Evaluation of a Continuous High Negative Pressure Suction Device in Treating Postoperative Thyroid Bleeding: A Retrospective Cohort Study

Evaluation of a Continuous High Negative Pressure Suction Device in Treating Postoperative Thyroid Bleeding: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of a Continuous High Negative Pressure Suction Device in Treating Postoperative Thyroid Bleeding: A Retrospective Cohort Study Xi Zhu, Lei Zhu, Bin Zhou, Zhouting Li, Yong Wu, Feng Cheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9189427/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background Postoperative hemorrhage, although infrequent, represents a potentially life-threatening complication subsequent to thyroidectomy, frequently leading to acute airway obstruction. Conventional negative pressure drainage (NPD) systems may prove inadequate in instances of rapid hemorrhage due to catheter occlusion by thrombi. This study assessed the effectiveness of a continuous high negative pressure suction device (CHNPD) in the management of suspected postoperative bleeding and its impact on decreasing the incidence of urgent reoperations. Methods A retrospective analysis was performed on a cohort of 5,251 patients who underwent thyroid surgery between 2015 and 2024. Of these, 126 patients exhibiting clinical indicators of postoperative hemorrhage, such as a sudden increase in drainage volume or neck swelling, were selected for further study. Based on the intervention strategies employed at the time of hemorrhage occurrence, patients were categorized into two groups: the conventional negative pressure drainage group (NPD, n = 45) and the continuous high negative pressure drainage group (CHNPD, n = 81). The primary outcome measure was the rate of emergency reoperation. Additionally, subgroup analyses were conducted according to pathological type (benign versus malignant) and surgical approach (laparoscopic versus open). Results The baseline characteristics of the two groups were comparable (P > 0.05). The reoperation rate in the CHNPD group was significantly lower than that in the NPD group (11.1% vs. 26.7%; P = 0.023). Subgroup analysis indicated that CHNPD was particularly effective in malignant cases involving lymph node dissection, reducing the reoperation rate from 32.0% to 9.4%. During reoperation, it was observed that the NPD group experienced a higher incidence of "diffuse bleeding" due to the failure of conservative treatment, necessitating surgical intervention. In contrast, CHNPD effectively managed such bleeding, enabling surgical exploration to concentrate more precisely on the specific arterial bleeding points. No complications associated with high-pressure suction were reported. Conclusion The prompt implementation of Closed Hemostatic Negative Pressure Drainage (CHNPD) following thyroid surgery for suspected hemorrhage constitutes a safe and cost-effective intervention. By ensuring unobstructed drainage and mitigating hematoma tension, CHNPD substantially decreases the incidence of unnecessary re-exploratory surgeries, particularly in cases of diffuse venous or capillary bleeding. Nonetheless, clinicians must maintain vigilance regarding the potential occurrence of arterial bleeding. Continuous negative pressure Thyroidectomy Postoperative complications Postoperative hemorrhage Figures Figure 1 Figure 2 1. Introduction Postoperative hemorrhage (POH) represents one of the most severe and potentially life-threatening complications associated with thyroid surgery, with an incidence rate ranging from approximately 0.53% to 4.2% [ 1 – 3 ]. Despite its relatively low occurrence, the confined anatomical space of the neck can lead to the rapid development of hematomas, resulting in acute airway compression and asphyxia within minutes. Approximately 25% of affected patients necessitate additional surgical intervention [ 2 , 4 , 5 ], which not only inflicts significant distress upon patients but also heightens the risk of postoperative hypoparathyroidism, incision infection, extended hospital stays, and increased demands on nursing care. Consequently, effective management of drainage is imperative, not only for the monitoring of bleeding but also for the prevention of tensional hematoma formation due to blood accumulation. In current clinical practice, the prevalent method employed is normal pressure drainage (NPD), which typically involves the use of a closed drainage ball with a negative pressure of approximately 5 kPa. However, numerous studies have indicated that the effectiveness of traditional NPD is frequently compromised in scenarios involving rapid or continuous bleeding. In such cases, blood clots can obstruct the drainage tube, creating a "false sense of security." This occurs when the externally observed drainage volume is minimal, while a tensional hematoma is developing within the deeper neck tissues, thereby obscuring the true extent of bleeding. To maintain the patency of the drainage tube and facilitate the closure of dead space, continuous high negative pressure drainage (CHNPD) is often employed in surgical disciplines, such as abdominal surgery. This approach aims to enhance granulation tissue proliferation, reduce the risk of infection, and minimize anastomotic leakage [ 6 – 8 ]. While CHNPD presents potential advantages, its application in thyroid surgery remains a subject of considerable debate. Proponents assert that the increased pressure can efficiently manage diffuse venous bleeding and inhibit hematoma formation [ 9 ]. Conversely, critics express concerns that employing high negative pressure suction postoperatively may inflict additional harm on surrounding soft tissues, including nerve damage or potential injury to major blood vessels [ 10 – 11 ]. At present, there is a paucity of high-quality studies that rigorously compare the clinical efficacy and safety of NPD and CHNPD in managing suspected postoperative bleeding following thyroid surgery. This study conducted a retrospective analysis of clinical data from 5,251 patients to investigate the effects of early implementation of Controlled Hypotensive Neck Pressure Drainage (CHNPD) on clinical outcomes following the onset of Postoperative Hemorrhage (POH) indicators, such as a sudden increase in drainage volume and neck swelling. The primary research objectives are as follows: (1) To evaluate whether CHNPD effectively reduces the incidence of emergency reoperations; (2) To examine the differential benefits of CHNPD across various surgical techniques, specifically open versus laparoscopic procedures, and across different pathological types; (3) To assess the incidence of complications to determine the safety of CHNPD when applied at a pressure range of 20–40 kPa. 2. Methods 2.1 Research Subjects and Design A retrospective analysis was performed on the clinical data of 5,251 patients who underwent thyroid surgery at the Head and Neck (Thyroid) Surgery Department of Lishui Central Hospital between December 2015 and October 2024. The inclusion criteria were as follows: (1) a sudden increase in the volume of neck drainage fluid, characterized by bloody discharge or the presence of blood clots (an increase of 20 ml or more than 50 ml/h), and (2) progressive neck swelling accompanied by symptoms of airway compression. Meeting one or more of these criteria was indicative of clinical consideration for postoperative bleeding following thyroid surgery. Ultimately, 126 patients who experienced postoperative thyroid bleeding necessitating either conservative management or reoperation were included in the study (Fig. 1 ).One patient who underwent parathyroid surgery and another diagnosed with Mardelein disease who subsequently underwent neck surgery were excluded from the study. The cohort comprised 52 males and 74 females, with a mean age of 47.51 ± 13.65 years. Patients experiencing postoperative thyroid bleeding were categorized into two distinct groups: the ordinary negative pressure drainage group (NPD) and the continuous high negative pressure drainage group (CHNPD).The electronic medical records of each patient were comprehensively analyzed, encompassing fundamental data, histological information, perioperative details, and laboratory reports. The database parameters included gender, preoperative thyroid-stimulating hormone (TSH) levels, preoperative hormonal status (categorized as hypothyroidism, euthyroidism, or hyperthyroidism), timing of bleeding detection, drainage volume, anticoagulant usage, maximum thyroid tumor diameter, presence of Hashimoto's thyroiditis, number of surgical sites, pathological classification (benign or malignant tumor), performance of lateral cervical lymph node dissection, and whether laparoscopic surgery was conducted. A 30-day postoperative follow-up was conducted for all patients to assess delayed bleeding or other complications. This study received approval from the Ethics Committee of Lishui Central Hospital, and informed consent was obtained from all patients and their families for inclusion in the study. 2.2 Surgical methods and intervention measures All surgical procedures were conducted by seasoned surgeons employing standard techniques, either open or laparoscopic. Hemostasis was accomplished intraoperatively utilizing bipolar electrocoagulation or an ultrasonic scalpel. Upon completion of the surgery, a silicone drainage tube was positioned in the thyroid bed. Patients were categorized into two groups based on the intervention strategies implemented upon the initial appearance of bleeding signs. 