Temporal fluctuations of post-tonsillectomy haemorrhage

Postoperative outcome of palatine tonsillectomy by tonsil pillar suture with knot-free suture

BACKGROUND

Postoperative haemorrhage following palatine tonsillectomy occurs in 5-14% of cases. Since 2021, our department has used knot suturing with 3-0 Vicryl, and from 2023, continuous suturing with the V-Loc™ closure device to reduce suture time. While knot suturing is reported to reduce postoperative bleeding and pain, no studies have compared outcomes between different suture methods.

AIMS

This study retrospectively analysed postoperative bleeding, pain, and complications in 125 patients undergoing palatine tonsillectomy, with or without sutures.

METHODS

Patients aged ≥15 years who underwent bilateral tonsillectomy from October 2019 to March 2024 were grouped into no-suture, knot-suture, and knot-free-suture categories. Data on operative time, pain, bleeding, suture dissection, and complications were compared using the Mann-Whitney U test for continuous variables and the chi-square test for nominal variables.

RESULTS

Knot-free sutures had the shortest operative time (53 ± 16 min) compared to no sutures (62 ± 19 min) and knot sutures (94 ± 22 min). Pain decreased over time across all groups. Bleeding rates were similar, though knot-free sutures required frequent removal (76%). Knot sutures had a significantly lower dissection rate (<0.001).

CONCLUSIONS AND SIGNIFICANCE

Knot-free sutures improve surgical efficiency but may require additional postoperative interventions, representing a cost-effective alternative to high-energy devices.

Comparison of Post-Tonsillectomy Hemorrhage Rate After Different Tonsillectomy Techniques: Systematic Review and Meta Analysis

Introduction: Post-tonsillectomy hemorrhage is a serious complication that varies according to the surgical technique used, potentially compromising patient safety and recovery. Even though several techniques were frequently used, including cold steel dissection, coblation, monopolar diathermy, and bipolar diathermy, there were certain discrepancies in hemorrhage rates in the literature. This meta-analysis aims to compare the rates of primary and secondary hemorrhage among these surgical techniques, with a focus on guiding clinical decision-making. Methodology: A total of 12 studies, published between 2005 and 2024, were selected from the PubMed, Web of Science, Scopus, and Cochrane Library databases, comprising 1684 participants from both pediatric and adult groups. Primary and secondary hemorrhage rates, surgical techniques, and study characteristics were extracted as data. Therefore, the aim of performing this meta-analysis with random-effects models was to calculate pooled estimates for hemorrhage rates and the heterogeneity index (I2). The techniques studied included cold steel dissection, coblation, monopolar diathermy, and bipolar diathermy. Results: The pooled primary hemorrhage rate across all techniques was 1.0% (95% Cl: 0.5-1.4%), with insignificant heterogeneity (I2 = 0.0%, p < 0.665). By contrast, pooled secondary hemorrhage occurred at a rate of 5.8% (95% CI: 3.9-7.6%). Cold steel tonsillectomy was associated with the lowest secondary hemorrhage rate of 3.7% (95% CI: 0.8-6.6%, I2 = 43.558%, p = 0.115), while bipolar diathermy had the highest secondary hemorrhage rate of 8.6% (95% CI: 2.3-15.0%, I2 = 86.448%, p < 0.001). Conclusions: This meta-analysis underscores the considerable variability in rates of post-tonsillectomy hemorrhage frequency among various surgical techniques. Cold steel dissection appears to be the safest regarding secondary hemorrhage, while coblation likely minimizes primary bleeding. Bipolar diathermy comes across as the technique with the highest risk for primary hemorrhage and requires special caution during its use. Such results emphasize the need for careful selection of the surgical technique concerning patients' particular conditions and the need to enhance care periods to reduce the bearing of any hemorrhagic complications.

Hemorrhage risk after coblation tonsillectomy in Chinese pediatric: a multicenter, prospective, observational cohort study

OBJECTIVES

The study aimed to assess the incidence of post-coblation tonsillectomy hemorrhage (PCTH) and identify associated risk factors in a pediatric Chinese population.

