{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T22:40:44Z","timestamp":1784932844928,"version":"3.55.0"},"reference-count":48,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T00:00:00Z","timestamp":1747353600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Background\/Objectives: Postoperative hemorrhage is the most common complication after Trans-Oral Robotic Surgery (TORS) described in the literature. The aim of this study is to assess the presence of any risk factors that may impact postoperative bleeding. Methods: This was a retrospective study based on the analysis of patient data. Patients undergoing TORS procedures at the ENT Unit of Forl\u00ec Hospital from 2008 to 2022 for OSA (obstructive sleep apnea) or oncological disease and with a minimum follow-up of 30 days were included. The comorbidities analyzed were perioperative anticoagulant\/antiplatelet therapy and clinicopathological features concerning the pathology. Total bleeding and severe bleeding (which required management in the operating room) were included. Results: A total of 414 patients (106 oncological TORS and 308 OSA TORS patients) were included. Post-TORS bleeding occurred in 47 cases (11.3%) and severe bleeding in 18 cases (4.3%). The pathology (oncology vs. OSA) treated with TORS did not represent a risk factor (p = 0.466). Antiplatelet intake represented an important risk factor (p = 0.002). Postoperative hemorrhage for oncological TORS occurred in 11.3% patients; of these, 6.6% had severe bleeding. Artery ligation during neck dissection prevented the risk of severe bleeding (p &lt; 0.001). In TORS for OSA, postoperative hemorrhage was found in 11.4% cases, of which 3.6% were major bleeding. Neither the degree of OSA nor the association with other concurrent procedures were risk factors for postoperative bleeding in this study. Conclusions: Patients taking perioperative antiplatelet therapy have an almost 5-fold increased risk of developing postoperative bleeding. The pathology (oncology vs. OSA) does not influence the risk of bleeding. Prophylactic arterial ligation during neck dissection significantly decreases the risk of severe bleeding.<\/jats:p>","DOI":"10.3390\/jpm15050201","type":"journal-article","created":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T06:57:28Z","timestamp":1747378648000},"page":"201","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Trans-Oral Robotic Surgery (TORS) and Postoperative Hemorrhage: An Analysis of Risk Factors"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-8980-3877","authenticated-orcid":false,"given":"Andrea","family":"Migliorelli","sequence":"first","affiliation":[{"name":"ENT & Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44100 Ferrara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elia","family":"Biancoli","sequence":"additional","affiliation":[{"name":"Otolaryngology Unit, Department of Neurosciences (DNS), University of Padova, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marianna","family":"Manuelli","sequence":"additional","affiliation":[{"name":"ENT & Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44100 Ferrara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0698-937X","authenticated-orcid":false,"given":"Alberto","family":"Caranti","sequence":"additional","affiliation":[{"name":"Gruppo Otorinolaringoiatrico della Romagna, GVM Care & Research, 48018 Faenza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3455-2295","authenticated-orcid":false,"given":"Andrea","family":"Ciorba","sequence":"additional","affiliation":[{"name":"ENT & Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44100 Ferrara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiara","family":"Bianchini","sequence":"additional","affiliation":[{"name":"ENT & Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44100 Ferrara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Meccariello","sequence":"additional","affiliation":[{"name":"ENT Department, Ospedale Morgagni Pierantoni, AUSL Romagna, 47121 Forl\u00ec, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudio","family":"Vicini","sequence":"additional","affiliation":[{"name":"Gruppo Otorinolaringoiatrico della Romagna, GVM Care & Research, 48018 Faenza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.soc.2018.07.008","article-title":"Robotic Head and Neck Surgery","volume":"28","author":"Finegersh","year":"2019","journal-title":"Surg. Oncol. Clin. N. Am."},{"key":"ref_2","unstructured":"US Food and Drug Administration (2009). 