Postoperative Neck Hematoma Research Articles

Practice variations, trends, and outcomes of drain use in thyroidectomy: A NSQIP study

BackgroundThe benefit of drains remains unclear and variable among thyroid surgeons. This study examines the utility and trend in drain use after thyroidectomy. MethodThis is a retrospective cross-sectional study utilizing a pooled sample of thyroidectomy patients from the 2016–2019 NSQIP. The impact of drain use on outcomes of interest (rate of postoperative neck hematoma (PNH)–primary outcome, and length-of-stay (LOS)–secondary outcome), as well as year-over-year and practice variations were evaluated using inverse-probability-weighted-regression adjustment and multivariable logistic regression analyses. ResultsOf 24,370 patients, 6673(27.4 ​%) received drains. The average LOS and PNH rates were 27.3 ​h and 1.87 %, respectively. Drain use increased year-over-year for concomitant neck dissections (OR ​= ​1.08,p ​= ​0.002). Year-over-year odds of drain use trended down across specialties (OR ​= ​0.96,p ​= ​0.005); however, ENT used drains more frequently than General Surgeons (RR ​= ​3.06, 95%CI ​= ​2.91–3.22). Drains were associated with longer LOS (mean-difference ​= ​9.6hrs, 95%CI 8.51–10.62) with no effect on PNH rates (RR ​= ​0.96,p ​< ​0.05). ConclusionDrain use is decreasing, but practice variations across specialties persist. Post-thyroidectomy drain use was associated with longer LOS with no effect on PNHR.

Is the Use of Dexmedetomidine Upon Emergence From Anesthesia Associated With Neck Hematoma Formation Following Head and Neck Microvascular Reconstruction?

Dexmedetomidine (DEX) is a highly selective alpha-2-receptor agonist, and its use has not been well studied in major microvascular reconstructive surgery of the head and neck. The purpose is to measure the association between DEX and neck hematoma formation in subjects undergoing head and neck microvascular reconstructive surgery. The investigators implemented a retrospective cohort study on subjects undergoing microvascular head and neck reconstruction for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Patients with unresectable tumors were excluded. The predictor variable was the intraoperative use of DEX upon emergence from general anesthesia. Subjects received standard anesthetic drugs and DEX, while control subjects received only standard anesthetic drugs. The primary outcome was postoperative neck hematoma formation necessitating a return to the operating theater. The secondary outcome was the length of stay (LOS). The covariates were demographic, operative, and oral morphine equivalents of anesthesia drugs. Bivariate analyses were performed using the Student's t-test and the χ2 test for continuous and categorical variables. Multivariate regression analyses were conducted to assess for associations between DEX and the outcomes adjusted for confounding variables when present. P values of < .05 were regarded as statistically significant. A total of 297 subjects (mean age, 59.6years, and standard deviation [SD], 14.9) with 61.6% male received DEX, and 304 subjects (mean age, 58.9years, and SD, 14.6) with 60.2% male served as controls (P>.5). A total of 11 postoperative neck hematoma occurred in the control group when compared to 2 in the DEX (relative risk=5.4, 95% confidence interval [CI], 1.2 to 24, P=.02). The mean LOS was 7.7 (SD, 4.3) and 9.4 (SD, 8.1) for the DEX and control groups (95% CI, 0.7 to 2.8, P<.01). After adjusting for tobacco history, tracheostomy, and neck dissection, DEX (Beta coefficient (B)=-1.7, 95% CI -2.7 to -0.7, P<.01) and neck dissection (B=2.2, 95% CI 1.0 to 3.4, P<.01) were statistically associated with LOS. The use of intraoperative DEX upon emergence from general anesthesia was associated with lower postoperative neck hematoma formation and a shorter length of stay following microvascular head and neck reconstruction.

Predictors and Preventive Strategies of Bleeding After Thyroid Surgery.

Postoperative compressive neck hematoma occurs in approximately 0.1% to 1.7% of cases, most occurring within the first six hours after surgery. Thyroid pathology, patient predisposition, and surgical technique are major risk factors for postoperative hematoma. This narrative review describes current perspectives on predicting and preventing bleeding following thyroid surgery. Predictors of bleeding after thyroid surgery include patient-related factors such as male sex and age, surgery-related factors like total thyroidectomy and operations for thyroid malignancy, and surgeon-related factors. Hemostasis is the primary focus after preserving critical structures in thyroid surgery. The clamp-and-tie technique has been the standard method for dividing the thyroid gland's main vascular pedicles for many years. Bipolar electrocautery has been used for vessels of small size. However, advanced bipolar and ultrasound energy and hybrid devices are now available options that may reduce operative time without increasing costs or complications. In cases where small bleeders close to critical structures are present and the clamp-and-tie technique is not feasible, hemostatic agents are commonly used. Drains do not appear to provide any significant benefits in preventing the sequelae of bleeding after thyroid surgery.