METHODS

This prospective, multicenter cohort study, conducted over 17 months, included 8854 pediatric patients who underwent coblation tonsillectomy across 15 research centers in China. Patient data were collected through an Electronic Data Capture (EDC) system. The primary outcome was the incidence of PCTH within 21 days post-surgery. Secondary outcomes involved analyzing risk factors for PCTH using multivariable logistic regression.

RESULTS

The incidence of PCTH was 1.99%, with 176 patients experiencing hemorrhage. Significant risk factors included abnormal coagulation indicators (OR 10.56), longer surgery duration (OR 1.02), simultaneous adenoidectomy (OR 0.35), semi-liquid diet (OR 0.13), postoperative cough (OR 1.76), and the use of hemostatic agents (OR 1.58), intravenous antibiotics (OR 2.34), and painkillers (OR 2.33). Regional variations showed lower hemorrhage rates in East, Southwest, Central, and South China compared to North China.

CONCLUSIONS

The study found that the hemorrhage rate after coblation tonsillectomy is comparable to traditional tonsillectomy. Risk factors include coagulation status, surgical duration, and postoperative care. Regional differences in hemorrhage rates suggest the need for tailored approaches based on location. Coblation tonsillectomy is a safe and effective procedure for pediatric patients. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: This study was registered on Clinical trials.gov (NCT05206799), and approved by the Ethics Committee of Shanghai Children's Hospital, Shanghai Jiaotong University (2021R096-E01).

Time-related variations in viability of random pattern skin flaps: An experimental study in rats

Chronobiological variations are in the fabric of life. The first ideas regarding the possible effects of circadian rhythm on surgical outcomes were published in the early 2000s. Some studies support and oppose this idea. The lack of experimental evidence in a controlled setting has led to this study. This study aimed to explore the chronobiological implications of surgical outcomes. The rats were divided into four groups. A random pattern dorsal skin flaps were elevated in all groups at six h intervals. Flap necrosis rates and melatonin, oxidant, and antioxidant factors were studied. Flap survival was better in the 06:00 h group. The flap necrosis was higher in the 18:00 h group. Some of the biochemical parameters displayed circadian variations. As an independent variable, the time of surgical intervention changed the flap survival rates. It should be noted that the study was held in a nocturnal animal model thus the pattern of flap survival can be in reversed fashion in a clinical scenario. This study is the first experimental evidence for "Chronosurgery" in a controlled setting. Further studies in all aspects of surgical disciplines are required.

Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding

Background: Tonsillectomy and/or adenoidectomy (T/A) are common surgical procedures. Postoperative uncontrolled bleeding is a well-established complication; however, the relation between certain variables and uncontrolled bleeding are unclear. Methods: We explored the Pennsylvania Patient Safety Reporting System database for event reports that described a patient who had a T/A procedure and later returned to surgery to control bleeding. We analyzed the post-T/A bleeding events according to numerous variables, such as patient sex and age, timing of the bleed, procedure performed (i.e., tonsillectomy and/or adenoidectomy), and bleeding site. Results: We identified 219 event reports from 56 healthcare facilities over a four-year period. The study revealed that 78% of the patients were discharged and then returned to surgery to control bleeding. Patients ranged in age from 1–45 years and 53% were female. Among the 219 events, 41% were a primary bleed (0–1 postoperative days) and 59% were a secondary bleed (2–30 postoperative day). Additionally, 0–1 days and 6–7 days after operation were the periods when patients most frequently returned to surgery (range of 0–30 days). We expanded upon much of the previous research by exploring the relation between patient age and days postoperative return to surgery. We found that a majority of patients in age categories 1–10, 11–20, and 21–30 years had a secondary bleed; in contrast, a majority of patients age 31–45 had a primary bleed. Conclusion: Our findings indicate that the post-T/A timing of uncontrolled bleeding may vary systematically as a function of patient age; however, future research is needed to better understand this topic. We encourage readers to use our findings, along with findings from previous research, to inform their practice and strategies to mitigate risk of patient harm.