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Late Bleeding Following Cleft Palate Repair: An Under-Reported Finding?
Abstract
The objective of this article is to assess the incidence of late bleeding following cleft palate repair (palatoplasty) in children. This is a retrospective review of a prospectively maintained database of patients treated for Cleft Lip and Palate in a tertiary academic pediatric hospital setting over 2 hospitals (Middlemore and Starship Hospitals) under the same multidisciplinary team of the Auckland Regional Cleft and Craniofacial Service, New Zealand. All patients with a diagnosis of Cleft Lip and/or Palate undergoing primary cleft palate repair over an 11 year period until March 2020 were included in the study. Our results found there were 482 patients with a new diagnosis of Cleft Lip and/or Palate from Jan 2009 through to March 2020. Three hundred sixty-six of those patients underwent primary palatoplasty at an average age of 10.5 months (range 8-18 months). The sub-types of cleft palate diagnoses were one-third Veau I, one-third Veau II, and the remaining one-third were Veau III, IV, and submucous cleft palate. One-third were syndromic. A total of 6 patients were re-admitted to hospital after discharge from their primary admission with bleeding from the cleft palate surgical site. Of the 6 patients re-admitted, 5 needed blood transfusions and 4 required an urgent return to the operating room. The authors found the rate of late bleeding following primary cleft palate repair in our unit is 1:61 operations or 1.6%. Late bleeding following cleft palate surgery is not well reported in the literature.
... experienced late bleeding, and only 0.7% encountered events severe enough to warrant readmission for transfusion or surgical hemostasis. These figures offer a substantial deviation from the higher rates historically reported and may reflect improvements in surgical techniques or postoperative care protocols [7]. ...
Introduction: The objective of this article is to assess and describe the incidence of postoperative hemorrhage following cleft palate surgery (palatoplasty), specifically focusing on need for return to the operating room for management of post-operative hemorrhage.
Methods: The TriNetX federated database was used to identify patients with a diagnosis of cleft lip and/or palate undergoing primary cleft palate repair over a twenty-year period from 2003 until2023. Primary endpoints assessed include post operative hemorrhage resulting in blood transfusion and/or return to the operating room; Kaplan-Meier analysis was used for statistical analysis.
Results: A total of 13,161 patients with cleft lip or palate over the last 20 years underwent operative intervention (palatoplasty). Of those patients, ninety-seven patients were found to have diagnosis of post-operative bleeding (confidence interval 1.196 +/-0.606). One hundred and seventy-five patients experienced post operative hemorrhage requiring transfusion of blood product (CI 1.491 +/-0.952). Seventy patients required return to the operating room for post-operative bleeding in the immediate post operative period.
Conclusions: Historic reporting of post-operative bleeding suggests a moderate rate of post-operative hemorrhage rate following palatoplasty, occasionally necessitating transfusion and return to operating room following index palatoplasty. Our retrospective review of a national database demonstrates a lesser incidence of post-operative hemorrhage than previously noted.
Objectives/hypothesis:
Tonsillectomy as a day-stay procedure remains controversial, although it is an established procedure in New Zealand. We reviewed our last 10 years' experience.
Methods:
A prospective audit was used to determine unplanned conversion from day-stay to overnight hospital admission rates and the incidence of postoperative complications.
Results:
There were 5,400 tonsillectomies performed over the 10-year study period (January 2004-January 2015); 71% as outpatients. The unplanned conversion rate to overnight stay was 0.4%. The median age of day-stay patients was 6.5 years (range 13 months-15 years) compared with those admitted for overnight stay (5 years; range 8 months-15 years). The primary postoperative bleed rate was 0.5% (confidence interval [CI] 0.3%-0.7%), and the combined primary and secondary posttonsillectomy bleed rate was 4.3% (CI 3.8%-5.0%). The rate of patients returning with postoperative complications within 1 month of surgery was 6.3% (CI 5.6%-7.0%).
Conclusion:
Day-stay tonsillectomy in the pediatric population is safe when performed using the described guidelines in a facility with appropriate resources.
