Post-tonsillectomy hemorrhage—some facts will never change

Abstract

Bleeding remains the most significant complication following tonsillectomy (TE), sometimes requiring revision surgery under general anesthesia. This study was undertaken to verify whether or not bleeding rates changed after bipolar coagulation was replaced by suture ligation to achieve hemostasis at a single institution. The charts of all patients who had undergone tonsillectomy between April 1, 2007, and April 30, 2013, at our institution were reviewed. The tonsils were bluntly dissected with scissors and a rasp. While hemostasis was achieved with bipolar coagulation during the first 36 months (group A), this method was replaced after a transition period of 1 month by intraoperative suture ligation (group B) during the last 36 months. Group A encompassed 2,137 patients including 963 children scheduled for adenotonsillectomy (ATE), and group B consisted of 1,521 patients and included 435 ATE cases. Bleeding from the tonsillar wounds occurred in 111/2,137 group A (5.2 %) and 68/1,521 group B patients (4.5 %). The difference was not found to be significant (p = 0.317). The incidence of primary bleeding (PB) and secondary bleeding (SB) was significantly (p = 0,000) associated with the method to achieve hemostasis: PB prevailed in group B and SB prevailed in group A. The overall incidence of post-tonsillectomy hemorrhage (PTH) varied at different ages, but the difference was not significant in group A (p = 0.401) and group B (p = 0.661). Repeated episodes of PTH occurred in 11/111 group A (9.9 %) and 8/68 group B (11.7 %) patients. The statistical difference was not found to be significant (p = 0.725). However, there were significantly more male patients with bleeding complications in both groups. Despite the strongest efforts to avoid it, the potential risk of PTH remains a fact to be accepted by surgeons and patients. An increased surgical precision achieved by introduction of a surgical microscope as well as replacing bipolar cautery by suture ligation to achieve hemostasis could only reduce the overall rate of PTH. Another fact remains unchanged: PB occurs predominantly when electrosurgical means are avoided and SB prevails, whenever surgeons use them. We will continue our research on refined methods of cold steel microsurgical TE including suture techniques.

Post-tonsillectomy bleeding: Our 10-year experience

“…[1,6,8,12] Bazı yazarlar primer kanamaların daha sık olduğunu belirtirken, aksini savunan yazarlar da vardır. [1,13] Kanama ciddiyeti açısından da sekonder ve primer kanamalar ile ilgili farklı görüşler söz konusudur fakat her iki durumda da mortalite ile karşılaşılabilmekte-dir. [1] Kliniğimize başvuran hastaların çoğunda sekonder kanama vardı.…”

“…Sekonder kanamalara çalışmamızda en fazla 5-10. günler arasında rastlandı. Sekonder kanamaların pik yaptığı günler 5-12 [14] ve ilk on gün [5,13] olarak vurgulanmaktadır. Sekonder kanamalara literatürde 54. güne kadar rastlanabilirken, [2] çalışmamızda bir hasta ameliyat sonrası 60. günde kanama yakınmasıyla başvurdu.…”

Secondary tonsillar hemorrhage requiring surgical intervention: Analysis of 1429 tonsillectomy cases on single surgeon experience

“…When we compared the dissection and snare method with bipolar dissection, although the percentage of second hemorrhage required in the bipolar dissection is not statistically significant, it can be explained by the more intensive use of the hot instrument in bipolar technique. In fact, it is stated in the literature that the use of hot instrumentation increases the hemorrhage and the use of bipolar technique to only control hemorrhage has moderate risk (17,19). On the other hand, secondary hemorrhage requiring a second surgery has a decline in percentage in monopolar dissection.…”

Wieviel Tonsillektomie darf es noch sein?

“…Wird auf elektrochirurgische Maßnahmen bei der Dissektion oder intraoperativen Blutungsstillung verzichtet, ist die intraoperative Übersicht wegen des Blutaustritts eingeschränkt und es scheinen sich vor allem Primärblutungen (bis 24 h nach OP) zu ereignen. Optische Vergrößerungshilfen (OP-Mikroskop) lassen nach einer Eingewöhnungsphase den Operateur exakter präparieren und scheinen revisionsp ichtige Nachblutungen zu reduzieren [16,17,18].…”

“…Diverse multizentrische Studien belegen, dass sich bisher keine einheitliche OP-Methode in Europa durchsetzen konnte [17,19,20].…”