Fistula In Children Research Articles

KTP laser assisted endoscopic tissue fibrin glue biocauterization for congenital pyriform sinus fistula in children

ObjectiveThis study aims to assess the efficacy of a novel endoscopic management for congenital pyriform sinus fistula (CPSF) using potassium titanyl phosphate (KTP) laser assisted endoscopic tissue fibrin glue biocauterization in children. MethodFrom 2010 to 2014, a total of 5 children with recurrent or acute suppurative thyroiditis or neck abscess secondary to CPSF were enrolled retrospectively in this study. ResultsMean age at the first time of endoscopic biocauterization was 6.2 ± 0.7 (5–7) years. The barium swallow study detected a fistula in four cases. Endoscopy identified an internal opening at the pyriform sinus in all cases with four on the left side and one on the right side. All patients underwent KTP laser assisted endoscopic tissue fibrin glue biocauterization as treatment for CPSF. Only one case required the second endoscopic procedure due to fluctuation of symptoms. Post-endoscopic follow-up duration of these patients was 24.6 ± 11.6 (7–36) months. Neither complications nor recurrences were noted during follow-up in all patients. ConclusionsFor children presenting with repeated acute suppurative thyroiditis or neck infections, clinicians should highly suspect the possibility of CPSF. Endoscopy should be performed not only to confirm the diagnosis but also could be served as an initial treatment modality of biocauterization by KTP laser and tissue fibrin glue, which was demonstrated as a less invasive, safe, and effective method in children.

Coagulation, thrombophilia and patency of arteriovenous fistula in children undergoing haemodialysis compared with healthy volunteers: a prospective analysis.

This study aimed to assess whether markers of coagulation, fibrinolysis or thrombophilia are increased in children on haemodialysis compared with controls and whether measurement of any of these factors could help to identify patients at an increased risk of arteriovenous fistula (AVF) occlusion. Blood samples were taken from 55 children immediately before a session of haemodialysis and from 20 healthy volunteers. Thrombin-antithrombin (TAT), D-dimer, plasmin-antiplasmin (PAP) and anticardiolipin immunoglobulin G (ACA-Ig G) were measured by ELISA. Factor V Leiden mutation (G1691A) was determined by gene polymorphism [restriction fragment length polymorphism (RFLP)]. Determination of the patency of the AVF was prospectively followed up for a minimum of 4 years or until the AVF was nonfunctioning. Fifty-five patients were studied with a median follow-up of 659 days (range 30-1670 days). A significant increase was found in the levels of D-dimer, PAP and ACA-Ig G in haemodialysis patients with thrombosed and nonthrombosed native AVFs vs. There was a significant difference between both chronic haemodialysis patients with thrombosed and nonthrombosed native AVF with regard to ACA-IgG levels. At 1 year follow-up, primary patency was 61.4% (27 patients). In multivariate analysis, D-dimer was inversely associated with secondary patency.Thrombophilia may predispose children with end stage renal disease to access failure. The promising finding is that in children on haemodialysis, D-dimer levels were increased and inversely correlated with secondary patency. Further evaluation is required into the possible role of D-dimer as a biomarker of AVF occlusion.

小児痔瘻に対する瘻管腐食療法の効果について

小児痔瘻に対する瘻管腐食療法の効果について

Vacuum-therapy for complicated anterior abdominal wall wounds and intestinal fistulas in children

To present results of VAC application in children with complicated wounds of anterior abdominal wall combined with intestinal and/or biliary fistulas. For the last 7 years 8 patients aged from 1.5 months to 15 years with infected postoperative wounds of anterior abdominal wall complicated by intestinal fistulas (6), biliary and intestinal fistulas (1) and biliary fistula (1) have been treated at the surgical department №2 of Russian Children's Clinical Hospital. All patients received complex medical therapy and local VAC-therapy. Granulation and wound's size reduction were observed within first 7 days of VAC-therapy application in 5 (62.5%) children. In 4 (50%) patients at least 1 intestinal fistula has been closed in 15 days after VAC-therapy initiation on the average (range 7--24). Closure of all fistulas and wounds healing were observed in all patients in 28 days (range 16--42) after VAC-therapy initiation on the average. VAC-therapy is safe and effective treatment of complicated wounds of anterior abdominal wall combined with intestinal and/or biliary fistulas in children.

Induction and Maintenance Infliximab Therapy for the Treatment of Crohn's Disease with Perianal Fistulas in Children: Retrospective, Multicenter Study.

