Table 5.

Surgeon volume and outcome for post-thyroidectomy hemorrhage

Author, year	Patients/procedures; disease (n)	Revision for hematoma/conservative (n/n)	Bleeding rate (%) overall/surg category	Outcome	Surgeon volume criteria	EL/RG	Comment	Suggested surgeon volume
Without impact surgeon volume
Bergamaschi [28] et al., 1998	1192/all types; benign and cancer	19/10	1.6	No further impairment	Low < 50 intermediate 50–100 high > 100	III/C	Equal distribution surg cat	No signif. diff. surg. vol. no minimum number
Sosa [34] et al., 2008	1199 pat. TT+PTX in pat. < 17years	NA	3.4%	Overall compl other 9.5% pediatric 11.0% high 5.6%, ns	Other pediatric high	IV/D		Low vol. surg powerful predictor worse outcome
Tuggle [35] et al., 2011	6762 thyroidectomy same day discharge					IV/D	Same day disch. more often high vol surg (p > 0.001)	No minimum number
Loyo [7] et al., 2013	871,644	NA	NA		Proc./annum ≤ 3/a very low 4–9/a low 9–23 intermediate > 23/a high	III/C		No minimum number
Perera [30] et al., 2015	205/HT+TT	9/205	4.4	Hemorrhage: A: 5/114 B: 4/91 (p = 0.78)	A: trainee B: surgeon	III/C		No diff. regarding hemorrhage for surg cat
Liang [12] et al., 2015	125,037 pat.	NA	NA		1–70/a low > 70/a high specific postop complic. intermediate surg OR 0.63 p = 0.86 high surg OR 0.63 p < 0.001	III/C	All over LOS 0.2 days (6.3%) p < 0.001; in-hospital mortality equal p = 1.000 § LOS high 1.2–3.2 vs. low 1.7–3.5 days; in-hospital mortality favorable high OR 5.99 (95% CI 1.98–18.12; p = 0.002); all over postop surg. complication OR 0.72 p < 0.001	Postop complications inversely correlated with surgeon volume; hemorrhage not specified
Gurrado [32] et al., 2016	8908/TT	NA	NA	Overall morbidity (22.3%) sign. ass. with A: OR 1.48 (95% CI 1.12–1–96; p = 0.005) B vs. A: 29.5%/22.3% and C: 21.3% hemorrhage: A: 53/7092 (0.7%) B: 1/261 (0.4%) C: 6/1555 (0.4%) OR B+C vs. A: 0.51 (0.23–1.13) p = 0.10	A: resident/cons. B: consultant C: resident/res.	III/C		No diff. regarding hemorrhage for surg cat
Meltzer [33] et al., 2016	3135/HT vs. TT/benign	NA	NA	All over complic lower in HVS: 5.7% vs. 7.5% p < 0.05 hemorrhage TT: LVS: 0.4/1779 HVS: 0.7/1779 (p = 0.25) hemorrhage HT: LVS: 0.3/1356 HVS: 0.6/1356 (p = 0.25)	LVS: ≤ 20/proc/a IVS: 21–40/proc/a HVS: > 4/proc/a	IV/C		No diff. regarding hemorrhage for surg cat
With impact surgeon volume
Sosa [4] et al., 1998	5860 pat. all types		Mean 1.5%		Total proc./6 years A: 1–9 = 2.0% B: 10–29 = 1.6% C: 30–100 = 1.2% D: > 100 = 1.4%	III/C		Sign. assoc. improved pat. outcome with increased surg vol (D 1/3 complic vs. A)
Mishra [36] et al., 1999	232/TT; benign and cancer	6/NA	2.6/1.6 vs. 3.8	Not specified	Cumulative proc. 1–120 in 1.6–8 years	III/C	Consultant vs. trainee 127/105	Signif. diff surg vol p > 0.05 diff. no minimum number
Stavrakis [37] et al., 2007	10,009/NA	NA	NA *2.77%	LOS prolonged; costs increased LOS 0.06 days/surg cat or decreased cost $365*	Proc./annum A: 1–3 B: 4–8 C: 9–19 D: 20–50 E: 51–99 F: ≥ 100	IV/C	All over compl. signif. higher A vs. F p < 0.02 inverse correlation surg cat to hemorrhage; hemorrhage single parameter influenced by surg vol; no hospital vol effect on compl. seen	Signif. diff surg vol. p < 0.10 no minimum number