Level of evidence:
4. Laryngoscope, 2016.
Bleeding, is one of the most common postoperative complications after palatoplasty in patients with cleft palate. The purpose of this article is to present our experience using a Foley catheter balloon for perioperative palatoplasty bleeding management. A retrospective data analysis was performed for all cases of palatoplasty performed by the author from 1999 to 2012 that experienced postoperative hemorrhage. These patients were managed by utilizing posterior nasal compression with a Foley catheter balloon for the period 2006 to 2012. We have compared two methods (we use before 2006 the reoperative method) with regards to the later development of palatal fistulae and cases with reoperative hemostasis. The study found no statistically significant differences between the conventional and proposed method in relation to the development of palatal fistulae (P=0.7). These findings suggest that nasal packing using a Foley balloon is a safe and effective method for postoperative bleeding control after palatoplasty in patients with cleft palate.
Background:
This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States.
Methods:
Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics.
Results:
Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all).
Conclusions:
Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery.
Clinical question/level of evidence:
Therapeutic, III.
We aimed to evaluate velopharyngeal function and speech outcomes of Sommerlad palatoplasty combined with sphincter pharyngoplasty in surgical repair of cleft palate in patients over five years old. Fifty-eight patients were reviewed between the years 2013 and 2017, 31 of whom were treated with Sommerlad palatoplasty combined with sphincter pharyngoplasty, (mean age 15 (range 9 - 22) years), and 27 were treated with Sommerlad palatoplasty alone (mean age 18 (range 10-25) years). Velopharyngeal function was evaluated by radiographic lateral cephalometry and nasoendoscopy. Hypernasality, nasal emissions, and intelligibility were used to assess speech. The rate of velopharyngeal competence was 20/31 in the palatoplasty plus pharyngoplasty group and 7/27 in the palatoplasty alone group after surgical treatment (p = 0.003). The improvements in hypernasality (p = 0.024), air emission (p = 0.004), and speech intelligibility (p = 0.004) in the palatoplasty plus pharyngoplasty group was better than that in the palatoplasty alone group. It has been suggested that the surgical approach with the palatoplasty together with the sphincter pharyngoplasty has a higher rate of success in surgical repair of older patients with cleft palate.
Objectives:
To investigate the dental caries experience of New Zealand children born with orofacial cleft (OFC), to compare this to age-specific national population-based data and to investigate any differences by demographic characteristics, cleft type and exposure to community water fluoridation.
Methods:
Nationwide retrospective study of 554 dental records from 478 children born after 1 January 2000 with OFC were assessed at aged 5 (n = 333) and 12 years (n = 221), with 76 children (15.9%) having records at both ages. Community Oral Health Service records were analysed to determine dental caries experience (dmft/DMFT). Logistic regression was used to assess the likelihood of having experienced dental caries (d3 mft/D3 MFT ≥ 1) and multivariable models for variables including demographic characteristics, cleft type and exposure to community water fluoridation.
Results:
A higher (49.6%) caries prevalence (dmft ≥ 1) and mean dmft at 5 years old (2.3; SD 3.6) were found in children with OFC than 5-year-olds in the general population (prevalence 40.4% and mean dmft 1.8). The 12-year-old (37.6%) caries prevalence (DMFT ≥ 1) and mean DMFT 0.8 (SD 1.4) were similar to population-based data (caries prevalence 37.3% and mean DMFT 0.9). Children with caries (dmf/DMF ≥ 1) had means of 4.8 (SD 3.8) at age 5 and 2.1 (SD 1.4) at age 12 years. Greater caries experience was associated Pacific and Māori ethnicity, and not receiving community water fluoridation. No differences were detected by sex or cleft type.
Conclusion:
The dental caries experience for 5-year-old children with OFC was poor in relation to population-based data and similar for 12-year-olds. Preventive guidelines for children with OFC from an early age should be a priority, along with the extension of community water fluoridation coverage.
Objectives
To (1) assess nasolabial outcomes across four main cleft subgroups, (2) assess agreement using a categorical and a continuous scoring measure and (3) compare outcomes to international studies.
Settings and Sample Population
Analysis of 470 images of which 218 were Unilateral Cleft Lip and Palate (UCLP), 128 Unilateral Cleft Lip (UCL), 90 Bilateral Cleft Lip and Palate (BCLP) and 34 Bilateral Cleft Lip (BCL). Images were taken around five (n=279) and eight‐ten (n=191) years of age.
Materials & Methods
Cropped images were assessed using the Asher McDade (AM) and a 100mm Visual Analogue Scale (VAS) by a panel of six raters. Scoring was undertaken for vermillion border and nasal form, symmetry and profile. Analysis was undertaken for each sub‐score, a total score with sensitivity analysis using a total score based on the sub scores for each patient. AM intra and inter rater reliability was assessed using weighted kappa and for the VAS components reliability was assessed using Pearson correlation.