Evaluation and Management of Postoperative Neck Hematoma after Benign Thyroid Surgery

Evaluation and Management of Postoperative Neck Hematoma after Benign Thyroid Surgery

Complete Airway Obstruction and Massive Hemorrhage from Post-Thyroidectomy Neck Hematoma: A Case Report and Management Algorithm

Postoperative Neck Hematoma (PONH) is a potentially life-threatening complication of neck/thyroid procedures due to massive hemorrhage and/or acute airway compromise (often associated with difficult airway management) requiring immediate surgical re-intervention. Patient survival often relies on optimal crisis resource management skills of the care team. We describe the case of a PONH in an elderly patient in the immediate post-thyroidectomy period, presenting with acute respiratory failure/arrest and massive hemorrhage with hemodynamic instability. We outline the approach taken to successfully manage this emergency and highlight critical management steps including the leadership role of the anesthesiologist that ultimately resulted in a positive outcome.

Intraoperative use of tranexamic acid eliminates bleeding complications in thyroid and parathyroid surgery

Abstract Introduction Postoperative neck bleeding is a rare but life-threatening complication in thyroid and parathyroid surgery. It requires an emergency treatment algorithm to prevent asphyxia and severe brain injury. Tranexamic acid is an antifibrinolytic medication which treats or prevents excessive blood loss in a variety of clinical situations such as, major trauma, postpartum bleeding, and heavy menstruation. We studied the use of tranexamic acid to eliminate the incidence of postoperative neck hematoma. Methods All thyroid and parathyroid patients operated from the same surgical team were evaluated. The patients were divided in two groups: Group A before and Group B after the use of tranexamic acid. The medication was used intravenously to all Group B patients during the hemostasis control and prior the neck wound closure. Results A total of 1457 consecutive patients were studied from 01-01-2001 to 06-06-2021. Group A included 669 patients (620 thyroid and 49 parathyroid patients) from 01-01-2001 until 27-06-2018. Group B included 788 patients (705 thyroid and 83 parathyroid patients) from 27-06-2018 until 06-06-2021. Group A had 15 (2,24% incidence) postoperative neck hematomas and 6 of them (0,89%) required emergency surgical drainage. Group B had no postoperative bleeding episodes with the intraoperative use of tranexamic acid. Conclusion The use of tranexamic acid eliminates postoperative bleeding episodes in thyroid and parathyroid surgery.

Full endoscopic anterior cervical discectomy and interbody fusion in patients with cervical spondylotic myelopathy

Background: For the surgical treatment of cervical spondylotic myelopathy (CSM), anterior decompression with fusion or posterior decompression using microscopy has been used widely as the standard procedure, depending on the location of pathology and the surgeon's preference. Endoscopic anterior cervical discectomy and interbody fusion (E-ACDF) is a minimally invasive, effective surgical option for the management of CSM. The advantages of using endoscopy for anterior cervical discectomy and interbody fusion (ACDF) are better visualization of the operative field with the possibility of changing the angle of the endoscope. This reduces the damage to the normal anatomical structure. Although long-term follow-up results are needed to evaluate fusion rate and complication, this appears to be a safe and feasible alternative to conventional ACDF for CSM. In this article, we have described the surgical technique, summarized the endoscopic process to discuss its operative strategies, and reviewed the radiographic records, pre- and postoperatively.Material and Methods: This retrospective review study included 36 cases aged 37 to 65 years, with CSM at one segment. All of them underwent full E-ACDF from January 2018 to April 2021. All patients were followed up for 12 months after the procedure by outpatient interviews. The clinical outcomes were evaluated based on the Visual Analog Scale (VAS) of the arm, and Japanese Orthopedic Association (JOA) score with clinical data at preoperative, 3, and 12 months after the operation. Hirabayashi method was used to assess the neurological recovery after 12 months of operation. Radiological outcomes were evaluated using plain radiography and magnetic resonance imaging, computed tomography scan to evaluate disc height, cervical lordosis (Cobb's angle), and solid fusion.Results: The mean operation time was 150 min (range 120–170 min) and the average length of hospital stay was 2 ± 3 days. There was one case of immediate postoperative anterior neck hematoma, which required open revision surgery. There was no case of infection or damage to the anterior visceral organ. The mean VAS scores for arm pain and mean JOA scores after endoscopic ACDF were significantly improved compared with before the operation during the follow-up period. The recovery rate, which was evaluated by the Hirabayashi method, looked good enough to indicate well recovered postoperatively. The disc height changed from 5.2 mm preoperatively to 6.2 mm after immediate postoperative and 5.9 mm after 6 months (P < 0.01). Cervical lordosis as Cobb's angle between C2 and C7 was significantly improved compared to the preoperative one during the follow-up periods also. The bone fusion rate was 100% at 6 months after the operation, and there was no segmental instability.Conclusions: The present study demonstrates that E-ACDF is a minimally invasive and effective surgical option for the surgical management of CSM. Based on the present study, E-ACDF may potentially enable the avoidance of various shortcomings related to surgical approaches. Through a sort of preliminary investigation, the authors confirmed the feasibility of E-ACDF and presented comparable outcome results, which might dispel the safety concern because of only one complication of wound hematoma. Better-designed randomized controlled studies with larger sample sizes in longer-term follow-ups are strongly warranted.