2.2.1. NPD After the operation, the wound indwelling drainage tube was connected to an ordinary NPD ball (model: BDA-YS-0200) with a 200 mL capacity. The maximum negative pressure of 5 kPa could be produced when the ball is collapsed. 2.2.2. CHNPD The ordinary NPD ball was connected to a central negative pressure suction device with a 3500 mL capacity (Fig. 2 B) through a glass straw (Fig. 2 C), and the negative pressure value was adjusted to 20–40 kPa (Fig. 2 A). Our treatment plan was routine indwelling of the ordinary NPD ball after the operation, which was replaced with continuous high negative pressure suction when suspected bleeding signs appear until reoperation or the bleeding stops. 2.2.3. Reoperation Progressive worsening of the bleeding or neck swelling under conservative treatment, dyspnea, and laborious ventilation necessitated suspending the conservative treatment plan and reoperating in time for intervention. We opened the incision under local or general anesthesia, initially removed the accumulated blood clots, then flushed and removed the blood clots in the tissue space with normal saline. We carefully looked for the bleeding point (recording the bleeding site) and ligated or sutured it. After hematoma removal, routine indwelling drainage and antibiotics were used to prevent infection. 2.3 Data collection and follow-up Analyze the statistical data pertaining to the patients, including their preoperative TSH levels, anticoagulant usage, tumor sizes, and surgical specifics (such as lymph node dissection status and the comparison between laparoscopic and open surgical procedures). The primary outcome measure is the reoperation rate. All patients were monitored for 30 days postoperatively to assess delayed bleeding or other complications, including recurrent laryngeal nerve injury, parathyroid injury, and wound infection. 2.4 Statistical analysis Statistical analyses were performed utilizing SPSS version 26.0. Continuous variables were assessed through the application of the t-test or the Mann-Whitney U test, while categorical variables were examined using the chi-square test or Fisher's exact test. Subgroup analyses were conducted to evaluate the effects based on pathological type (benign versus malignant) and surgical method (laparoscopic versus open). A P-value of less than 0.05 was considered indicative of statistical significance. 3. Results 3.1 Basic Information The study included a total of 126 patients who met the suspected POH criteria, comprising 52 males and 74 females, with a mean age of 47.51 ± 13.65 years. Pathological analysis revealed that 82 cases were malignant tumors, while 44 cases were benign tumors. The cohort was divided into two groups: 45 patients in the NPD group and 81 patients in the CHNPD group. As detailed in Table 1 , no statistically significant differences were observed between the CHNPD and NPD groups with respect to gender, age, bleeding time, drainage fluid, preoperative TSH levels, preoperative thyroid function status, history of anticoagulant use, current anticoagulant use, maximum tumor diameter, presence of Hashimoto's disease, or the number of surgical sides (P > 0.05). Additionally, an analysis of the necessity for conservative or surgical intervention for postoperative bleeding among all postoperative patients indicated no statistically significant difference in the rate of postoperative bleeding between the CHNPD and NPD groups (P > 0.05), suggesting that the likelihood of postoperative bleeding following thyroid surgery did not differ between the two groups (refer to Table 2 ). Table 1 Comparison of Baseline Clinical Characteristics Between NPD and CHVS Groups Characteristics NPD Group (n = 45) CHNPD Group (n = 81) /t/Z/Fisher P Gender, n (%) 1.819 0.177 Male 15(33.3%) 37(45.7%) Female 30(66.7%) 44(54.3%) Age (years),x¯±s 49.29 ± 12.40 46.53 ± 14.28 1.087 0.279 Time to Bleeding(h), M(Q1, Q3) 13.5(3.25, 16.5) 8(4.5, 17) -0.311 0.756 Drainage Volume(ml), M(Q1, Q3) 119(81, 162.5) 116(90, 173.5) -0.346 0.729 Preoperative TSH, M(Q1, Q3) 1.52(0.58, 2.52) 1.72(1.06, 2.3) -1.064 0.287 Preoperative Thyroid Status, n (%) 4.906 0.088 Euthyroid 38(84.4%) 74(91.4%) Hyperthyroidism 4(8.9%) 7(8.6%) Hypothyroidism 3(6.7%) 0(0.0%) Anticoagulant Use History, n (%) 1.291 0.256 Use 3(6.7%) 1(1.2%) Not in Use 42(93.3%) 80(98.8%) Whether to continue using anticoagulants at present, n (%) 3.628 0.237 Aspirin 1(2.2%) 1(1.2%) Heparin 2(4.4%) 0(0.0%) Non 42(93.3%) 80(98.8%) Tumor Diameter(mm), M(Q1, Q3) 20(8, 40.5) 10(5.5, 22.5) -1.841 0.066 Hashimoto's Thyroiditis, n (%) 2.635 0.105 Yes 12(26.7%) 12(14.8%) No 33(73.3%) 69(85.2%) Surgical Scope, n (%) 2.174 0.337 Bilateral 29(64.4%) 45(55.6%) Unilateral 16(35.6%) 36(44.4%) Table 2 Comparison of postoperative bleeding NPD Group (n = 1813) CHNPD Group (n = 3438) P Postoperative hemorrhage 45 (2.5%) 81 (2.4%) 0.081 0.777 3.2 Comparison of Reoperation Rates The primary outcome measure for this study was the rate of emergency reoperation. Additionally, we investigated the necessity for emergency reoperation following the implementation of different drainage methods post-bleeding. The analysis revealed a statistically significant difference in reoperation rates between the CHNPD group and the NPD group (P < 0.05). Specifically, among the 45 patients in the NPD group, 12 cases (26.7%) required reoperation, whereas only 9 cases (11.1%) in the CHNPD group underwent surgical exploration. The reoperation rate in the CHNPD group was significantly lower than that in the NPD group (χ² = 5.138, P = 0.023) (refer to Table 3 ) Table 3 Comparison of Reoperation Rates and Subgroup Analysis Groups / Subgroups NPD Group(n = 45) CHNPD Group (n = 81) P-value Overall Reoperation Rate 12 (26.7%) 9 (11.1%) 5.138 0.023 Pathology - Malignant 10/27 (37.0%) 5/53 (9.4%) 7.234 0.007* - Benign 2/18 (11.1%) 4/28 (14.3%) - 1.000 Surgical Approach - Open Surgery 11/39 (28.2%) 7/65 (10.8%) 4.032 0.045* - Endoscopic 1/6 (16.7%) 2/16 (12.5%) - 1.000 *P < 0.05. 3.3 Subgroup Analysis To further assess the efficacy of CHNPD, we performed a subgroup analysis based on pathological type (malignant vs. benign). Among patients with malignant tumors, the reoperation rate was 32.0% (8/25) in the NPD group and 9.4% (5/53) in the CHNPD group, with the difference being statistically significant (P < 0.05). In contrast, for patients with benign conditions, the reoperation rates were 11.1% (2/18) in the NPD group and 14.3% (4/28) in the CHNPD group, with no statistically significant difference observed. Regarding the surgical method (open vs. laparoscopic), CHNPD significantly decreased the reoperation rate in open surgeries compared to NPD (10.8% vs. 24.3%). In laparoscopic surgeries, the reoperation rates were 12.5% for the CHNPD group and 16.7% for the NPD group, as detailed in Table 3 . 3.4 Findings from the Reoperation Exploration In the cohort of patients who required reoperation, the etiology of hemorrhage was determined. Within the NPD group, 16.7% (2 out of 12) of cases exhibited "diffuse bleeding," with no distinct arterial bleeding sites identified. Conversely, in the CHNPD group, all reoperation cases revealed specific arterial and venous branches, such as the superior and inferior thyroid artery branches, as the sources of hemorrhage. These findings indicate that CHNPD is effective in managing diffuse capillary bleeding, thereby reducing the need for additional surgical interventions for non-arterial bleeding sources (refer to Table 4 ). Table 4 Analysis of Bleeding Sources Identified During Reoperation Bleeding Source NPD Group(n = 45) CHNPD Group (n = 81) Findings Details Diffuse Oozing 2 (16.7%) 0 (0.0%) CHNPD effectively controls non-arterial oozing Specific Vessel 10 (83.3%) 6 (66.7%) Targeted intervention for active arterial bleeders - Superior/Inferior Artery 3 2 - Other Small Vessels 7 4 Unknown / Hematoma 0 (0.0%) Deep clots cleared with no active bleeder found Table 5 Comparison of Postoperative Complications and Safety Indicators [n (%)] (A) Comparison of postoperative complications among different groups (NPD vs. CHNPD) complication NPD Group(n = 45) CHNPD Group (n = 81) χ2/F P-value recurrent nerve injury 3 (6.7%) 5 (6.2%) 0.012 1.000 parathyroid injury 6 (13.3%) 5 (6.2%) 1.884 0.198 wound infection 9 (20.0%) 5 (6.2%) 6.046 0.035* *P < 0.05. (B) Analysis of Complications from Different Treatment Methods (Expectant treatment Group vs. Reoperation Group) complication Expectant treatment Group(n=105) Reoperation Group (n=21) OR P-value recurrent nerve injury 4 (3.8%) 4 (19.0%) 6 0.027* parathyroid injury 4 (3.8%) 7 (33.3%) 12.63 < 0.001* wound infection 0 (0.0%) 14 (66.7%) - < 0.001* *P < 0.05. 3.5 Analysis of Complications and Safety Indicators after POH During the 30-day postoperative follow-up period, no instances of rebleeding were observed among the patients. The safety assessment of the POH intervention, as detailed in Table 5 A, revealed the following: Comparative analysis between groups indicated no statistically significant difference in the incidence of recurrent laryngeal nerve injury (6.7% vs. 6.2%, P = 1.000) or parathyroid gland injury (13.3% vs. 6.2%, P = 0.198) between the NPD and CHNPD groups, thereby affirming the safety of high negative pressure aspiration. Notably, the rate of incision infection was significantly lower in the CHNPD group compared to the NPD group (6.2% vs. 20.0%, P = 0.035). Comparison of Treatment Modalities: A more detailed analysis, as presented in Table 5 B, reveals that reoperation constitutes a primary risk factor for the development of complications. Specifically, the incidence of parathyroid injury was significantly elevated in patients undergoing reoperation compared to those receiving conservative treatment (33.3% vs. 3.8%, P < 0.001). Similarly, the incidence of incision infection was markedly higher in the reoperation cohort (66.7% vs. 0%, P < 0.001). Additionally, there was a notable upward trend in the risk of recurrent laryngeal nerve injury among patients in the reoperation group (19.0% vs. 3.8%, P = 0.027). 