Infliximab is a biological drug used for the treatment of Crohn's disease in children. The aim of this retrospective study was the estimation of effectiveness and safety of infliximab in the treatment of Crohn's disease with perianal fistulas in children. Analysis comprised 50 children with Crohn's disease with perianal fistulas aged 9 to 18 years (16 girls and 34 boys) who failed to respond to conventional therapy. The children were divided into two groups: the first group contained 23 children with simple fistulas and the second - 27 children with complex fistulas. All children were treated with infliximab, administered in the dose of 5 mg per kilogram of the body mass. In the induction phase infliximab was administered at weeks 0, 2 and 6 and after clinical response in maintenance phase the drug was administered every 8 weeks; together for 12 months. In 76% of children after induction therapy with infliximab and in 71.87% after maintenance therapy the complete closure of fistula occurred. During the first year after the treatment a recurrence of a fistula was observed in 30.43% of the children. In two children anaphylactic shock was observed during injection of infliximab. The remaining children tolerated the drug well. The treatment with infliximab was effective in the majority of fistulazing Crohn's disease and caused the closure of perianal fistula which improved quality of life.

A Novel Technique of Branchial Fistula Tract Delineation and Excision In Children Allergic To Dyes

IntroductionBranchial arch fistula which results from a second arch anomaly is rarely seen in practice. The patients usually seek medical advice for persistent discharge from an opening in the neck or mucopurulent discharge from the opening of an infected fistulous tract. The treatment of choice for such a fistula is excision.
 Materials and MethodsA total of seven patients were operated for branchial fistula between 2010 and 2012. Among them, three children could not undergo a fistulogram due to allergy to the dye used and hence they were selected for our modified procedure.
 Surgical ProcedureA 3-0 or 4-0 polypropylene (Prolene™) thread was inserted into the fistulous tract. Both the ends of the tract were secured with the thread and the sinus tract was dissected out under gentle traction.
 ResultsThe patients who were allergic to dye could not have preoperative fistulograms and per-operative injection of dye was also avoided. The blue colour of the polypropylene thread inserted in the fistula tract helped in tracing and excision of the sinus tract. No major complications occurred during or after fistulectomy and the post-operative recovery was uneventful. No recurrence was seen in the scheduled follow-ups.
 ConclusionSurgical excision of branchial fistulas in children with allergy to dyes can be challenging. Insertion of a polypropylene thread into the fistula tract makes its subsequent dissection easy with minimal disruption of adjacent structures.

Small coronary artery fistulae in childhood: a 6-year experience of 31 cases in a tertiary paediatric cardiac centre.

This study describes the incidence and course of children with small coronary artery fistulae over a period of 6 years who presented at a paediatric tertiary-care centre. Materials and methods Age at diagnosis, mode of presentation, location (origin and drainage), and association with a cardiac defect were documented and analysed. All patients obtained an electrocardiogram, and older patients were further evaluated with an exercise treadmill test. A total of 31 patients were diagnosed with coronary artery fistula via transthoracic echocardiogram and comprised 0.43% of our entire patient group. Mean age was 6.14 years (standard deviation 5.4); 16 patients (52%) had associated cardiac defects. In the remaining 15 patients, the coronary artery fistula was discovered incidentally during diagnostic work-up for heart murmur or chest pain. Among all, 26 patients (84%) had left-sided and five patients (16%) had right-sided coronary artery fistulae. All right coronary artery fistula patients had associated cardiac defects; this was true for 42% of the patients with left coronary artery fistulae. None of the patients required any intervention due to the fistula, and spontaneous closure occurred in 12 patients (39%). Small coronary artery fistulae in children are frequently an incidental finding, and many will close spontaneously. Our data are supportive of a conservative, observant approach in asymptomatic patients with small coronary artery fistula in the paediatric population.

Closure of palatal fistulae

The occurrence of palatal fistulae in children with a cleft palate deformity after primary palatoplasty remains a relatively common complication. Symptomatic fistulae may cause problems with nasal air escape, nasal regurgitation, decreased speech intelligibility, articulation errors, and halitosis. A thorough understanding of the multiple reconstructive options, ranging from local flaps to free tissue transfer, is important in obtaining good patient outcomes. In this article, we describe some of the most commonly used methods for palatal closure.