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study.

Objective:Examine the association of Graves’ disease with the development of postoperative neck hematoma.Design:A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.Setting:A North American surgical cohort study.Methods:17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.Results:One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.Conclusions:Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.

To drain or not to drain following carotid endarterectomy: a systematic review and meta-analysis.

A postoperative neck hematoma can be a life-threatening complication after carotid endarterectomy necessitating urgent surgical decompression to avoid airway compromise. The practice of routine incisional drain placement is variable with few published studies evaluating the "to drain versus not to drain" approach. We conducted a systematic review and meta-analysis of the safety and efficacy of neck drain placement for prevention of neck hematoma requiring re-exploration for decompression. This study is a systematic review and meta-analysis performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios with 95% confidence intervals were calculated for the outcome of surgical re-exploration for neck decompression among patients receiving or not receiving wound drainage. We identified 5 studies for inclusion, comprising 48,297 patients with 19,832 (41.1%) patients receiving a drain after carotid endarterectomy. Patients in the drain group had a significantly higher re-exploration rate after carotid endarterectomy compared to those who did not receive a drainage (OR=1.24, 95% CI: 1.03-1.49; P=0.02) with no heterogeneity (I2=0%). Routine drain placement does not offer complete protection against neck hematoma development and may give the surgeon a false sense of security in wound drainage. Thus, we conclude that drain placement following carotid endarterectomy should be selective, not routine.

Risk Factors and Outcomes of Postoperative Neck Hematomas: An Analysis of 5,900 Thyroidectomies Performed at a Cancer Center.

Introduction Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery. Objective To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes. Methods We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution. Results In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH. Conclusion Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

Energy vessel sealant devices are associated with decreased risk of neck hematoma after thyroid surgery.

Postoperative neck hematomas following thyroidectomy occur in up to 6.5% of cases. It is unclear whether the use of energy vessel sealant devices effects the rate of PNH. We hypothesized use of an EVSD to be associated with decreased risk of PNH in patients undergoing thyroidectomy. The 2016-2017 American College of Surgeons Thyroidectomy database was queried for patients undergoing thyroidectomy with and without EVSDs. A multivariable logistic regression analysis was performed to evaluate for risk of PNH. From 11,355 patients undergoing thyroidectomy, an EVSD was used for 7460 (65.7%) patients. Age distribution was similar between the two groups (52 vs. 53-years old, p = 0.467). Compared to patients without EVSD used, patients with EVSD used had higher rates of comorbid hypertension (40.6% vs. 34.8%, p < 0.001) and diabetes (14.2% vs. 11.5%, p < 0.001); however, a lower rate of PNH (1.4% vs. 2.4%, p < 0.001). After adjusting for known risk factors for PNH including age, prior neck surgery, and comorbidities, EVSD use was associated with a decreased risk of PNH (OR 0.453, 95% CI 0.330-0.620, p < 0.001). The strongest associated risk factors for PNH were hypertension (OR 1.823, 95% CI 1.283-2.591, p = 0.001) and toxic goiter (OR 1.837, 95% CI 1.144-2.949, p = 0.012). When compared to standard vessel ligation, EVSD use was associated with a lower risk of PNH in patients undergoing thyroidectomy. The strongest associated risk factor for PNH was toxic goiter. Future prospective research is needed to confirm these findings and if corroborated, then increased use of an EVSD should be employed.

Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery: a nested case-control study

PurposePostoperative bleeding after thyroid surgery remains a potentially lethal complication. Outpatient thyroidectomy is an increasing trend in the high volume centers. There is a need to identify risk factors for postoperative bleeding in order to select proper patients for outpatient thyroidectomy. This study aimed to investigate this issue using a national population-based register.Material and methodA nested case-control study on patients registered in the Swedish national register for endocrine surgery (SQRTPA) was performed. Patients with postoperative bleeding were matched 1:1 by age and gender to controls. Additional information on cases and controls was obtained from attending surgeons using a questionnaire. Risk factors for postoperative bleeding were evaluated with logistic regression and are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The time of bleeding in relation to surgery was also investigated.ResultsThere were 9494 operations, and 174 (1.8%) of them involved postoperative bleeding. In the whole cohort, patients with postoperative bleeding were older, 58 (46–69) vs. 49 (37–62) years, than patients without, p < 0.01. Male patients had a higher risk of bleeding, OR 2.18 (95% CI 1.58–2.99). In the case-control cohort, drain was an independent risk factor for bleeding, OR 1.64 (1.05–2.57). Two-thirds of patients bled within 6 h after surgery. The incidence of bleeding after 24 h was 10%.ConclusionHigh age, male gender, and drain are independent risk factors for bleeding after thyroid surgery. Even with careful patient selection, prolonged observation might be necessary in thyroid surgery.

Association of Vessel-Sealant Devices vs Conventional Hemostasis With Postoperative Neck Hematoma After Thyroid Operations

Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied. To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma. This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups. The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay. One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24). Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.

Observation of stand-alone MC+polyether-ether-ketone (PEEK) Cage in anterior cervical double-level fusion for more than 2 years follow-up

To investigate the effectiveness of stand-alone MC+polyether-ether-ketone (PEEK) Cage (single blade type) in anterior cervical double-level fusion for more than 2 years follow-up. A clinical data of 30 patients who were treated with anterior cervical fusion surgery with stand-alone MC+PEEK Cage (single blade type) between January 2013 and December 2016 and followed up for more than 2 years, was retrospectively analyzed. There were 16 males and 14 females, aged from 34 to 72 years with an average of 52.2 years. There were 16 cases of cervical spondylotic myelopathy, 8 cases of cervical spondylotic myelopathy, and 6 cases of traumatic cervical disc herniation. The continuous double segments were C 4, 5, C 5, 6 in 12 cases and C 5, 6, C 6, 7 in 18 cases; and the disease duration ranged from3 days to 24 months (mean, 12 months). Postoperative neck hematoma and wound healing were observed; dysphagia was assessed by Bazaz system; and bone fusion was assessed by Suk method. Before operation, at 1 week after operation, and at last follow-up, the Japanese Orthopaedic Association (JOA) score was used to evaluate the neurological recovery; the cervical X-ray film was performed to record the cervical curvature (C 2-C 7 Cobb angle), the height of the intervertebral space of the fusion segment, and to judge the occurrence of the fusion Cage subsidence. No complication such as neck hematoma, incision infection, or esophageal fistula was found, primary healing of incisions was obtained in all cases. All patients were followed up 24-72 months (mean, 46 months). Neurological symptoms such as limb numbness and pain gradually disappeared after operation; during the follow-up period, the cervical curvature could be effectively maintained; dysphagia and internal fixation related complications such as displacement of Cages were not found. All patients obtained bony fusion from 3 to 8 months with an average time of 4.3 months. Compared with preoperative ones, the JOA score, intervertebral space height, and Cobb angle of cervical spine were significantly improved at 1 week after operation and at last follow-up ( P<0.05), but there was no significant difference between 1 week after operation and last follow-up ( P>0.05). The application of stand-alone MC+PEEK Cage (single card type) in anterior cervical fusion can provide early cervical stability, effectively maintain the physiological curvature of cervical spine and the height of fusion intervertebral space.

