Objective: To evaluate postoperative hemorrhage following transoral resection of oropharyngeal squamous cell carcinoma with associated risk factors and preventative measures.

Design: Multi-institution, retrospective chart review

Setting: Tertiary academic referral center, level of evidence: 2b

Patients: 906 patients treated with transoral surgery for oropharyngeal squamous cell carcinoma between 1994 and 2012 were analyzed for postoperative bleed. Tumor stage, previous treatment (surgery or radiation), resection method (laser, robot, cautery), and concomitant transcervical external carotid system ligation were analyzed in relationship to bleed presence and severity. Presentation and management of postoperative bleed was evaluated. Severity of bleed was graded as minor, major, severe, or catastrophic based on bleed control method and related sequellae.

Results: Postoperative bleed occurred in 5.4% (49/906) of patients with 32.7% (16/49) managed conservatively and 67.3% (33/49) requiring operative intervention. Transcervical external carotid system vessel ligation was performed with the primary resection in 15.6% of patients with no significant bleed rate difference between ligated (6.7%) and non-ligated (5.5%) groups (p= 0.213). Vessel ligation was performed more frequently in higher T-stage patients (p= 0.002); specifically T4 vs. T1 (p= 0.0014) and T3 vs. T1 (p= 0049). Intraoperative vessel ligation did not affect bleed severity. (p= 0.526) Numbers of severe bleeds were small (n=10), only one occurred in a ligated patient.
No increase in postoperative bleed rate was seen in previously treated patients (7.8%) compared to previously untreated patients (5.4%) (p= 0.511). Bleed rates were similar between laser (5.6%) and robotic (5.9%) oropharyngectomy (p= 0.799) however, significantly larger T-stages were treated with laser surgery vs. robot (T3 vs. T1 & T3 vs. T2; p< 0.0001).
Larger T-stage tumors had a higher bleed rate (p= 0.015); specifically T4 vs. T1 (p= 0.0014) and T3 vs. T1 (p= 0049). No difference in bleed severity was found between T-stages (p= 0.34). Male patients were more likely to have a bleed requiring operative intervention (p= 0.018).

Conclusions: Transcervical external carotid system vessel ligation performed at the time of primary oropharyngectomy does not decrease postoperative bleed rate, however, large T-stage tumors bleed more frequently and tend to be ligated more frequently. For larger T-stage tumors or previously treated patients, simultaneous vessel ligation should be considered and may reduce the severity of a severe bleed. Procedure method (laser vs. robot) does not alter bleed rate. Male gender is correlated with increased bleed severity.