4. Discussion The potential gap in the deep fascia of the neck is relatively narrow. When a hematoma forms rapidly after thyroid surgery, even if its volume is very small, it may lead to increased pressure, which may compress the trachea and cause dyspnea and even suffocation to some extent, endangering life in severe cases[ 12 ].In this study, the postoperative bleeding rates in the CHNPD and NPD groups were 2.4% and 2.5%, respectively, similar to previous studies [ 1 – 3 ]. There are many reasons for postoperative bleeding of the thyroid gland, of which the main reasons relate to the operation[ 13 – 15 ], including the shedding of the ligation line of the upper and lower thyroid arteries, bleeding from the residual thyroid gland or muscle section, and venous injury. However, patient factors cannot be ignored[ 16 – 18 ]. Hypertension, abnormal coagulation function, postoperative cough, vomiting, and other factors may increase the risk of postoperative bleeding, so it is necessary to actively treat the patient’s primary diseases. Finally, a choking cough should be avoided when tracheal intubation is removed after the operation, and stable postoperative Allen Su is also vital to reduce postoperative bleeding of the thyroid gland[ 19 ]. For a long time, conventional placement of the drainage tube after thyroid surgery can relieve neck pressure but also induce active postoperative bleeding. NPD can drain subcutaneous effusion and hematocele, ensure that the flap and neck tissues are closely attached, reduce exudation, and promote healing. The advantage of a conventional disposable NPD ball is that it is small and portable, making it convenient for patients to get out of bed for exercise, preventing complications caused by long-term bed rest after the operation, and benefiting the patients’ rehabilitation. However, its disadvantage is that its maximum negative pressure is only 5 kPa, which is low and unstable. When the negative pressure ball is half full, the pressure spring automatically loosens, and the negative pressure disappears. It is necessary to replace the suction ball in a timely manner to prevent interrupting the negative pressure due to untimely observation, defeating the purpose of effective negative pressure. Especially with postoperative bleeding, it is easy to cause blockage of the drainage tube, leading to poor drainage and aggravation of the pressure of the neck wound. In addition, it is necessary to squeeze or replace the suction ball by hand constantly, placing a significant workload on the nursing staff.In this study, we have summarized the following points: 4.1 The Core Role of CHNPD in Reducing the Rate of Reoperation The findings of this study indicate that the reoperation rate in the CHNPD group was significantly lower than that in the NPD group (11.1% vs. 26.7%, P = 0.023). This result underscores the efficacy of high negative pressure drainage in managing suspected postoperative bleeding. Traditional negative pressure drainage (NPD) frequently fails to ensure effective drainage due to inadequate negative pressure, leading to blood clot formation and pipeline obstruction, which creates a misleading appearance of effective drainage. In reality, a tensional hematoma compressing the airway may develop within the neck. This perspective is corroborated by Weaver et al. [ 20 ]. Conversely, the 20–40 kPa continuous negative pressure provided by CHNPD can more effectively maintain catheter patency. Our subgroup analysis revealed that patients who underwent resection of malignant tumors experienced more pronounced benefits, aligning with the assertions of Campbell et al. [ 21 ] and Lee et al. [ 22 ] that more aggressive drainage strategies should be employed for high-risk patients. Simultaneously, it was observed that 16.7% of patients in the NPD group did not exhibit identifiable active bleeding points during reoperation, with only diffuse bleeding being present. This suggests that, retrospectively, these surgical interventions might have been deemed "unnecessary" and could have been more effectively managed through conservative approaches. Conversely, in the CHNPD group, 100% of reoperation cases revealed distinct vascular bleeding points. This finding implies that CHNPD is capable of "filtering out" cases where bleeding can be managed solely with negative pressure suction, thereby ensuring that each reoperation specifically targets genuine active arterial or venous injuries. Consequently, this enhances the precision of surgical interventions. This suggests that a sustained high negative pressure of 20–40 kPa exerts a dual effect: (1) Physical Hemostasis: The application of high negative pressure facilitates the closure of postoperative dead spaces by exerting pressure on capillaries and small veins through close tissue adhesion, thereby directly reducing bleeding. (2) Efficient Clearance Mechanism: Continuous High Negative Pressure Drainage (CHNPD) effectively suctions out uncoagulated blood, preventing the accumulation of hematomas beneath the flap and the generation of tension. This mechanism helps to avoid misleading clinicians into performing unnecessary emergency surgical explorations due to tension-induced swelling. 4.2 Potential Costs of Reoperation Our comprehensive analysis (refer to Table 4 B) indicates that the incidence of parathyroid gland injury among patients undergoing conservative treatment was notably low at 3.8%. However, this incidence markedly increased to 33.3% following reoperation (P < 0.001). A similar significant disparity was observed in the rate of incision infections. These findings align closely with the national cohort study conducted by Godballe et al. [ 1 ], which identified emergency reoperation as an independent risk factor for heightened permanent iatrogenic damage. In emergency scenarios, hematoma infiltration significantly obscures the anatomical layers of the neck, increasing the likelihood of inadvertent damage to the delicate parathyroid glands and the deep recurrent laryngeal nerve during the search for the bleeding source. Consequently, the advantage of Conservative Hemostatic Neck Pressure Device (CHNPD) extends beyond its drainage efficacy; it also serves as a "protective buffer zone," mitigating the need for high-risk secondary surgical exploration by reducing the reoperation rate. 4.3 Evaluation of Safety In this study, 5 cases (6.2%) of nerve injury were observed in the CHNPD group. Statistical analysis indicated no significant difference when compared to the NPD group (6.7%) (P = 1.000). This finding suggests that continuous high negative pressure suction does not contribute to additional physical harm. It is posited that, provided the pressure is maintained within a reasonable range, the mechanical impact of negative pressure on surrounding tissues is minimal. Notably, these 5 cases of nerve injury predominantly occurred in patients with malignant conditions undergoing concurrent lateral cervical lymph node dissection. This suggests that nerve injury is more likely attributable to the complexity of the initial surgical procedures rather than the CHNPD intervention. Consequently, this approach is considered to be safe. 4.4 Deep Integration of Infection Control with the Concept of Minimally Invasive Surgery The postoperative wound infection rate of 66.7% observed in the reoperation group suggests that hematoma serves as an optimal medium for bacterial proliferation, and the re-exposure of tissues during surgery collectively heightens the risk of postoperative wound infection. Consequently, early and unobstructed drainage is crucial for preventing infection following thyroid surgery. The use of CHNPD facilitates the effective removal of accumulated blood while preserving the integrity of the incision, thereby eliminating the necessity for a secondary incision. This approach aligns with the contemporary surgical trend of minimizing incision size. 4.5 Limitations and Future Directions This study employed a single-center retrospective design, which may introduce selection bias. Future research should involve a multi-center prospective study to further investigate the optimal pressure gradient for CHNPD intervention, specifically examining whether the range of 20–40 kPa is most appropriate. Additionally, it should aim to elucidate the clinical manifestations associated with the use of various hemostatic materials, such as thrombin sealant, in combination. In conclusion, the author posits that the critical factor in managing post-thyroid surgery hemorrhage is not the volume of bleeding per se, but rather the ability to maintain unobstructed drainage. This approach alleviates pressure on the surgical site, thereby enhancing the prospects for conservative management and ensuring preparedness for potential emergency re-operations. Consequently, this center has initiated a research protocol as a strategic response to post-thyroid surgery bleeding, accompanied by a comparative data analysis. The findings indicate that the implementation of this protocol significantly reduces the rate of re-operation in bleeding patients, as well as the array of potential complications associated with subsequent surgical interventions.This study redefines the role of post-operative drainage, suggesting that the drainage tube serves not only as an "observation window" but also as an "intervention tool." As an effective conservative intervention method, it can significantly mitigate most diffuse bleeding on the wound surface. Consequently, with the assistance of CHNPD, clinicians must continue to closely monitor the respiratory status and local changes in patients undergoing conservative treatment following bleeding. Indicators such as a progressive increase in tension, heightened pain, and sensations of compression or breathing difficulty should prompt consideration of active vascular bleeding. In such instances, immediate surgical exploration is warranted. Abbreviations NPD Negative Pressure Drainage CHNPD Continuous High Negative Pressure Suction Device POH Postoperative Hemorrhage TSH Thyroid-stimulating Hormone Declarations Ethics approval and consent to participate Written informed consent for publication was obtained from the patient. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to institutional restrictions regarding patient privacy and data security, but are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Clinical trial number Not applicable. Funding The author(s) declare financial support was received for the research and publication of this article. This study was supported by Lishui Municipal Science and Technology Program (Grant No,2024SJZC088). Authors' contributions Author 1: made substantial contributions to conception and design and has been involved in drafting the manuscript. JK has been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript. Acknowledgments We thank Home for Researchers editorial team (https:// www.home-for-researchers.com/#/) for language editing service. References Godballe C, Madsen AR, Pedersen HB, Sørensen CH, Pedersen U, Frisch T, Helweg-Larsen J, Barfoed L, Illum P, Mønsted JE, Becker B, Nielsen T. Post-thyroidectomy hemorrhage: a national study of patients treated at the Danish departments of ENT Head and Neck Surgery. Eur Arch Otorhinolaryngol. 2009;266(12):1945–52. 10.1007/s00405-009-0949-0 . Idrees S, Mayilvaganan S, Bothra S, Mahalakshmi V. Comment on: Post-thyroidectomy bleeding: analysis of risk factors from a national registry. Br J Surg. 2021;108(9):e305. 10.1093/bjs/znab166 . 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Leyre P, Desurmont T, Lacoste L, Odasso C, Bouche G, Beaulieu A, Valagier A, Charalambous C, Gibelin H, Debaene B, Kraimps JL. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg. 2008;393(5):733–7. 10.1007/s00423-008-0362-y . Lee HS, Lee BJ, Kim SW, Cha YW, Choi YS, Park YH, Lee KD. Patterns of Post-thyroidectomy Hemorrhage. Clin Exp Otorhinolaryngol. 2009;2(2):72–7. 10.3342/ceo.2009.2.2.72 . Liu J, Sun W, Dong W, Wang Z, Zhang P, Zhang T, Zhang H. Risk factors for post-thyroidectomy haemorrhage: a meta-analysis. Eur J Endocrinol. 2017;176(5):591–602. 10.1530/EJE-16-0757 . Perera M, Anabell L, Page D, Harding T, Gnaneswaran N, Chan S. Risk factors for post-thyroidectomy haematoma. J Laryngol Otol. 2016;130(Suppl 1):S20–5. 10.1017/S0022215115003199 . Dehal A, Abbas A, Hussain F, Johna S. Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database. Perm J 2015 Winter;19(1):22–8. 10.7812/TPP/14-085 Harding J, Sebag F, Sierra M, Palazzo FF, Henry JF. Thyroid surgery: postoperative hematoma–prevention and treatment. Langenbecks Arch Surg. 2006;391(3):169–73. 10.1007/s00423-006-0028-6 . Weaver JL, Kaufman EJ, Young AJ, Keating JJ, Subramanian M, Cannon JW, Shiroff A, Seamon MJ. Outcomes in Delayed Drainage of Hemothorax. Am Surg. 2021;87(7):1140–4. 10.1177/0003134820956343 . Campbell MJ, McCoy KL, Shen WT, Carty SE, Lubitz CC, Moalem J, Nehs M, Holm T, Greenblatt DY, Press D, Feng X, Siperstein AE, Mitmaker E, Benay C, Tabah R, Oltmann SC, Chen H, Sippel RS, Brekke A, Vriens MR, Lodewijk L, Stephen AE, Nagar S, Angelos P, Ghanem M, Prescott JD, Zeiger MA, Aragon Han P, Sturgeon C, Elaraj DM, Nixon IJ, Patel SG, Bayles SW, Heneghan R, Ochieng P, Guerrero MA, Ruan DT. A multi-institutional international study of risk factors for hematoma after thyroidectomy. Surgery. 2013;154(6):1283–89. 10.1016/j.surg.2013.06.032 . discussion 1289-91. Lee JS, Lee JS, Yun HJ, Chang H, Kim SM, Lee YS, Chang HS. Comparison of delayed bleeding to immediate bleeding following thyroidectomy. Sci Rep. 2023;13(1):18342. 10.1038/s41598-023-44323-z . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 15 Apr, 2026 Reviews received at journal 14 Apr, 2026 Reviews received at journal 12 Apr, 2026 Reviews received at journal 12 Apr, 2026 Reviews received at journal 10 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers agreed at journal 05 Apr, 2026 Reviewers invited by journal 05 Apr, 2026 Editor invited by journal 30 Mar, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 22 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9189427","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619928851,"identity":"6ededadd-92ce-4b61-8e22-77eb3e22c8ae","order_by":0,"name":"Xi Zhu","email":"","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xi","middleName":"","lastName":"Zhu","suffix":""},{"id":619928852,"identity":"60a28107-a8c0-41a9-aeaa-3bc6682c4f30","order_by":1,"name":"Lei Zhu","email":"","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Zhu","suffix":""},{"id":619928853,"identity":"d8fcb635-f477-4018-ab45-b51ad84bc36a","order_by":2,"name":"Bin Zhou","email":"","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Zhou","suffix":""},{"id":619928854,"identity":"fef804dd-8ad9-49d7-886b-ba5a51078148","order_by":3,"name":"Zhouting Li","email":"","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhouting","middleName":"","lastName":"Li","suffix":""},{"id":619928855,"identity":"7a63e033-c46a-42a3-8103-5b2be1c32d55","order_by":4,"name":"Yong Wu","email":"","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Wu","suffix":""},{"id":619928856,"identity":"0bb2e21a-be25-4c26-9934-18e72d0ffd4c","order_by":5,"name":"Feng Cheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIie3PsYrCQBCA4ZGFvWYw7QSC9woDwlYHvsouASsFyxQpAoop9M5XufLKhIOt1j7dRSxstbvC4tKfuLGz2K+aYn9mFiAInpCMdofjlXOMXsq61VnuT4bkBOPCJvHWpdw6609GMJOEZ/HGjVbxYSV6HAb7byaWCJWeZqaQEJUbfT8RH6ZlTnBQ1LYxXwmQ2396tlRj1t0WMSimjXESmOa+RCuqWKAUoBZmLfokMxUXXYISFPRLyKZjYIuEmJJ23eD7y+tuWR/hmk8mP6f68pvlo6h8v5/8g489D4IgCG76A1jERaULb7paAAAAAElFTkSuQmCC","orcid":"","institution":"the Fifth Hospital Affiliated to Wenzhou Medical University, Lishui Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Feng","middleName":"","lastName":"Cheng","suffix":""}],"badges":[],"createdAt":"2026-03-22 06:38:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9189427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9189427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106545389,"identity":"cb04bbbb-edfa-4f17-b2fd-6c4cf8b93a78","added_by":"auto","created_at":"2026-04-09 16:45:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":454839,"visible":true,"origin":"","legend":"\u003cp\u003eSubject disposition for the study cohort\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9189427/v1/febf97e9af8e232248d408c0.png"},{"id":106725172,"identity":"8d8d7ebe-24d1-4509-b4d8-e06b00f27d01","added_by":"auto","created_at":"2026-04-12 18:31:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1301436,"visible":true,"origin":"","legend":"\u003cp\u003eContinuous High Negative Pressure Drainage Device. (A) central negative pressure dial with adjustable pressure; (B) central negative pressure suction device (capacity 3500ml); (C) negative pressure drainage ball\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9189427/v1/2f2ad50ac4f9038f4ca72e15.png"},{"id":106726933,"identity":"f29bb360-755d-4fda-a696-44590aee9889","added_by":"auto","created_at":"2026-04-12 18:37:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2719123,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9189427/v1/6a3f477f-0e91-43cd-858e-5f377cca2040.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of a Continuous High Negative Pressure Suction Device in Treating Postoperative Thyroid Bleeding: A Retrospective Cohort Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePostoperative hemorrhage (POH) represents one of the most severe and potentially life-threatening complications associated with thyroid surgery, with an incidence rate ranging from approximately 0.53% to 4.2% [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite its relatively low occurrence, the confined anatomical space of the neck can lead to the rapid development of hematomas, resulting in acute airway compression and asphyxia within minutes. Approximately 25% of affected patients necessitate additional surgical intervention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which not only inflicts significant distress upon patients but also heightens the risk of postoperative hypoparathyroidism, incision infection, extended hospital stays, and increased demands on nursing care. Consequently, effective management of drainage is imperative, not only for the monitoring of bleeding but also for the prevention of tensional hematoma formation due to blood accumulation.\u003c/p\u003e\n\u003cp\u003eIn current clinical practice, the prevalent method employed is normal pressure drainage (NPD), which typically involves the use of a closed drainage ball with a negative pressure of approximately 5 kPa. However, numerous studies have indicated that the effectiveness of traditional NPD is frequently compromised in scenarios involving rapid or continuous bleeding. In such cases, blood clots can obstruct the drainage tube, creating a \u0026quot;false sense of security.