Results
The AM intra‐rater reliability was moderate/substantial, while inter‐rater reliability was fair. The VAS intra‐rater correlations were high and inter‐rater correlations were moderate. Better outcomes were found with CL vs CLP. No differences were found for sex, ethnicity, age and cleft laterality (unilateral). The AM found no difference between unilateral or bilateral. The VAS found bilateral scored worse than unilateral for both CL and CLP.
Conclusions
The nasolabial outcomes differ by cleft type. The correlation was relatively high for the VAS while the AM had relatively poor reliability.
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Objective
To investigate the amount of bone fill post‐secondary alveolar bone grafting for children with cleft in New Zealand.
Settings and Sample Population
Retrospective analysis of post‐operative intraoral peri‐apical and upper anterior occlusal radiographs of 45 grafted sites where all grafting was undertaken within the New Zealand public hospital service.
Materials and Methods
A modified Kindelan Index and a 100 mm Visual Analogue Scale (VAS) were used to assess the amount of bone fill using intra oral radiographs by 4 orthodontists experienced in cleft care and who were blind to the patient's identity. Fourteen duplicated radiographs were randomly selected and added to the sample for reliability assessment.
Results
The Kindelan Index rated 37.8% Grade 1 (Good), 31.1% rated Grade 2 (Satisfactory), 22.2% rated Grade 3 (Unsatisfactory) and 8.9% Grade 4 (Failure), a combined unsatisfactory/failure rate of 31.1%. The average VAS score was 50mm +/‐24mm and there was a strong relationship between Kindelan and VAS assessments.
Those patients aged 10‐11 years had significantly better outcomes using both assessments compared to those aged <10 and >11. The VAS assessment found that higher caseload surgeons had better outcomes, although the difference was of borderline statistical significance (mean VAS 56mm vs 44mm p=0.07).
Conclusions
Contemporary secondary alveolar bone grafting bone fill outcomes in New Zealand are poor when compared to contemporary international studies. These findings indicate a review of secondary bone grafting is required to improve outcomes for New Zealand children with cleft.
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Objectives
To evaluate dental arch relationships of patients with complete unilateral and complete bilateral cleft lip and palate (CUCLP/CBCLP) in New Zealand.
Setting and Sample Population
Retrospective nationwide observational outcomes study involving 100 CUCLP and 32 CBCLP non‐syndromic patients.
Material and Methods
Four calibrated assessors, blinded to the origin of the randomised digital models, used the GOSLON (UCLP) and the Bauru‐BCLP (BCLP) Yardsticks and a 100mm Visual Analogue Scale (VAS) (UCLP&BCLP) to assess dental arch relationships. Weighted Kappa statistics were used to determine the intra and inter‐rater reliability for the GOSLON/Bauru‐BCLP Yardsticks and correlations for the VAS.
Results
Intra‐ rater reliability ranged from 0.57‐0.88 (GOSLON), 0.62‐0.84 (Bauru‐BCLP) and 0.45‐0.93 (VAS). Inter‐rater reliability ranged from 0.62‐0.86, (GOSLON), 0.48‐0.75 (Bauru‐BCLP) and 0.64‐0.93 (VAS). Of the 100 CUCLP models, 46% had poor/very poor, 28% fair and 26% had good/very good dental arch relationships. Of the 32 CBCLP models, 37.5% were poor/very poor, 40.6% fair and 21.9% had good/very good dental arch relationships. The mean CUCLP VAS score was 50.5mm (SD 19.9mm) while the mean CBCLP VAS score was 40.0mm (SD 22.0mm) and both showed a strong relationship with their respective Yardstick scorings.
Conclusion
The dental arch relationships of children in New Zealand with CUCLP are similar to those centres in the Eurocleft and Americleft studies which had less favourable outcomes. Those with CBCLP are inferior to those reported elsewhere. Continued monitoring will allow for tracking of improvement in outcomes.
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A composite technique was developed for repair of the complete unilateral cleft palate. Using a Veau type pushback on the cleft side simplified anterior closure, and the cleft hemipalate was lengthened. A von Langenbeck procedure on the noncleft side minimized anterior raw area and provided a stable point for fixation. Fourteen consecutive patients with unilateral complete cleft palate underwent hybrid palatoplasties. There were no significant intra- or postoperative complications. No differences in speech development have been noted. The procedure was no more difficult than either of the standard procedures and offers technical and theoretical benefits.
