Post-thyroidectomy bleeding: analysis of risk factors from a national registry

Abstract

Background Post-thyroidectomy haemorrhage occurs in 1–2 per cent of patients, one-quarter requiring bedside clot evacuation. Owing to the risk of life-threatening haemorrhage, previous British Association of Endocrine and Thyroid Surgeons (BAETS) guidance has been that day-case thyroidectomy could not be endorsed. This study aimed to review the best currently available UK data to evaluate a recent change in this recommendation. Methods The UK Registry of Endocrine and Thyroid Surgery was analysed to determine the incidence of and risk factors for post-thyroidectomy haemorrhage from 2004 to 2018. Results Reoperation for bleeding occurred in 1.2 per cent (449 of 39 014) of all thyroidectomies. In multivariable analysis male sex, increasing age, redo surgery, retrosternal goitre and total thyroidectomy were significantly correlated with an increased risk of reoperation for bleeding, and surgeon monthly thyroidectomy rate correlated with a decreased risk. Estimation of variation in bleeding risk from these predictors gave low pseudo-R2 values, suggesting that bleeding is unpredictable. Reoperation for bleeding occurred in 0.9 per cent (217 of 24 700) of hemithyroidectomies, with male sex, increasing age, decreasing surgeon volume and redo surgery being risk factors. The mortality rate following thyroidectomy was 0.1 per cent (23 of 38 740). In a multivariable model including reoperation for bleeding node dissection and age were significant risk factors for mortality. Conclusion The highest risk for bleeding occurred following total thyroidectomy in men, but overall bleeding was unpredictable. In hemithyroidectomy increasing surgeon thyroidectomy volume reduces bleeding risk. This analysis supports the revised BAETS recommendation to restrict day-case thyroid surgery to hemithyroidectomy performed by high-volume surgeons, with caution in the elderly, men, patients with retrosternal goitres, and those undergoing redo surgery.

Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study

“…Morbidity is mainly represented by hypoparathyroidism, recurrent laryngeal nerve injury, cervical haematoma and wound infection. These complications lead to a reduction in the quality of life of the patients and increased costs for healthcare systems [24][25][26][27][28][29][30][31][32][33].…”

Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery

“…Postoperative haemorrhage is a well‐recognised complication of thyroid surgery with an incidence between 0.45% and 4.2% [ 1 , 2 , 3 , 4 ]. Rapid haematoma formation, even with small volumes, can result in significant airway obstruction requiring emergency intervention.…”

“…Several factors have been associated with an increased risk of haematoma following thyroid surgery including increasing age and male sex, but the patterns and individual risk factors have been shown to be unpredictable [ 4 , 26 ]. However, any recognised risk factors should be considered when determining appropriate postoperative monitoring and subsequent management strategies.…”

“…Some units offer day‐case thyroid surgery [ 4 , 71 ]. Discussion on the suitability of thyroidectomy as a day‐case procedure falls outside the scope of these guidelines.…”

“…There are more than 11,000 thyroid procedures performed annually in England alone and >150,000 in the USA; the scale of peri‐operative adverse events in this cohort is substantial [ 22 , 23 ]. Postoperative haemorrhage is a well‐recognised complication of thyroid surgery, with an incidence between 0.45% and 4.2%, which has not been reducing over time [ 1 , 2 , 3 , 4 ]. Evidence suggests that subsequent haematoma formation leads to acute airway compromise necessitating emergency bed‐side intervention in up to a quarter of these patients [ 24 , 25 ].…”