\u0026quot; This occurs when the externally observed drainage volume is minimal, while a tensional hematoma is developing within the deeper neck tissues, thereby obscuring the true extent of bleeding. To maintain the patency of the drainage tube and facilitate the closure of dead space, continuous high negative pressure drainage (CHNPD) is often employed in surgical disciplines, such as abdominal surgery. This approach aims to enhance granulation tissue proliferation, reduce the risk of infection, and minimize anastomotic leakage [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWhile CHNPD presents potential advantages, its application in thyroid surgery remains a subject of considerable debate. Proponents assert that the increased pressure can efficiently manage diffuse venous bleeding and inhibit hematoma formation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Conversely, critics express concerns that employing high negative pressure suction postoperatively may inflict additional harm on surrounding soft tissues, including nerve damage or potential injury to major blood vessels [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. At present, there is a paucity of high-quality studies that rigorously compare the clinical efficacy and safety of NPD and CHNPD in managing suspected postoperative bleeding following thyroid surgery.\u003c/p\u003e\n\u003cp\u003eThis study conducted a retrospective analysis of clinical data from 5,251 patients to investigate the effects of early implementation of Controlled Hypotensive Neck Pressure Drainage (CHNPD) on clinical outcomes following the onset of Postoperative Hemorrhage (POH) indicators, such as a sudden increase in drainage volume and neck swelling. The primary research objectives are as follows: (1) To evaluate whether CHNPD effectively reduces the incidence of emergency reoperations; (2) To examine the differential benefits of CHNPD across various surgical techniques, specifically open versus laparoscopic procedures, and across different pathological types; (3) To assess the incidence of complications to determine the safety of CHNPD when applied at a pressure range of 20\u0026ndash;40 kPa.\u003c/p\u003e\n"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Research Subjects and Design\u003c/h2\u003e \u003cp\u003eA retrospective analysis was performed on the clinical data of 5,251 patients who underwent thyroid surgery at the Head and Neck (Thyroid) Surgery Department of Lishui Central Hospital between December 2015 and October 2024. The inclusion criteria were as follows: (1) a sudden increase in the volume of neck drainage fluid, characterized by bloody discharge or the presence of blood clots (an increase of 20 ml or more than 50 ml/h), and (2) progressive neck swelling accompanied by symptoms of airway compression. Meeting one or more of these criteria was indicative of clinical consideration for postoperative bleeding following thyroid surgery. Ultimately, 126 patients who experienced postoperative thyroid bleeding necessitating either conservative management or reoperation were included in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).One patient who underwent parathyroid surgery and another diagnosed with Mardelein disease who subsequently underwent neck surgery were excluded from the study. The cohort comprised 52 males and 74 females, with a mean age of 47.51\u0026thinsp;\u0026plusmn;\u0026thinsp;13.65 years. Patients experiencing postoperative thyroid bleeding were categorized into two distinct groups: the ordinary negative pressure drainage group (NPD) and the continuous high negative pressure drainage group (CHNPD).The electronic medical records of each patient were comprehensively analyzed, encompassing fundamental data, histological information, perioperative details, and laboratory reports. The database parameters included gender, preoperative thyroid-stimulating hormone (TSH) levels, preoperative hormonal status (categorized as hypothyroidism, euthyroidism, or hyperthyroidism), timing of bleeding detection, drainage volume, anticoagulant usage, maximum thyroid tumor diameter, presence of Hashimoto's thyroiditis, number of surgical sites, pathological classification (benign or malignant tumor), performance of lateral cervical lymph node dissection, and whether laparoscopic surgery was conducted. A 30-day postoperative follow-up was conducted for all patients to assess delayed bleeding or other complications. This study received approval from the Ethics Committee of Lishui Central Hospital, and informed consent was obtained from all patients and their families for inclusion in the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Surgical methods and intervention measures\u003c/h2\u003e \u003cp\u003eAll surgical procedures were conducted by seasoned surgeons employing standard techniques, either open or laparoscopic. Hemostasis was accomplished intraoperatively utilizing bipolar electrocoagulation or an ultrasonic scalpel. Upon completion of the surgery, a silicone drainage tube was positioned in the thyroid bed. Patients were categorized into two groups based on the intervention strategies implemented upon the initial appearance of bleeding signs.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1. NPD\u003c/h2\u003e \u003cp\u003eAfter the operation, the wound indwelling drainage tube was connected to an ordinary NPD ball (model: BDA-YS-0200) with a 200 mL capacity. The maximum negative pressure of 5 kPa could be produced when the ball is collapsed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2. CHNPD\u003c/h2\u003e \u003cp\u003eThe ordinary NPD ball was connected to a central negative pressure suction device with a 3500 mL capacity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB) through a glass straw (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), and the negative pressure value was adjusted to 20\u0026ndash;40 kPa (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Our treatment plan was routine indwelling of the ordinary NPD ball after the operation, which was replaced with continuous high negative pressure suction when suspected bleeding signs appear until reoperation or the bleeding stops.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3. Reoperation\u003c/h2\u003e \u003cp\u003eProgressive worsening of the bleeding or neck swelling under conservative treatment, dyspnea, and laborious ventilation necessitated suspending the conservative treatment plan and reoperating in time for intervention. We opened the incision under local or general anesthesia, initially removed the accumulated blood clots, then flushed and removed the blood clots in the tissue space with normal saline. We carefully looked for the bleeding point (recording the bleeding site) and ligated or sutured it. After hematoma removal, routine indwelling drainage and antibiotics were used to prevent infection.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection and follow-up\u003c/h2\u003e \u003cp\u003eAnalyze the statistical data pertaining to the patients, including their preoperative TSH levels, anticoagulant usage, tumor sizes, and surgical specifics (such as lymph node dissection status and the comparison between laparoscopic and open surgical procedures). The primary outcome measure is the reoperation rate. All patients were monitored for 30 days postoperatively to assess delayed bleeding or other complications, including recurrent laryngeal nerve injury, parathyroid injury, and wound infection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed utilizing SPSS version 26.0. Continuous variables were assessed through the application of the t-test or the Mann-Whitney U test, while categorical variables were examined using the chi-square test or Fisher's exact test. Subgroup analyses were conducted to evaluate the effects based on pathological type (benign versus malignant) and surgical method (laparoscopic versus open). A P-value of less than 0.05 was considered indicative of statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Basic Information\u003c/h2\u003e \u003cp\u003eThe study included a total of 126 patients who met the suspected POH criteria, comprising 52 males and 74 females, with a mean age of 47.51\u0026thinsp;\u0026plusmn;\u0026thinsp;13.65 years. Pathological analysis revealed that 82 cases were malignant tumors, while 44 cases were benign tumors. The cohort was divided into two groups: 45 patients in the NPD group and 81 patients in the CHNPD group. As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, no statistically significant differences were observed between the CHNPD and NPD groups with respect to gender, age, bleeding time, drainage fluid, preoperative TSH levels, preoperative thyroid function status, history of anticoagulant use, current anticoagulant use, maximum tumor diameter, presence of Hashimoto's disease, or the number of surgical sides (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Additionally, an analysis of the necessity for conservative or surgical intervention for postoperative bleeding among all postoperative patients indicated no statistically significant difference in the rate of postoperative bleeding between the CHNPD and NPD groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that the likelihood of postoperative bleeding following thyroid surgery did not differ between the two groups (refer to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Baseline Clinical Characteristics Between NPD and CHVS Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNPD Group (n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCHNPD Group (n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e/t/Z/Fisher\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37(45.