The aim of this study was to analyze the location and cause of postoperative bleeding after posterior pharyngeal flap pharyngoplasty and to investigate the surgical techniques with the goal of treating the bleeding. The patients received posterior pharyngeal flap pharyngoplasty in the Cleft Lip and Palate Treatment and Research Center of Shanghai Jiaotong University School of Medicine from January 2003 to December 2014, and postoperative bleeding in the surgical area was retrospectively analyzed. According to the record of the exploration of hemostasis, the locations and causes of the bleeding were summarized. In the 12-year study, a total of 1037 patients received posterior pharyngeal flap pharyngoplasty, including 621 males and 416 females with ages ranging from 4 to 40 years and a mean age of 13.7 years. Among these patients, 7 individuals (0.68%) experienced significant postoperative bleeding with the exploration of hemostasis. All patients were male, aged 5 to 26 years with a mean age of 15.7 years, and all were sent back to the operating room for exploration of hemostasis under general anesthesia. The sites of bleeding included 2 patients (28.6%) of the soft palate, 2 patients (28.6%) of the pharyngeal flap pedicle, and 3 patients (42.8%) of the nasopharynx. In posterior pharyngeal flap pharyngoplasty, particular attention should be paid to the protection of the blood vessels in the soft palate and the treatment of the vascular pedicle. Postoperative bleeding is very dangerous and generally requires immediate exploration in the operating room under general anesthesia.
Background:
Blood loss during cleft palate surgery has been investigated in previous research, but there is no report regarding blood loss when performing Furlow's double opposing Z-plasty (DOZ). In the present study, we evaluated intraoperative blood loss in patients with cleft palate who underwent the DOZ procedure.
Materials and methods:
Intraoperative blood loss was prospectively investigated in 59 patients undergoing palatoplasty with DOZ by a single surgeon between August 2012 and July 2013. Demographic factors and clinical status, including cleft type and palatal gap, were recorded. Blood loss was evaluated by measuring the change in weight of a suction bottle, suction line, and gauze balls.
Results:
Mean blood loss was 16.61 ± 10.33 mL, which accounted for 5% of total blood volume. Male sex, older age, severe cleft type, larger palatal gap, relaxed incision, and increased operative time contributed to greater blood loss. The amount of intraoperative bleeding could be predicted by the following equation: Blood loss = -5.64 + 6.18 (male patients) + 7.58 (severe type cleft) + 0.88 × age (months) + 0.84 × palatal gap (mm).
Conclusions:
We found that the DOZ technique causes mild blood loss, but bleeding amount tended to increase in older male patients with a severe cleft and a larger palatal gap. The use of relaxed incisions during palatoplasty and prolonged operation times also contributed to greater blood loss.
Aim:
To determine the incidence of orofacial cleft at birth in New Zealand over 10 years from January 2000.
Methods:
Comparison of data collected from cleft units and data held on the national minimum dataset.
Results:
The overall incidence of OFC in New Zealand over a 10 year period was found to be 1.79 per 1,000 live births, higher than the norm for Western society. The major reason for this increased rate was an increased rate for the Māori 2.37 per 1,000 live births, specifically related to a Cleft Palate alone rate over twice that of the European (1.54 vs 0.73 per 1,000 live births). The rate for Pacific was half way between (1.04 per 1,000 live births). The rate of Cleft Lip alone was significantly lower in both Māori and Pacific populations. Different sex ratios were also seen in relation to Cleft Lip and Cleft Lip and Palate for Māori and Pacific compared to those normally reported.
Conclusions:
Māori have an increased incidence of Orofacial Cleft due to one of the highest rates of Cleft Palate alone in the world. Further aetiological studies involving genetic and environmental factors are required to elicit the reasons for this increased incidence.