Sosa [38] et al., 2008	22,848/all types; benign and cancer/age > 65 years/≥ 80 years	NA	NA	High vol surg sign. lower all over endocr. compl. 4.5% ≥ 80 years vs. low vol surg (13%); higher costs; LOS 2.3 days vs. 4.8 days; in-hospital mortality	Very low: 1–9/a low: 10–29 intermediate: 30–100/a high: > 100/a	III/C	All over endocrine complic. signif. higher in low surg vol for pat > 65 years, more so pat ≥ 80 years	Signif. diff surg vol* no minimum number
Tuggle [39] et al., 2008	607/TT/PTX/age ≤ 17 years	NA	NA	High vol surg improved outcome: fewest compli general/endocrine high:8.7%/5.6% ped.: 13.4%/11% other: 13.2%/9.5%	Pediatric (2 proc/a) other (M 7 proc/a) high (M 72 proc/a)	IV/C		Signif. diff surg vol.* p < 0.10 no minimum number
Boudourakis [40] et al., 2009	Cross-sectional in patient database various surgical proc 1999–2005: TT	NA	NA	High vs. low: mortality 1999: 2.5%/7.1% mortality 2005: 4.9%/7.9% general compl 1999: 2.5%/7.1% 2005: 4.9%/7.9% LOS 1999: 1.4d/2.4 LOS 2005: 1.3 days/3.9 days OR mortality: low vs. high 1999: 1.8 2005: 1.4	Low:9/a medium high:30/a	III/C	Increase proportion high vol surg 23% in 6 years	Signif. diff surg vol.* p < 0.001 no minimum number
Kandil [9] et al., 2013	46,261 proc	NA	NA	*Tracheostomy low 0.05% intermediate 0.02% high 0% *in-hospital mortality low 0.2% intermediate 0.03% high 0.02%	Proc/10 years < 10 low 10–99 intermediate ≥ 100 high	III/C	Low 2.3% intermediate 1.6% high 1.0%	Diff. surg vol influences hematoma rate
Adkisson [41] et al., 2014	1249/HT+TT/DTC ≥ 1 cm	3/359	0.8	High vol surg signif less all over compl in all categories hemorrhage: HVS 1/175 (0.4%) LVS 2/84 (2%)	10/a 20/a 25/a (< 30 LVS) 30/a (≥ 30 HVS) 50/a 100/a	III/C		Diff surg vol p < 0.58 no minimum number
Hauch [42] et al., 2014	62,722/HT vs. TT/benign	TT vs. HT: 1.54% vs. 1.24% (p = 0.0027)	NA	LVS higher OR overall compl vs. HVS: 1.53 (95% CI 1.12, 2.11; p = 0,0083 LVS: 24.1% complic IVS: 18.8% HVS: 14.5% hemorrhage: LVS: 0.274/18,954 IVS: 0.103/16,797 HVS: 0.000/1799	LVS: <10 proc/a IVS >10 < 99 proc/a HVS: > 99 proc/a	III/C	Hospital vol associated with gen. complic (p = 0.0046)	Signif. diff surg vol.* p < 0.0001 no minimum number
Adam [11] et al., 2017	16,954/TT/ benign and cancer	254	1.5	All over complic 6% LVS vs. HVS OR: 1.51 (p = 0.002) LOS + 12%, p = 0.006) hemorrhage: LVS: 1.6% HVS: 1.0% (p = 0.006)	LVS: ≤ 25/proc/a HVS	III/C	Median vol all surg: 7 linear decline all over complic. with no./proc performed/a	Sign. improved outcome* at ≥ 25/proc/a

DTC differentiated thyroid cancer, HT hemithyroidectomy, LOS length of hospital stay, TT total and near-total thyroidectomy, proc. procedure thyroid/±parathyroid resection, NA not assessed or not provided

*All over postoperative complication without specifically detailing hemorrhage

^§Meta-analysis data additionally provided