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44(54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years),x\u0026macr;\u0026plusmn;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.29\u0026thinsp;\u0026plusmn;\u0026thinsp;12.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.53\u0026thinsp;\u0026plusmn;\u0026thinsp;14.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to Bleeding(h), M(Q1, Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.5(3.25, 16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(4.5, 17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrainage Volume(ml), M(Q1, Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119(81, 162.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116(90, 173.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative TSH, M(Q1, Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.52(0.58, 2.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.72(1.06, 2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Thyroid Status, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuthyroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38(84.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74(91.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperthyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4(8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7(8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant Use History, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1(1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot in Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42(93.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80(98.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhether to continue using anticoagulants at present, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspirin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1(1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeparin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42(93.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80(98.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Diameter(mm), M(Q1, Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20(8, 40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10(5.5, 22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHashimoto's Thyroiditis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33(73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69(85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Scope, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(64.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45(55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16(35.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36(44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative bleeding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNPD Group (n\u0026thinsp;=\u0026thinsp;1813)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCHNPD Group (n\u0026thinsp;=\u0026thinsp;3438)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparison of Reoperation Rates\u003c/h2\u003e \u003cp\u003eThe primary outcome measure for this study was the rate of emergency reoperation. Additionally, we investigated the necessity for emergency reoperation following the implementation of different drainage methods post-bleeding. The analysis revealed a statistically significant difference in reoperation rates between the CHNPD group and the NPD group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Specifically, among the 45 patients in the NPD group, 12 cases (26.7%) required reoperation, whereas only 9 cases (11.1%) in the CHNPD group underwent surgical exploration. The reoperation rate in the CHNPD group was significantly lower than that in the NPD group (χ\u0026sup2; = 5.138, P\u0026thinsp;=\u0026thinsp;0.023) (refer to Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Reoperation Rates and Subgroup Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups / Subgroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNPD Group(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCHNPD Group (n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Reoperation Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Malignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10/27 (37.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5/53 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Benign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2/18 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/28 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Open Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11/39 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7/65 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.045*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Endoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/6 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2/16 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Subgroup Analysis\u003c/h2\u003e \u003cp\u003eTo further assess the efficacy of CHNPD, we performed a subgroup analysis based on pathological type (malignant vs. benign). Among patients with malignant tumors, the reoperation rate was 32.0% (8/25) in the NPD group and 9.4% (5/53) in the CHNPD group, with the difference being statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, for patients with benign conditions, the reoperation rates were 11.1% (2/18) in the NPD group and 14.3% (4/28) in the CHNPD group, with no statistically significant difference observed. Regarding the surgical method (open vs. laparoscopic), CHNPD significantly decreased the reoperation rate in open surgeries compared to NPD (10.8% vs. 24.3%). In laparoscopic surgeries, the reoperation rates were 12.5% for the CHNPD group and 16.7% for the NPD group, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Findings from the Reoperation Exploration\u003c/h2\u003e \u003cp\u003eIn the cohort of patients who required reoperation, the etiology of hemorrhage was determined. Within the NPD group, 16.7% (2 out of 12) of cases exhibited \"diffuse bleeding,\" with no distinct arterial bleeding sites identified. Conversely, in the CHNPD group, all reoperation cases revealed specific arterial and venous branches, such as the superior and inferior thyroid artery branches, as the sources of hemorrhage. These findings indicate that CHNPD is effective in managing diffuse capillary bleeding, thereby reducing the need for additional surgical interventions for non-arterial bleeding sources (refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of Bleeding Sources Identified During Reoperation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNPD Group(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCHNPD Group (n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFindings Details\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiffuse Oozing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCHNPD effectively controls non-arterial oozing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific Vessel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTargeted intervention for active arterial bleeders\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Superior/Inferior Artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Other Small Vessels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown / Hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeep clots cleared with no active bleeder found\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Postoperative Complications and Safety Indicators [n (%)] \u003cb\u003e(A)\u003c/b\u003e Comparison of postoperative complications among different groups (NPD vs. CHNPD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNPD Group(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCHNPD Group (n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ2/F\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003erecurrent nerve injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eparathyroid injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.035*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e(B) Analysis of Complications from Different Treatment Methods (Expectant treatment Group vs. Reoperation Group)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003ecomplication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eExpectant treatment\u0026nbsp;\u0026nbsp;Group(n=105)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eReoperation Group (n=21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003erecurrent nerve injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e0.027*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eparathyroid injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e12.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003ewound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e14 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*P \u0026lt; 0.05.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Analysis of Complications and Safety Indicators after POH\u003c/h2\u003e \u003cp\u003eDuring the 30-day postoperative follow-up period, no instances of rebleeding were observed among the patients. The safety assessment of the POH intervention, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA, revealed the following: Comparative analysis between groups indicated no statistically significant difference in the incidence of recurrent laryngeal nerve injury (6.7% vs. 6.2%, P\u0026thinsp;=\u0026thinsp;1.000) or parathyroid gland injury (13.3% vs. 6.2%, P\u0026thinsp;=\u0026thinsp;0.198) between the NPD and CHNPD groups, thereby affirming the safety of high negative pressure aspiration. Notably, the rate of incision infection was significantly lower in the CHNPD group compared to the NPD group (6.2% vs. 20.0%, P\u0026thinsp;=\u0026thinsp;0.035).