501(k) Summary: Indications for Use of Intuitive Surgical Endoscopic Instrument Control System for Transoral Otolaryngology Procedures."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Vicini, C., Hoff, P.T., and Montevecchi, F. (2016). Transoral Robotic Surgery for Obstructive Sleep Apnea: A Practical Guide to Surgical Approach and Patient Management, Springer.","DOI":"10.1007\/978-3-319-34040-1"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1002\/hed.28033","article-title":"Short- and Long-Term Swallowing Outcomes in Head and Neck Cancer Patients Receiving TORS and Adjuvant Therapy","volume":"47","author":"Weiland","year":"2025","journal-title":"Head Neck"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"885","DOI":"10.1177\/0194599813503446","article-title":"Surgeon experience and complications with transoral robotic surgery (TORS)","volume":"149","author":"Chia","year":"2013","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1016\/j.oraloncology.2017.02.022","article-title":"Complications following transoral robotic surgery (TORS): A detailed institutional review of complications","volume":"67","author":"Hay","year":"2017","journal-title":"Oral Oncol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1465","DOI":"10.1097\/01.mlg.0000227184.90514.1a","article-title":"Transoral robotic surgery (TORS) for base of tongue neoplasms","volume":"116","author":"Weinstein","year":"2006","journal-title":"Laryngoscope"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1007\/s11701-015-0542-z","article-title":"Morbidity and mortality review of the French group of transoral robotic surgery: A multicentric study","volume":"10","author":"Aubry","year":"2016","journal-title":"J. Robot. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1111\/coa.13041","article-title":"Haemorrhage following transoral robotic surgery","volume":"43","author":"Hay","year":"2018","journal-title":"Clin. Otolaryngol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1007\/s40136-013-0022-9","article-title":"Robotic surgery for obstructive sleep apnea","volume":"1","author":"Vicini","year":"2013","journal-title":"Curr. Otorhinolaryngol. Rep."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1001\/jamaoto.2015.3673","article-title":"Morbidity and mortality associated with robotic head and neck surgery: An inquiry of the Food and Drug Administration manufacturer and user facility device experience database","volume":"142","author":"Chen","year":"2016","journal-title":"JAMA Otolaryngol. Head Neck Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1159\/000521288","article-title":"Charlson Comorbidity Index: A Critical Review of Clinimetric Properties","volume":"91","author":"Charlson","year":"2022","journal-title":"Psychother. Psychosom."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"313","DOI":"10.4103\/aca.ACA_205_20","article-title":"A simple and validated test for detecting patients with OSA: STOP-BANG questionnaire","volume":"24","author":"Nurgul","year":"2021","journal-title":"Ann. Card. Anaesth."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"97","DOI":"10.4103\/joacp.JOACP_176_20","article-title":"El-Ganzouri multivariate risk index based airway management in head and neck cancer patients: A retrospective analysis of 1000 patients in a tertiary care center","volume":"38","author":"Gupta","year":"2022","journal-title":"J. Anaesthesiol. Clin. Pharmacol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"311","DOI":"10.53350\/pjmhs22168311","article-title":"Adherence on recommended guidelines for pre-operative routine investigations in ASA (American Society of Anaesthesiologists) Grade 1 and 2 by anaesthesiologists working at tertiary care hospitals in the province of Sindh","volume":"16","author":"Siddiqui","year":"2022","journal-title":"Pak. J. Med. Health Sci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1007\/s11912-019-0799-x","article-title":"Changes in the 8th Edition of the American Joint Committee on Cancer (AJCC) Staging of Head and Neck Cancer: Rationale and Implications","volume":"21","author":"Zanoni","year":"2019","journal-title":"Curr. Oncol. Rep."},{"key":"ref_17","unstructured":"Rezaei, N. (2024). The Role of HPV in Head and Neck Cancer. Handbook of Cancer and Immunology, Springer."