The aims of palatoplasty are to improve feeding, to achieve normal speech, and to minimize maxillary growth restriction. The technique of palate repair may also have an impact on middle ear function and hearing. Cleft palate repair is the most important component of cleft surgery, not only in that it determines the outcome as far as speech and communication is concerned, but also in that it potentially has the greatest impact on maxillary growth and the dental arch relationship. But the evolution of palatoplasty has been relatively slower than cheiloplasty. Most of the frequently used techniques nowadays are derived from the early 1900s [1–5]. Though surgeons have started to highlight the reconstruction of the levator veli palatine (LVP) the anatomic restoration has never been accomplished [6–8]. On the other hand, the success of velopharyngeal closure (VPC) can be influenced by a number of factors, such as patient age [9, 10], the surgeon’s expertise and width of cleft [11]. Therefore, it is difficult currently to assess the significance of velo palatine levator reconstruction in palatoplasty. In addition, VPC is the result of multiple factors, and muscular reconstruction is only a technique affecting the soft palate. However, the operative anatomic restoration of LVP is definitely an ideal worth pursuing. The authors have persisted in practising this technique in different countries during the past decades and have achieved better results than traditional techniques [12]. The better results include both a higher post-operative VPC ratio and maximizing development of the maxilla and maxillary dental arch [13], since there is less use of releasing incisions and therefore reduced scarring [14]. These results make us firmly convinced that complete anatomic reconstruction of the LVP is a promising technique, which has radically changed the techniques and conceptualization of palatoplasty.
Objective:
To assess the effect of tranexamic acid on the quality of the surgical field.
Design:
Prospective, randomized, double-blind study.
Setting:
Institutional, tertiary referral hospital.
Participants:
American Society of Anesthesiologists physical status class I patients, aged 8 to 60 months with Group II or III (Balakrishnan's classification) clefts scheduled for cleft palate repair.
Interventions:
Children were randomized into two groups. The control group received saline, and the tranexamic acid group received tranexamic acid 10 mg/kg as a bolus, 15 minutes before incision.
Main outcome measures:
Grade of surgical field on a 10-point scale, surgeon satisfaction, and primary hemorrhage.
Results:
Significant improvements were noted in surgeon satisfaction and median grade of assessment of the surgical field (4 [interquartile range, 4 to 6] in the control group vs. 3 [interquartile range, 2 to 4] in the test group; P = .003) in the tranexamic acid group compared to the control group.
Conclusion:
Preincision administration of 10 mg/kg of tranexamic acid significantly improved the surgical field during cleft palate repair.
Objectives
To analyse post-tonsillectomy haemorrhage (PTH) rates related to technique for dissection and haemostasis.Study designRegister study from the National Tonsil Surgery Register in Sweden (NTSRS)Methods
All patients, subjected to tonsillectomy (TE) without adenoidectomy 1st March 2009 - 26th April 2013 were included in the study. The surgeon reports data about technique and early PTH, while late PTH is reported by the patient in a questionnaire 30 days after surgery.Results15734 patients with complete data concerning technique for dissection and for haemostasis were identified in the NTSRS. Techniques used were cold steel dissection with uni- or bipolar diathermy haemostasis (65.3%), diathermy scissors (15.7%), coblation (9.1%), cold steel dissection with cold haemostasis (7.4%) and ultrascision (2.5%). Early and late PTH were reported in 3.2% and 9.4% of the cases respectively, and return to theatre (RTT) in 2.7%.The rates for PTH and RTT related to technique were analysed. Compared with cold dissection+ cold haemostasis, late PTH rate was 2.8 times higher after cold dissection + hot haemostasis, 3.2 times higher after coblation, 4.3 times higher after diathermy scissors, and 5.6 times higher after ultrascision. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH.Conclusions
All hot techniques resulted in a higher risk for late PTH compared with cold steel dissection +cold haemostasis. The risk for RTT was higher for all hot techniques except for coblation, while ultrascision resulted in a lower risk for early PTH. An early PTH was associated with an increased risk for late PTH.This article is protected by copyright. All rights reserved.
Background:
The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice.
Methods:
A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used.
Results:
A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip-cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent).
Conclusions:
Palatal fistulae were more likely to occur in cases of combined cleft lip-cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme.
Clinical question/level of evidence:
Therapeutic, III.
Objective:
To analyze short term surgical complications after primary cleft lip repair.
Patients and design:
A total of 3108 consecutive lip repairs with 2062 follow-ups were reviewed retrospectively through medical records. Patients were aged 3 months to 75 years at the time of surgery, with a median of 7 years.
Setting:
Guwahati Comprehensive Cleft Care Center, Assam, India.
Intervention:
Primary cleft lip repair.
Main outcome measures:
Documented complications in terms of dehiscence, necrosis, infection, and suture granuloma were compiled. Logistic regression was used with dehiscence (yes/no) or infection (yes/no) as binary dependant variables. Age, cleft type, and surgeon (visiting/long term) were used as covariates.