\u003c/p\u003e \u003cp\u003eComparison of Treatment Modalities: A more detailed analysis, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB, reveals that reoperation constitutes a primary risk factor for the development of complications. Specifically, the incidence of parathyroid injury was significantly elevated in patients undergoing reoperation compared to those receiving conservative treatment (33.3% vs. 3.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, the incidence of incision infection was markedly higher in the reoperation cohort (66.7% vs. 0%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, there was a notable upward trend in the risk of recurrent laryngeal nerve injury among patients in the reoperation group (19.0% vs. 3.8%, P\u0026thinsp;=\u0026thinsp;0.027).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe potential gap in the deep fascia of the neck is relatively narrow. When a hematoma forms rapidly after thyroid surgery, even if its volume is very small, it may lead to increased pressure, which may compress the trachea and cause dyspnea and even suffocation to some extent, endangering life in severe cases[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].In this study, the postoperative bleeding rates in the CHNPD and NPD groups were 2.4% and 2.5%, respectively, similar to previous studies [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There are many reasons for postoperative bleeding of the thyroid gland, of which the main reasons relate to the operation[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], including the shedding of the ligation line of the upper and lower thyroid arteries, bleeding from the residual thyroid gland or muscle section, and venous injury. However, patient factors cannot be ignored[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hypertension, abnormal coagulation function, postoperative cough, vomiting, and other factors may increase the risk of postoperative bleeding, so it is necessary to actively treat the patient\u0026rsquo;s primary diseases. Finally, a choking cough should be avoided when tracheal intubation is removed after the operation, and stable postoperative Allen Su is also vital to reduce postoperative bleeding of the thyroid gland[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor a long time, conventional placement of the drainage tube after thyroid surgery can relieve neck pressure but also induce active postoperative bleeding. NPD can drain subcutaneous effusion and hematocele, ensure that the flap and neck tissues are closely attached, reduce exudation, and promote healing. The advantage of a conventional disposable NPD ball is that it is small and portable, making it convenient for patients to get out of bed for exercise, preventing complications caused by long-term bed rest after the operation, and benefiting the patients\u0026rsquo; rehabilitation. However, its disadvantage is that its maximum negative pressure is only 5 kPa, which is low and unstable. When the negative pressure ball is half full, the pressure spring automatically loosens, and the negative pressure disappears. It is necessary to replace the suction ball in a timely manner to prevent interrupting the negative pressure due to untimely observation, defeating the purpose of effective negative pressure. Especially with postoperative bleeding, it is easy to cause blockage of the drainage tube, leading to poor drainage and aggravation of the pressure of the neck wound. In addition, it is necessary to squeeze or replace the suction ball by hand constantly, placing a significant workload on the nursing staff.In this study, we have summarized the following points:\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1 The Core Role of CHNPD in Reducing the Rate of Reoperation\u003c/h2\u003e \u003cp\u003eThe findings of this study indicate that the reoperation rate in the CHNPD group was significantly lower than that in the NPD group (11.1% vs. 26.7%, P\u0026thinsp;=\u0026thinsp;0.023). This result underscores the efficacy of high negative pressure drainage in managing suspected postoperative bleeding. Traditional negative pressure drainage (NPD) frequently fails to ensure effective drainage due to inadequate negative pressure, leading to blood clot formation and pipeline obstruction, which creates a misleading appearance of effective drainage. In reality, a tensional hematoma compressing the airway may develop within the neck. This perspective is corroborated by Weaver et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Conversely, the 20\u0026ndash;40 kPa continuous negative pressure provided by CHNPD can more effectively maintain catheter patency. Our subgroup analysis revealed that patients who underwent resection of malignant tumors experienced more pronounced benefits, aligning with the assertions of Campbell et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and Lee et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] that more aggressive drainage strategies should be employed for high-risk patients.\u003c/p\u003e \u003cp\u003eSimultaneously, it was observed that 16.7% of patients in the NPD group did not exhibit identifiable active bleeding points during reoperation, with only diffuse bleeding being present. This suggests that, retrospectively, these surgical interventions might have been deemed \"unnecessary\" and could have been more effectively managed through conservative approaches. Conversely, in the CHNPD group, 100% of reoperation cases revealed distinct vascular bleeding points. This finding implies that CHNPD is capable of \"filtering out\" cases where bleeding can be managed solely with negative pressure suction, thereby ensuring that each reoperation specifically targets genuine active arterial or venous injuries. Consequently, this enhances the precision of surgical interventions. This suggests that a sustained high negative pressure of 20\u0026ndash;40 kPa exerts a dual effect: (1) Physical Hemostasis: The application of high negative pressure facilitates the closure of postoperative dead spaces by exerting pressure on capillaries and small veins through close tissue adhesion, thereby directly reducing bleeding. (2) Efficient Clearance Mechanism: Continuous High Negative Pressure Drainage (CHNPD) effectively suctions out uncoagulated blood, preventing the accumulation of hematomas beneath the flap and the generation of tension. This mechanism helps to avoid misleading clinicians into performing unnecessary emergency surgical explorations due to tension-induced swelling.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Potential Costs of Reoperation\u003c/h2\u003e \u003cp\u003eOur comprehensive analysis (refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) indicates that the incidence of parathyroid gland injury among patients undergoing conservative treatment was notably low at 3.8%. However, this incidence markedly increased to 33.3% following reoperation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A similar significant disparity was observed in the rate of incision infections. These findings align closely with the national cohort study conducted by Godballe et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which identified emergency reoperation as an independent risk factor for heightened permanent iatrogenic damage. In emergency scenarios, hematoma infiltration significantly obscures the anatomical layers of the neck, increasing the likelihood of inadvertent damage to the delicate parathyroid glands and the deep recurrent laryngeal nerve during the search for the bleeding source. Consequently, the advantage of Conservative Hemostatic Neck Pressure Device (CHNPD) extends beyond its drainage efficacy; it also serves as a \"protective buffer zone,\" mitigating the need for high-risk secondary surgical exploration by reducing the reoperation rate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Evaluation of Safety\u003c/h2\u003e \u003cp\u003eIn this study, 5 cases (6.2%) of nerve injury were observed in the CHNPD group. Statistical analysis indicated no significant difference when compared to the NPD group (6.7%) (P\u0026thinsp;=\u0026thinsp;1.000). This finding suggests that continuous high negative pressure suction does not contribute to additional physical harm. It is posited that, provided the pressure is maintained within a reasonable range, the mechanical impact of negative pressure on surrounding tissues is minimal. Notably, these 5 cases of nerve injury predominantly occurred in patients with malignant conditions undergoing concurrent lateral cervical lymph node dissection. This suggests that nerve injury is more likely attributable to the complexity of the initial surgical procedures rather than the CHNPD intervention. Consequently, this approach is considered to be safe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Deep Integration of Infection Control with the Concept of Minimally Invasive Surgery\u003c/h2\u003e \u003cp\u003eThe postoperative wound infection rate of 66.7% observed in the reoperation group suggests that hematoma serves as an optimal medium for bacterial proliferation, and the re-exposure of tissues during surgery collectively heightens the risk of postoperative wound infection. Consequently, early and unobstructed drainage is crucial for preventing infection following thyroid surgery. The use of CHNPD facilitates the effective removal of accumulated blood while preserving the integrity of the incision, thereby eliminating the necessity for a secondary incision. This approach aligns with the contemporary surgical trend of minimizing incision size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Limitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study employed a single-center retrospective design, which may introduce selection bias. Future research should involve a multi-center prospective study to further investigate the optimal pressure gradient for CHNPD intervention, specifically examining whether the range of 20\u0026ndash;40 kPa is most appropriate. Additionally, it should aim to elucidate the clinical manifestations associated with the use of various hemostatic materials, such as thrombin sealant, in combination.