P.098 Primary closure versus expansile patch angioplasty for carotid endarterectomy: a single center series

Background: Carotid endarterectomy (CEA) is a common treatment option for patients presenting with carotid stenosis; however, the optimal method for arterial closure remains unclear. Therefore, we examined our single center series to compare primary closure versus patch angioplasty for carotid endarterectomy. Methods: We reviewed all patients who underwent CEA from 2008 to 2016. Closure method was entirely based on the surgeon style (i.e., all patients treated by vascular surgeons underwent patch angioplasty and all individuals managed by neurosurgeons undergone primary closure). Data were reported as frequencies and outcomes as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Results: A total of 713 patients were included (349 in the primary closure group and 364 in the patch group). Underlying baseline characteristics were similar between both groups. The risk of transient ischemic attack (OR, 7.08; 95%CI, 0.41-2.84; P=0.872), stroke (OR, 1.14; 95%CI, 0.58-2.22; P=0.697), myocardial infarction (OR, 1.10; 95% CI, 0.39-3.07; P=0.851), cranial nerve palsy (OR, 1.79; 95%CI, 0.65-4.91; P=0.248), and post-operative neck hematoma (OR, 1.04; 95%CI, 0.48-2.24; P=0.923) didn’t differ significantly between the two closure options. Conclusions: Our findings suggest that primary closure and expansile angioplasty have similar safety and efficacy profiles as treatment closure options among patients undergoing CEA.

Carotid Endarterectomy on Antiplatelet Agents in the Era of Point-of-Care Testing

The safety of carotid endarterectomy in patients with a response to antiplatelet agents (aspirin and clopidogrel) confirmed by point-of-care testing is unknown. Thus, we sought to determine whether using point-of-care assessment of platelet inhibition reveals risk factors for operative complications or predicts clinical outcomes. We reviewed records of carotid endarterectomy patients treated from March 2013 to July 2015 to extract demographics, lesion characteristics, laboratory data, procedural complications, and follow-up. Administration of aspirin, clopidogrel, or therapeutic anticoagulation within 5 days before surgery was recorded. We analyzed 79 patients with 86 lesions (mean age 70.9 ± 10.0 years). More patients with a P2Y12 reaction unit (PRU) <170 had neck hematomas (4/10, 40.0%) than those with a PRU ≥170 (2/9, 22.2%) (P= 0.63). Estimated blood loss ≥100 mL was more frequent among patients with PRU <170 (9/10, 90.0%) than among those with PRU ≥170 (5/9, 55.6%) (P= 0.09). Clopidogrel use, regardless of response, independently predicted neck hematoma in a logistic regression model, with increased odds of 8.5. Mean postoperative modified Rankin Scale scores did not differ statistically between clopidogrel users and nonusers at a mean follow-up of 108.5 ± 146.3 days (P= 0.27). Clopidogrel use within 5 days of carotid endarterectomy independently predicted postoperative neck hematomas, most of which were managed conservatively. Patients with PRU <170 were more likely to have estimated blood loss ≥100 mL during surgery and surgery lasting ≥3 hours.

Cervical hematoma following an endocrine surgical procedure: The MD Anderson experience

Airway compromise from postoperative neck hematoma remains the most feared complication after cervical endocrine operative procedures. Events are rare and potentially lethal, and clear multidisciplinary guidelines for management of these patients are lacking. The aim of our study was to review the experience of a tertiary cancer center in this scenario. Data prospectively collected over a 10-year period, between 2005 and 2014, were retrospectively analyzed. We included all adult patients who had had a neck operation and needed reoperation for postoperative neck hematoma after an endocrine procedure. We excluded pediatric patients and cases with incomplete records. The inclusion criteria were met for 21 patients (21/2,930; 0.7%). The median age at operation was 56.2years (SD: 16.7). The M:F ratio was 1:2. All 21 patients presented with a neck swelling at the time of reoperation. Eight of 21 patients (38%) underwent emergency bedside clot evacuation. Presentation was within 6hours for two thirds (14/21) of the patients; the remaining one third of the patients had the hematoma develop during the evening/night (from 1700-0500). The mean estimated hematoma size was 98cc (SD: 58). A source of bleeding was identified in 12 of 21 cases (57%). A total of 15.8% of patients had an airway classified as difficult/awkward under the American Society of Anesthesiologists classification for their wound re-exploration. Postoperation, increased vigilance is needed for the first 6hours to detect patients with neck swelling. Emergency drainage by the bedside was performed in 38% of patients. A difficult airway was uncommon in our series.

Does the Technique of Carotid Endarterectomy Determine Postoperative Hypertension?