Early Surgical Repair of the Coronary Artery Fistulae in Children: 30 Years of Experience

Congenital coronary artery fistula (CAF) is a rare anomaly that may lead to the development of early heart failure or late complications. We reviewed our experience and outcomes of surgically corrected CAF. From June 1982 to October 2012, 13 children aged between 3 days and 5.2 years (median 13.9 months) underwent repair of CAF. Four patients (30.8%) presented with congestive heart failure. Both coronary arteries were affected with equal incidence. All patients underwent preoperative cardiac catheterization. Repair was undertaken with cardiopulmonary bypass in 10 patients (76.9%), and 5 patients (38.5%) had concomitant repair of associated cardiac lesions. Seven patients (53.8%) underwent epicardial closure, and in 6 patients (46.2%), transcoronary/endocardial closure was used. There were no early or late deaths. Transient myocardial ischemia occurred in 2 patients (14.4%). One patient (7.7%) underwent reoperation (aortic valve repair) for a bicuspid aortic valve, 22 years after initial surgery. Follow-up data were complete for 12 patients (92.3%), with a median follow-up of 6 years (range, 1 month to 31 years). All patients were in New York Heart Association class I with no symptoms. There were no long-term cardiovascular sequelae, and no patient required coronary reintervention. Early surgical repair of CAF in children can be performed safely and carries an excellent long-term prognosis.

Acquired tubercular bronchoesophageal fistula in a hemophiliac child

Acquired bronchoesophageal fistula in children is usually a late diagnosis, due to the rarity of the condition. The diagnosis was further complicated by presence of multiple co-morbid conditions. We would like to emphasize the importance of tackling the co-morbid factors strategically along with the surgical aspects in this case report.

Endoscopic closure of persistent gastrocutaneous fistula in children.

The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips. A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa. Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage. While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

Management of H-type tracheoesophageal fistula in children: A report of 3 cases

H-type tracheoesophageal fistula (TEF) is a relatively uncommon congenital anomaly that can be difficult to identify and sometimes, challenging to repair. It is the Gross E type of esphageal atresia (EA) and constitutes 4% of all EA cases. Three infants with TEF were treated between 2003 and 2012. The diagnostic workup, surgical technique, and postoperative course of patients who underwent repair of H-TEF were reviewed. Conventional esophagram demonstrated the fistula in 2 of the patients and a cineradiographic procedure was performed to outline the H-TEF in the last patient. In all 3 cases the location of the fistula was confirmed by tracheoscopy. The closure of the fistula was made by cervical route in 2 cases and by thoracotomy in the remainig patient with distal located fistula. A high index of suspicion for an H-TEF should be maintained in the presence of neonatal respiratory symptoms. Since H-TEFs are known to be complicated with lower respiratory tract infection, early referral of these patients to pediatric surgeons and accurate and timely surgical treatment should be realized.

Use of the star sign to diagnose internal fistulas in pediatric patients with penetrating Crohn disease by MR enterography

Development of internal fistula due to extramural spread of inflammatory bowel disease is a characteristic feature of penetrating disease in patients with Crohn disease. The "star sign" is a radiological finding of internal fistula that has previously been described in the gastroenterology literature in adult Crohn disease patients undergoing MR enteroclysis. The goal of this paper is to review the clinical and imaging features of penetrating disease in pediatric Crohn disease patients, highlighting the star sign as a useful diagnostic tool for diagnosing internal fistula in children by MR enterography. The recognition of penetrating complications by MR imaging can have important therapeutic and prognostic implications.

Transcatheter closure of coronary arterial fistula in children and adolescents

Transcatheter closure of coronary arterial fistula (CAF) is being utilized increasingly as an alternative to surgical closure, but most of the literature on transcatheter closure of CAF in children and adolescents consists of case reports and reports of small series. The aim of this study was therefore to describe our experience of percutaneous closure of CAF in children and adolescents. Between April 1998 and December 2012, 37 children and adolescents with congenital CAF underwent percutaneous transcatheter closure. After aortic root angiography and selective coronary angiography, a guidewire was positioned to the fistula. In some cases, an arteriovenous wire loop (AV loop) was created. The sheath passed along the wire to the site of the desired occlusion of the fistula. One or more occlusion devices were selected to embolize the fistula. Occlusion devices were placed in 33 procedures (32 patients). Occlusion was unsuccessful in five patients. Duct occluders were placed in 12 procedures, coils in 11 (10 patients), muscular ventricular septal occluders in six, and vascular plugs in four procedures. The tricuspid valve was injured in two patients. One patient with a giant CAF aneurysm had a thrombosis within the aneurysm after transcatheter closure. There were no deaths, fistula dissection or myocardial infarction. Transcatheter closure of CAF is feasible in anatomically suitable cases, but injury to the tricuspid valve involved with AV loop methods can occur in closure procedures, and thrombus formation is possible in the blind pouch of the residual fistula after closure. Long-term follow up after fistula closure is necessary.