\u003c/p\u003e \u003cp\u003eIn conclusion, the author posits that the critical factor in managing post-thyroid surgery hemorrhage is not the volume of bleeding per se, but rather the ability to maintain unobstructed drainage. This approach alleviates pressure on the surgical site, thereby enhancing the prospects for conservative management and ensuring preparedness for potential emergency re-operations. Consequently, this center has initiated a research protocol as a strategic response to post-thyroid surgery bleeding, accompanied by a comparative data analysis. The findings indicate that the implementation of this protocol significantly reduces the rate of re-operation in bleeding patients, as well as the array of potential complications associated with subsequent surgical interventions.This study redefines the role of post-operative drainage, suggesting that the drainage tube serves not only as an \"observation window\" but also as an \"intervention tool.\" As an effective conservative intervention method, it can significantly mitigate most diffuse bleeding on the wound surface. Consequently, with the assistance of CHNPD, clinicians must continue to closely monitor the respiratory status and local changes in patients undergoing conservative treatment following bleeding. Indicators such as a progressive increase in tension, heightened pain, and sensations of compression or breathing difficulty should prompt consideration of active vascular bleeding. In such instances, immediate surgical exploration is warranted.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNegative Pressure Drainage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCHNPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContinuous High Negative Pressure Suction Device\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePOH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative Hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThyroid-stimulating Hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient.\u003c/p\u003e\n\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to institutional restrictions regarding patient privacy and data security, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare financial support was received for the research and publication of this article. This study was supported by Lishui Municipal Science and Technology Program (Grant No,2024SJZC088).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor 1: made substantial contributions to conception and design and has been involved in drafting the manuscript. JK has been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgments \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Home for Researchers editorial team (https:// www.home-for-researchers.com/#/) for language editing service.\u003c/p\u003e\n\n\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGodballe C, Madsen AR, Pedersen HB, S\u0026oslash;rensen CH, Pedersen U, Frisch T, Helweg-Larsen J, Barfoed L, Illum P, M\u0026oslash;nsted JE, Becker B, Nielsen T. 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Sci Rep. 2023;13(1):18342. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-023-44323-z\u003c/span\u003e\u003cspan address=\"10.1038/s41598-023-44323-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Continuous negative pressure, Thyroidectomy, Postoperative complications, Postoperative hemorrhage","lastPublishedDoi":"10.21203/rs.3.rs-9189427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9189427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative hemorrhage, although infrequent, represents a potentially life-threatening complication subsequent to thyroidectomy, frequently leading to acute airway obstruction. Conventional negative pressure drainage (NPD) systems may prove inadequate in instances of rapid hemorrhage due to catheter occlusion by thrombi. This study assessed the effectiveness of a continuous high negative pressure suction device (CHNPD) in the management of suspected postoperative bleeding and its impact on decreasing the incidence of urgent reoperations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was performed on a cohort of 5,251 patients who underwent thyroid surgery between 2015 and 2024. Of these, 126 patients exhibiting clinical indicators of postoperative hemorrhage, such as a sudden increase in drainage volume or neck swelling, were selected for further study. Based on the intervention strategies employed at the time of hemorrhage occurrence, patients were categorized into two groups: the conventional negative pressure drainage group (NPD, n\u0026thinsp;=\u0026thinsp;45) and the continuous high negative pressure drainage group (CHNPD, n\u0026thinsp;=\u0026thinsp;81). The primary outcome measure was the rate of emergency reoperation. Additionally, subgroup analyses were conducted according to pathological type (benign versus malignant) and surgical approach (laparoscopic versus open).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe baseline characteristics of the two groups were comparable (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The reoperation rate in the CHNPD group was significantly lower than that in the NPD group (11.1% vs. 26.7%; P\u0026thinsp;=\u0026thinsp;0.023). Subgroup analysis indicated that CHNPD was particularly effective in malignant cases involving lymph node dissection, reducing the reoperation rate from 32.0% to 9.4%. During reoperation, it was observed that the NPD group experienced a higher incidence of \"diffuse bleeding\" due to the failure of conservative treatment, necessitating surgical intervention. In contrast, CHNPD effectively managed such bleeding, enabling surgical exploration to concentrate more precisely on the specific arterial bleeding points. No complications associated with high-pressure suction were reported.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe prompt implementation of Closed Hemostatic Negative Pressure Drainage (CHNPD) following thyroid surgery for suspected hemorrhage constitutes a safe and cost-effective intervention. By ensuring unobstructed drainage and mitigating hematoma tension, CHNPD substantially decreases the incidence of unnecessary re-exploratory surgeries, particularly in cases of diffuse venous or capillary bleeding. Nonetheless, clinicians must maintain vigilance regarding the potential occurrence of arterial bleeding.\u003c/p\u003e","manuscriptTitle":"Evaluation of a Continuous High Negative Pressure Suction Device in Treating Postoperative Thyroid Bleeding: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 16:45:30","doi":"10.21203/rs.3.rs-9189427/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-15T08:36:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T00:05:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-12T14:57:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-12T14:46:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T03:36:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241349112598716062401868043118192506008","date":"2026-04-11T03:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299299083673818162864515923968790967328","date":"2026-04-10T20:20:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15679321836526995797888474447528281405","date":"2026-04-09T07:03:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62244032429813909795312285781162902149","date":"2026-04-08T15:49:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77791706087862540163323745691608410353","date":"2026-04-08T09:29:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232550149083938273965960328624838105113","date":"2026-04-07T22:56:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12527787490322985712085837306545587692","date":"2026-04-06T22:10:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324808878255161078601153649621260982263","date":"2026-04-06T13:17:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137284846867900804301241622691601294832","date":"2026-04-05T21:04:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-05T20:14:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T17:22:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T04:33:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-27T04:32:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-22T06:25:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10ecb009-da53-4ee7-9563-64b5b4e91505","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T19:08:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 16:45:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9189427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9189427","identity":"rs-9189427","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}