Results:
Among the 2062 patients who returned for early follow-up, 90 (4.4%) had one or more complications. Dehiscence (3.2%) and infection (1.1%) were the most common types of complication. Visiting surgeon, complete cleft, and bilateral cleft were significantly associated with wound dehiscence, and complete cleft was associated with wound infection according to the logistic regression analysis. Of patients with bilateral complete clefts, 6.9% suffered from some degree of wound dehiscence.
Conclusion:
In a setting where presurgical molding is unavailable and patients present at all ages, lip wound dehiscence is a relatively common complication in patients with bilateral complete clefts. The risk of dehiscence, however, is reduced when these cases are assigned to surgeons with experience with these types of clefts. We also found that the incidence of wound infection can be kept relatively low, even without the use of postoperative antibiotics.
The aim of palate repair is to restore normal eating and drinking function and normal speech development and still maintain undisturbed facial growth. The repair should be performed with a low frequency of complications. A number of factors are thought to contribute to the formation of fistulas after palatoplasty; they include patient factors and treatment issues. The aim of this study was to review all patients operated on with palatoplasties according to Sommerlad in our clinic, examine the fistula frequency and analyse risk factors for the development of fistulas after palate repair. During the study period, 175 patients were operated on with palatoplasties according to Sommerlad by the senior cleft surgeon. The group included 150 native patients and 25 adopted children. In the native population, seven patients developed fistulas and the fistula frequency was thus 5%. In the non-native group four patients developed fistulas, which gave a fistula frequency of 16%. In conclusion, the fistula frequency after Sommerlad repair of cleft palate is low in our material and few patients need fistula repair. The liberal usage of Langenbeck flaps might give a lower fistula rate. The most common place for fistulas is the junction of the soft and hard palate. No clear difference could be seen between different types of clefts. Syndromes and associated malformation seem to play a small role in the formation of fistulas. The fistula frequency in the non-native population is higher. A number of factors are different in the non-native population.
Introduction:
Infants are obligate nasal breathers. Cleft palate closure may result in upper airway compromise. We describe children undergoing corrective palatal surgery who required unplanned airway support.
Setting:
Tertiary referral unit.
Method:
Retrospective study (2007-2009) of 157 cleft palate procedures (70 primary procedures) in 43 patients. Exclusion criteria comprised combined cleft lip and palate, secondary palate procedure, and pre-existing airway support.
Results:
The children's mean age was 7.5 months and their mean weight 7.72 kg. Eight children were syndromic, and eight underwent pre-operative sleep studies (five positive, three negative). Post-operatively, five developed respiratory distress and four required oxygen, both events significantly associated with pre-operative obstructive sleep apnoea (p = 0.001 and 0.015, respectively). Four desaturated within 24 hours. Five required a nasopharyngeal airway. Hospital stay (mean, 4 days) was significantly associated with obstructive sleep apnoea (p = 0.002) and nasopharyngeal airway insertion (p = 0.017).
Discussion:
Pre-operative obstructive sleep apnoea correlated significantly with post-operative respiratory distress, supplementary oxygen requirement, nasopharyngeal airway insertion and hospital stay. We recommend pre-operative sleep investigations for all children undergoing cleft palate repair, to enable appropriate timing of the procedure.
A method of continuously assessing peroperative blood loss is presented. A calibrated trap which collects all the blood loss is placed in the suction tubing. Bipolar diathermy and suction maintain a bloodless wound. A test using 20 ml of fresh venous blood showed that approximately 5 ml remained clotted in the tubing and 15 ml entered the trap. The method is particularly applicable to cleft lip and palate surgery. © 1990 The Trustees of British Association of Plastic Surgeons. All rights reserved.
The author has developed a technique of palate repair that combines minimal hard palate dissection with radical retropositioning of the velar musculature and tensor tenotomy. The repair is performed under the operating microscope. Results are reported for 442 primary palate repairs performed between 1978 and 1992 inclusive, with follow-up of at least 10 years. In 80 percent of these palate repairs, repair was carried out through incisions at the margins of the cleft and without any mucoperiosteal flap elevation or lateral incisions. Secondary velopharyngeal rates have decreased from 10.2 to 4.9 to 4.6 percent in successive 5-year periods within this 15-year period. Evidence from independent assessment of speech results in palate re-repair and submucous cleft palate repair suggests that this more radical muscle dissection improves velar function.
Early complications after cleft palate repair
- Deshpande
Effectiveness of tranexamic acid for reducing intraoperative bleeding in palatoplasties: a randomized clinical trial
- Arantes