year). Based on this categorization, 258 (46.4%) institutions were classified as low volume, 269 (48.4%) as intermediate, and 29 (5.2%) as high volume. In the same year, 848 (5.5%) thyroidectomies were performed in low-volume, 9,404 (61.4%) in intermediate-volume, and 5,079 (33.1%) in high-volume institutions. The proportion of thyroidectomies performed in high-volume institutions among all states in 2019 displayed a median of 28.5% (interquartile range 0.0-43.5%) (⁹). Still, an important point raised in the letter by Matos and cols. (¹) is the need for further studies to better understand real-life surgical expertise throughout the country.

REFERENCES

• ¹
  Matos F, Vartanian JG, Barauna Neto JC, Santos A, Machado A, Pedruzzi PA, et al. Thyroid surgical volume - Statement of SBCCP (Brazilian Head and Neck Surgery). Archives of Endocrinology and Metabolism, 2024.
• ²
  Ward LS, Scheffel RS, Hoff AO, Ferraz C, Vaisman F. Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM). Arch Endocrinol Metab. 2022;66(4):522-3. https://doi.org/10.20945/2359-3997000000512
  » https://doi.org/10.20945/2359-3997000000512
• ³
  Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1-133. doi: 10.1089/thy.2015.0020.
  » https://doi.org/10.1089/thy.2015.0020
• ⁴
  Liang TJ, Liu SI, Mok KT, Shi HY. Associations of Volume and Thyroidectomy Outcomes: A Nationwide Study with Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2016;155(1):65-75. doi: 10.1177/0194599816634627.
  » https://doi.org/10.1177/0194599816634627
• ⁵
  Gao TP, Green RL, Kuo LE. Disparities in Access to High-Volume Surgeons and Specialized Care. Endocrinol Metab Clin North Am. 2023;52(4):689-703. doi: 10.1016/j.ecl.2023.05.006.
  » https://doi.org/10.1016/j.ecl.2023.05.006
• ⁶
  Issa PP, Hossam E, Cheng JH, Magazine BM, Hussein M, Luo X, et al. Completion thyroidectomy: A safe option for high-volume surgeons. Head Neck. 2024;46(1):57-63. doi: 10.1002/hed.27551.
  » https://doi.org/10.1002/hed.27551
• ⁷
  Papini E, Crescenzi A, D’Amore A, Deandrea M, De Benedictis A, Frasoldati A, et al. Italian Guidelines for the Management of Non-Functioning Benign and Locally Symptomatic Thyroid Nodules. Endocr Metab Immune Disord Drug Targets. 2023;23(6):876-85. doi: 10.2174/1871530323666230201104112.
  » https://doi.org/10.2174/1871530323666230201104112
• ⁸
  D-TISS – Painel dos Dados do TISS – Agência Nacional de Saúde Suplementar. Available from: https://www.gov.br/ans/pt-br/acesso-ainformacao/perfil-do-setor/dados-e-indicadores-do-setor/d-tiss-paineldos-dados-do-tiss Accessed in: Feb. 8, 2024.
  » https://www.gov.br/ans/pt-br/acesso-ainformacao/perfil-do-setor/dados-e-indicadores-do-setor/d-tiss-paineldos-dados-do-tiss
• ⁹
  Schwengber WK, Walter LB, Zanella AB, Scheffel RS, Maia AL, Dora JM. Thyroidectomy volume by Institutions in Brazil: a DATASUS-based overview and future challenges. Arch Endocr Metab. 2021;65(Suppl 3):S39.

Publication Dates

• Publication in this collection
  24 June 2024
• Date of issue
  2024

History

• Received
  09 Feb 2024
• Accepted
  23 Feb 2024