Hypertension (HT) after carotid endarterectomy (CEA) is a risk factor for postoperative myocardial infarction, stroke, and neck hematoma. We compared the incidence of postoperative HT within the week after eversion CEA (e-CEA) and patch closure CEA (p-CEA). Postoperative HT was defined as a systolic blood pressure (sBP) ≥ 160 mm Hg and/or the need for postoperative vasodilatators. The aim of our study was to determine if the technique of CEA had an effect on postoperative HT. Between January 2010 and June 2011, we prospectively reviewed 560 consecutive endarterectomies (340 p-CEAs and 220 e-CEAs) performed in 443 patients under general anesthesia. All had >70% stenoses, 119 were symptomatic, and 441 asymptomatic. We compared preoperative, peroperative, and postoperative sBP and diastolic blood pressure, carotid sinus nerve block, postoperative intravenous and oral antihypertensive medications, neurologic and cardiac complications, and mortality. The e-CEA group had a higher incidence of women (36.4% vs. 21.8%, P = 0.0002) and HT (85.0% vs. 78.2%, P = 0.04). The e-CEAs had a significantly higher incidence of carotid sinus nerve block (93.6% vs. 15.6%, P < 0.0001). The incidence of postoperative HT was not significantly different between the 2 groups (75.9% in the e-CEA group versus 68.5% in the p-CEA group, P = 0.06). The average postoperative sBP between postoperative hour (H) 2 and H12 was significantly higher in the e-CEA group but <160 mm Hg. The sBP dropped between H2 and H6, and this decrease was greater in the p-CEA group (30% vs. 15% in the e-CEA group). The need for postoperative antihypertensive medication was not different between the 2 groups. One independent risk factor of postoperative HT was identified: history of HT. The rate of postoperative complications was not significantly different between the 2 groups. The e-CEA technique is not a risk factor and does not have an effect on postoperative HT. The postoperative sBP was more stable in this group. Eversion carotid endarterectomy has been considered, in the literature, as a risk factor of postoperative hypertension. We conducted a large prospective and comparative study of the endarterectomy technique by eversion and with conventional patch closure. The primary end point was the blood pressure value and the administration of antihypertensive treatment. Our study shows that postoperative hypertension after carotid endarterectomy is not related to the surgical technique. Changes in blood pressure after carotid endarterectomy by eversion are lower than those observed after conventional endarterectomy with patch closure. This technique prevents the occurrence of possible hypotension occurrence, which can be the cause of perioperative complications.

Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database.

Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations. To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery. Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database. Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma. We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4-2.1), male sex (OR = 1.3, 95% CI = 1.2-1.4), African-American race (OR = 1.5, 95% CI = 1.2-1.7), being from the South (OR = 1.3, 95% CI = 1-1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6-2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6-2.5), Graves disease (OR = 3, 95% CI = 2.1-4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8-3.9) were associated with a higher risk of neck hematoma. We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.

Impact of Surgeon Volume on Incidence of Neck Hematoma after Thyroid and Parathyroid Surgery: Ten Years’ Analysis of Nationwide In-patient Sample Database

The study's objective is to examine the impact of surgeon experience on the incidence and the severity of neck hematoma after thyroid and parathyroid surgery using a nationwide database. The Nationwide In-patient Sample is a nationwide clinical and administrative database. We used the International Classification of Diseases, 9th Revision diagnosis and procedures codes to identify adult patients who underwent thyroid and parathyroid surgery and subsequently developed neck hematoma. Patient and hospital characteristics were collected along with surgeon volume to predict patient outcomes. Surgical procedures were stratified into three groups according to surgeon volume: low (less than 10 operations), intermediate (10 to 99), and high (100 or more). We identified 147,344 thyroid and parathyroid surgery performed between 2000 and 2009 nationwide. Overall incidence of postoperative neck hematoma was 1.5 per cent (n = 2210). This was 2.1, 1.4, and 0.9 per cent among procedures performed by low-volume, intermediate-volume, and high-volume surgeons, respectively. After adjusting for other confounders, compared with procedures performed by low-volume surgeons, those performed by intermediate- (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.6 to 0.8; P < 0.01) and high-volume surgeons (OR, 0.5; 95% CI, 0.4 to 0.6; P < 0.01) were less to likely to develop neck hematoma. Surgeon experience is significantly associated with the development of neck hematoma after thyroid and parathyroid surgery.