Only hepatic venous blood closes intrapulmonary shunts after cavopulmonary connection

In patients with a functional univentricular heart good results are nowadays accomplished with a staged approach to a total cavopulmonary connection (TCPC) [ [1] d'Udekem Y. Iyengar A.J. Cochrane A.D. et al. The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation. 2007; 116: I157-I164 PubMed Google Scholar ]. However, there are certain complications leading to a diminished quality of life as well as significant morbidity and mortality [ [2] Hess J. Long-term problems after cavopulmonary anastomosis: diagnosis and management. Thorac Cardiovasc Surg. 2001; 49: 98-100 Crossref PubMed Scopus (21) Google Scholar ]. Beside protein-losing enteropathy, plastic bronchitis, dysrhythmias, ventricular dysfunction and arteriovenous fistulas or venovenous collaterals due to increased venous pressure [ 2 Hess J. Long-term problems after cavopulmonary anastomosis: diagnosis and management. Thorac Cardiovasc Surg. 2001; 49: 98-100 Crossref PubMed Scopus (21) Google Scholar , 3 Lenz D. Hambsch J. Schneider P. et al. Protein-losing enteropathy in patients with Fontan circulation: is it triggered by infection?. Crit Care. 2003; 7: 185-190 Crossref PubMed Scopus (48) Google Scholar ], microscopic intrapulmonary shunts are one of the major complications [ [4] Bernstein H.S. Brook M.M. Silverman N.H. Bristow J. Development of pulmonary arteriovenous fistulae in children after cavopulmonary shunt. Circulation. 1995; 92: II309-II314 Crossref PubMed Google Scholar ]. The incidence is reported to be up to 25% [ [5] Cloutier A. Ash J.M. Smallhorn J.F. et al. Abnormal distribution of pulmonary blood flow after the Glenn shunt or Fontan procedure: risk of development of arteriovenous fistulae. Circulation. 1985; 72: 471-479 Crossref PubMed Scopus (162) Google Scholar ]. The pathophysiology of these shunts is discussed and associated with a so-called liver factor. It has been observed, that the shunts become present in lungs without direct perfusion with hepatic venous blood, which means hepatic venous drainage has to pass another capillary bed first [ [6] Srivastava D. Preminger T. Lock J.E. et al. Hepatic venous blood and the development of pulmonary arteriovenous malformations in congenital heart disease. Circulation. 1995; 92: 1217-1222 Crossref PubMed Scopus (304) Google Scholar ]. The absence of venous hepatic blood flow into the lungs then leads to development and progression of the intrapulmonary shunts. This is the case in patients with partial cavopulmonary connection (PCPC) or after completion to TCPC with the hepatic venous drainage being directed mainly to one lung. The liver-factor-hypothesis is also supported by the fact that the shunts disappear after redirecting hepatic venous blood to the affected lung [ 7 Shah M.J. Rychik J. Fogel M.A. Murphy J.D. Jacobs M.L. Pulmonary AV malformations after superior cavopulmonary connection: resolution after inclusion of hepatic veins in the pulmonary circulation. Ann Thorac Surg. 1997; 63: 960-963 Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar , 8 Praus A. Eicken A. Balling G. Schreiber C. Hess J. Progressive intrapulmonary shunting in a child after bidirectional Glenn operation only resolved after total cavopulmonary completion. Int J Cardiol. 2008; 128: e12-e15 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ]. However, the exact pathophysiology or details about the hepatic factor are still not completely understood. In this study we analyzed the results of different therapeutic approaches in patients with severe intrapulmonary shunting and functional univentricular heart.

Endoscopic-assisted surgery for pyriform sinus fistula in children: Experience of 165 cases from a single institution