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1002\/hed.28007","article-title":"First Prospective Study on Single-Port Robotic Tongue Base Resection for Sleep Apnea","volume":"47","author":"Jeong","year":"2025","journal-title":"Head Neck"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1111\/coa.14230","article-title":"Eagle\u2019s Syndrome Treated With Transoral Robotic Surgery Approach: A Single Centre Experience and Literature Review","volume":"50","author":"Caranti","year":"2025","journal-title":"Clin. Otolaryngol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.21037\/ajo.2018.01.09","article-title":"Evolution of neck dissections performed in conjunction with transoral robotic surgery lateral oropharyngectomy","volume":"1","author":"Krishnan","year":"2018","journal-title":"Aust. J. Otolaryngol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Baptista, P.M., Diaz Zufiaurre, N., Garaycochea, O., Alcalde Navarrete, J.M., Moffa, A., Giorgi, L., Casale, M., O\u2019Connor-Reina, C., and Plaza, G. (2022). TORS as Part of Multilevel Surgery in OSA: The Importance of Careful Patient Selection and Outcomes. J. Clin. Med., 11.","DOI":"10.3390\/jcm11040990"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Cammaroto, G., Migliorelli, A., and Vicini, C. (2022). OSA: Treatments beyond CPAP. J. Clin. Med., 11.","DOI":"10.3390\/jcm11195938"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1510","DOI":"10.1002\/hed.24677","article-title":"Effect of transcervical arterial ligation on the severity of postoperative hemorrhage after transoral robotic surgery","volume":"39","author":"Kubik","year":"2017","journal-title":"Head Neck"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.oraloncology.2017.04.014","article-title":"The impact of prophylactic external carotid artery ligation on postoperative bleeding after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma","volume":"70","author":"Gleysteen","year":"2017","journal-title":"Oral Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2287","DOI":"10.1002\/lary.26626","article-title":"Postoperative hemorrhage and hospital revisit after transoral robotic surgery","volume":"127","author":"Zenga","year":"2017","journal-title":"Laryngoscope"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.oraloncology.2017.11.009","article-title":"Unplanned readmission following transoral robotic surgery","volume":"75","author":"Topf","year":"2017","journal-title":"Oral Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1002\/lary.28580","article-title":"Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review","volume":"131","author":"Stokes","year":"2021","journal-title":"Laryngoscope"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"902","DOI":"10.1080\/00016489.2023.2282149","article-title":"Transoral robotic surgery\u2014Time for consensus on pain assessment. A review","volume":"143","author":"Larsen","year":"2023","journal-title":"Acta Otolaryngol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1177\/0194599811434262","article-title":"Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome","volume":"146","author":"Friedman","year":"2012","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1811","DOI":"10.1002\/lary.23913","article-title":"Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome","volume":"123","author":"Lin","year":"2013","journal-title":"Laryngoscope"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1002\/hed.26480","article-title":"Transcervical arterial ligation for prevention of postoperative hemorrhage in transoral oropharyngectomy: Systematic review and meta-analysis","volume":"43","author":"Sharbel","year":"2021","journal-title":"Head Neck"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1177\/0194599813486254","article-title":"Hemorrhage after transoral robotic-assisted surgery","volume":"149","author":"Asher","year":"2013","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/EJA.0000000000002069","article-title":"Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care","volume":"42","author":"Lamperti","year":"2025","journal-title":"Eur. J. Anaesthesiol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Nichols, A.C., Yoo, J., Hammond, J.A., Fung, K., Winquist, E., Read, N., Venkatesan, V., MacNeil, S.D., Ernst, D.S., and Kuruvilla, S. (2013). Early-stage squamous cell carcinoma of the oropharynx: Radiotherapy vs. transoral robotic surgery (ORATOR)\u2014Study protocol for a randomized phase II trial. BMC Cancer, 13.","DOI":"10.1186\/1471-2407-13-133"},{"key":"ref_35","first-page":"1425","article-title":"Randomized Trial of Radiotherapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Long-Term Results of the ORATOR Trial","volume":"38","author":"Nichols","year":"2020","journal-title":"J. Clin. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Nichols, A.C., Lang, P., Prisman, E., Berthelet, E., Tran, E., Hamilton, S., Wu, J., Fung, K., de Almeida, J.R., and Bayley, A. (2020). Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): Study protocol for a randomized phase II trial. BMC Cancer, 20.","DOI":"10.1186\/s12885-020-6607-z"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Owadally, W., Hurt, C., Timmins, H., Parsons, E., Townsend, S., Patterson, J., Hutcheson, K., Powell, N., Beasley, M., and Palaniappan, N. (2015). PATHOS: A phase II\/III trial of risk-stratified, reduced-intensity adjuvant treatment in patients undergoing transoral surgery for Human Papillomavirus (HPV)-positive oropharyngeal cancer. BMC Cancer, 15.","DOI":"10.1186\/s12885-015-1598-x"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Chia, C., Sharp, S., Zhang, H., and Magarey, M.J. (2025). Lingual Artery Identification for Ligation in Neck Dissection and Transoral Surgery for Oropharyngeal Tumors. Laryngoscope.","DOI":"10.1002\/lary.32025"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1002\/hed.26020","article-title":"Prophylactic arterial ligation following transoral robotic surgery: A systematic review and meta-analysis","volume":"42","author":"Bollig","year":"2020","journal-title":"Head Neck"},{"key":"ref_40","unstructured":"ClinicalTrials.gov (2025, March 28). NCT01898494, Available online: https:\/\/clinicaltrials.gov\/show\/NCT01898494."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1016\/j.oraloncology.2017.06.012","article-title":"Reduction of severe oropharyngeal hemorrhage following transoral robotic surgery","volume":"72","author":"Old","year":"2017","journal-title":"Oral Oncol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1002\/lary.27005","article-title":"First bite syndrome following transcervical arterial ligation after transoral robotic surgery","volume":"128","author":"Topf","year":"2018","journal-title":"Laryngoscope"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Mouratidou, S., and Chaidas, K. (2024). Transoral Robotic Surgery for Patients with Obstructive Sleep Apnoea: A Systematic Literature Review of Current Practices. Life, 14.","DOI":"10.3390\/life14121700"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2216","DOI":"10.1002\/hed.26702","article-title":"Surgical, clinical, and functional outcomes of transoral robotic surgery used in sleep surgery for obstructive sleep apnea syndrome: A systematic review and meta-analysis","volume":"43","author":"Lechien","year":"2021","journal-title":"Head Neck"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1002\/lary.26060","article-title":"Transoral robotic base of tongue reduction for obstructive sleep apnea: A systematic review and meta-analysis","volume":"127","author":"Miller","year":"2017","journal-title":"Laryngoscope"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Tsou, Y.A., Hsu, C.C., Shih, L.C., Lin, T.C., Chiu, C.J., Tien, V.H., Tsai, M.H., and Chang, W.D. (2021). Combined Transoral Robotic Tongue Base Surgery and Palate Surgery in Obstructive Sleep Apnea Syndrome: Modified Uvulopalatopharyngoplasty versus Barbed Reposition Pharyngoplasty. J. Clin. Med., 10.","DOI":"10.3390\/jcm10143169"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Bosco, G., Morato, M., P\u00e9rez-Mart\u00edn, N., Navarro, A., Racionero, M.A., O\u2019Connor-Reina, C., Baptista, P., and Plaza, G. (2021). One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome. J. Clin. Med., 10.","DOI":"10.3390\/jcm10214822"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Iannella, G., Magliulo, G., Lo Iacono, C.A.M., Visconti, I.C., Lechien, J.R., Perrone, T., Cammaroto, G., Meccariello, G., Maniaci, A., and Cocuzza, S. (2022). Quality of Life and Excessive Daytime Sleepiness in Adults with Obstructive Sleep Apnea Who Are Treated with Multilevel Surgery or Adherent to Continuous Positive Airway Pressure. J. Clin. Med., 11.","DOI":"10.3390\/jcm11092375"}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/15\/5\/201\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:33:51Z","timestamp":1760031231000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/15\/5\/201"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,16]]},"references-count":48,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,5]]}},"alternative-id":["jpm15050201"],"URL":"https:\/\/doi.org\/10.3390\/jpm15050201","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,16]]}}}