Watanabe Akie, Yao Susan, Prisman Eitan, Groot Gary, Mitmaker Elliot, Walker G Ross, Wu Jonn, Pasternak Jesse, Lai Chi Kien, Eskander Antoine, Wasserman Jonathan D, Mercier Frederic, Roth Kathryn, Gill Sabrina, Villamil Carlos, Goldstein David, Munro Vicki, Pathak Alok, Lee Debon, Nguyen Anne, Wiseman Sam M
Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
Division of General Surgery, University of Saskatchewan, Saskatoon, SK, Canada.
Ann Surg Oncol. 2025 Feb 7. doi: 10.1245/s10434-025-16957-y.
Narrative operative reports (NORs) often lack key information that can guide postoperative management of thyroid disease. We aimed to develop and validate a nationally standardized synoptic operative report (SOR) for thyroid surgery.
Surgeons were surveyed for their opinions of current operative reporting practices. Reportable elements from thyroidectomy NORs were ranked by thyroid disease specialists and reviewed by a national advisory committee to develop a standardized SOR using the Modified Delphi Method. Six thyroid surgeons piloted the SOR. Completeness and reporting frequencies of SOR elements were compared with pre-pilot NORs using Wilcoxon rank sum, chi-squared, and Fisher's exact analyses. A post-pilot survey assessed provider satisfaction.
Among 42 Canadian thyroid surgeons from 9 provinces, 31% expressed dissatisfaction with current reporting practices and 100% expressed interest in a SOR. In total, 109 reportable thyroidectomy elements were collected from 142 NORs and ranked by 46 thyroid disease specialists. Consensus agreed upon a 21-element SOR by a national advisory committee. Among 172 NORs and 170 piloted SORs, SORs had higher median overall completeness (100% [100-100%]) than NORs (65% [47-70%], p < 0.001). SORs improved reporting of cancer-specific elements, including the presence of gross extrathyroidal cancer extension (SOR: 100%, NOR: 43%, p < 0.001) and residual gross disease (SOR: 100%, NOR: 16%, p < 0.001). More than half of users and readers reported improved reporting completeness and impact on patient care with SORs.
Implementation of a nationally developed thyroid surgery SOR enhanced completeness, delivery of cancer-specific information, and provider satisfaction, which can improve quality of patient care.
叙述性手术报告（NORs）往往缺乏可指导甲状腺疾病术后管理的关键信息。我们旨在开发并验证一份全国标准化的甲状腺手术概要性手术报告（SOR）。
就外科医生对当前手术报告做法的看法进行了调查。甲状腺疾病专家对甲状腺切除术NORs中的可报告要素进行了排序，并由一个全国咨询委员会进行审核，以采用改良德尔菲法制定一份标准化的SOR。六位甲状腺外科医生对SOR进行了试点。使用威尔科克森秩和检验、卡方检验和费舍尔精确分析，将SOR要素的完整性和报告频率与试点前的NORs进行了比较。一项试点后调查评估了医疗服务提供者的满意度。
在来自9个省份的42名加拿大甲状腺外科医生中，31%对当前的报告做法表示不满，100%对SOR表示感兴趣。总共从142份NORs中收集了109个可报告的甲状腺切除要素，并由46名甲状腺疾病专家进行了排序。全国咨询委员会就一份包含21个要素的SOR达成了共识。在172份NORs和170份试点SOR中，SOR的总体完整性中位数更高（100%[100 - 100%]），高于NORs（65%[47 - 70%]，p < 0.001）。SOR改进了癌症特异性要素的报告，包括肉眼可见的甲状腺外癌扩展情况（SOR：100%，NOR：43%，p < 0.001）和残留肉眼可见疾病（SOR：100%，NOR：16%，p < 0.001）。超过一半的使用者和读者报告称SOR提高了报告的完整性以及对患者护理的影响。
实施全国制定的甲状腺手术SOR提高了完整性、癌症特异性信息的传递以及医疗服务提供者的满意度，这可以改善患者护理质量。
