The ATA consensus emphasises the importance of comprehensive and reliable clinical pathways with clear communication. New technologies can potentially reduce the occurrence of complications and improve detection of impending life threatening postoperative emergencies, for example recurrent laryngeal nerve injury by endotracheal nerve monitoring and pre-empting of significant postoperative hypocalcaemia Doxorubicin nmr from parathyroid hormone measurement.

Postoperative haemorrhage is the critical factor determining risk acceptability for day case thyroid surgery. Whilst it is unrealistic to expect to be able to eliminate the occurrence of bleeding from the day case pathway the reduction of a significant adverse consequence may be possible with the appropriate set-up. Postoperative haemorrhage occurs between 0.9%–1.25% [3], [10], [13] and [25] and 2.1% Compound C chemical structure [11] of all thyroidectomies. The frequency of life threatening airway obstruction (due to local compression and laryngeal oedema) however is much less clear. The incidence of patients requiring tracheostomy may be a surrogate marker. Of 10, 201 thyroidectomies performed over a 40-year period at the Royal North Shore hospital 124 (1.2%) required re-operation for haemorrhage

with 31 (0.3%) requiring a tracheostomy [26]. This is comparable to Burkey’s data with a quarter requiring bedside decompression [25]. In Promberger’s series of over 30,000 thyroidectomies [24], there were 3 fatal outcomes (1 per 10,000 surgeries) and 9 of 591 (1.5%) bleeds requiring tracheostomy. Thirty-day mortality following thyroid surgery in the UK is 1 in 500 [10] and at least some of these deaths will be secondary to a postoperative haemorrhage. Incidence of fatal haematoma has not been reported in the large US studies. A postoperative thyroid bleed needs urgent assessment and at least a quarter require immediate perhaps even bedside intervention [3], [25] and [26]. Intuitively, a post-thyroidectomy haemorrhage occurring

at home would increase the mortality the risk but there is no data to prove this. In Promberger’s series, patients requiring tracheostomy had a three-fold longer interval between skin closure and recognition of symptoms/re-operation indicating that delay in diagnosis leads to laryngeal/supraglottic oedema and increased morbidity [24]. This infers that a patient bleeding at home would fare worse due to inevitable delays in intervention, but this may not necessarily be so if such bleeds were not life threatening. To assure against an increased risk from the day case setting, a reliable form of risk stratification to identify patients with a minimal bleed risk is required. Unfortunately, even with experienced clinical judgement, there is no reliable and reproducible patient and disease specific criteria to risk stratify patients for postoperative haemorrhage. A large retrospective review of 7921 thyroidectomies and 5896 parathyroidectomies over 25 years compared 21 (0.26%) and 21 (0.