BackgroundCongenital pyriform sinus fistula (PSF) is relatively rare, but often presents diagnostic and therapeutic challenges. Herein, we report our experience of endoscopic-assisted surgery of PSF in children. MethodsSince 1999, 165 children (100 males, 65 females) with PSF had been enrolled. Their clinical manifestations were recurrent lateral neck infection, cervical mass and respiratory distress. Preoperative investigations included barium swallow, ultrasound, computed tomography, and thyroid scan. After resolution of the infection, the fistulas were identified by the endoscopic-assisted technique at operation. The fistula tract was completely excised just at the apex of the pyriform sinus. More recently, the anatomic point where the fistula tract penetrated into the pharynx was specified and recorded. ResultsOf the 165 cases, the male to female ratio was 1.54:1, the median age of onset was 3.2 years (range, 1 day to 13.8 years), and median age at operation was 5.0 years (range, 17 days to 15.0 years). One hundred fifty-six (94.6%) fistulas located on the left side, 7 right, and 2 bilateral. Twelve neonates and young infants (younger than 3 months) presented with a large cervical cyst. The fistulas were completely excised in all but 2 (98.8%) with intraoperative gastroscopy successfully conducted in 160 cases (97.0%). In 77 cases the points where fistulas penetrated into the pharynx were specified intraoperatively, which were classified into 3 types according to their anatomic relationship with the inferior cornu of the thyroid cartilage (ICTC): type I (anterior to ICTC), 22 cases (28.5%); type II (inferior to ICTC), 18 cases (23.4%); and type III (posterior to ICTC), 37 cases (48.1%). Postoperatively, 160 cases recovered well without complications. PSF recurred in 5 cases, 2 of whom were cured by fistula re-excision and 3 remained asymptomatic. Esophageal perforation was found and repaired uneventfully in 1 neonate and 1 young infant. Transient postoperative hoarseness happened in 1 neonate. All the latter 3 cases had cervical cysts. ConclusionsTo our knowledge, this series is the largest report of PSF in children. Our results suggested that PSF is more common in males. With the help of endoscopy and a better understanding of the anatomic relationship between ICTC and the points where the fistulas penetrated into the pharynx, PSF excision can be done successfully with minimized complications. For neonates and young infants with a cervical cyst, however, the management of PSF continues to be a challenge.

Differential Lung Ventilation and Venovenous Extracorporeal Membrane Oxygenation for Traumatic Bronchopleural Fistula

A 16-year-old adolescent boy sustained traumatic bronchopleural fistula, refractory to conventional management, which was treated successfully with differential lung ventilation and extracorporeal membrane oxygenation support. This case highlights a novel approach for managing traumatic bronchopleural fistula in children.

Coronary artery fistulas in children

There are various types of coronary artery fistulas (CAF) with complex shapes. Therefore, it is important to make a correct diagnosis and to understand the relationship of the CAF to the adjacent structures before transcatheter occlusion or surgery. This study evaluated the feasibility of using 64-slice multidetector computed tomography (MDCT) angiography in diagnosing CAF. Two readers who were blinded to the results of echocardiography, intervention, or surgery retrospectively evaluated the coronary MDCT appearances of CAF in 10patients (4boys and 6girls; mean age, 2.9years; range, 1-6years). The origin, course, and distal entry site of the fistula were determined. The diameters of the origin and the distal entry site were measured and compared with those seen during intervention or surgery. The origin, course, and distal vessel entry site of the CAF were clearly outlined in all patients by MDCT. The distal vessel draining site involved a single entry vessel in all patients. Seven fistulas involved the right coronary artery, and three involved the left coronary artery. Four fistulas drained into the right ventricle, four into the right atrium, and two into the left ventricle. The diagnosis of CAF using MDCT was in accordance with diagnoses made during intervention or surgery. There was an excellent correlation between MDCT and transcatheter occlusion in quantifying the diameters of the origin and distal entry site (R = 0.90 and 0.92, respectively, P < 0.05). Coronary 64-slice MDCT angiography depicted the whole shape and course of the CAF as well as of the surrounding structures. It may serve as a noninvasive diagnostic tool when planning a therapeutic strategy.

Case series: Endoscopic management of fourth branchial arch anomalies

IntroductionFourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery. ObjectivesTo determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute. MethodsRetrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively. ResultsIn total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO2 laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11–41 months). ConclusionEndoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.

Incidence of Residual Oronasal Fistulas: A 20-Year Experience

To determine the incidence and most frequent anatomical locations of residual oronasal fistulas in children with different types of clefts who were treated at the University Department of Maxillofacial and Oral Surgery in Ljubljana. Retrospective analysis of 857 consecutive patients with cleft born between 1984 and 2003. After primary surgical repair, 33 out of 857 (3.9%) children had residual oronasal fistulas. The incidence of clinically significant fistulas that required surgical repair was 17 of 857 (2.0%). In children with unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), or isolated cleft palate (CP), the incidence of palatal fistulas was 23 of 644 (3.6%). Of these palatal fistulas, 12 (1.9%) were clinically significant. Oronasal fistulas were most frequently found in children with BCLP (9 of 88, 10.2%), followed by UCLP (12 of 215, 5.6%) and CP (12 of 341, 3.5%). No fistulas were found in children with unilateral cleft lip and alveolar ridge. In 10 cases (30.3%), the oronasal fistula remained in the alveolar ridge, in 11 cases (33.3%) in the anterior part of the hard palate, and in 11 cases (33.3%) at the junction of the hard and soft palates. In one case (3%), the records were lost. The low incidence of oronasal fistulas is the result of a surgical technique and tensionless suturing, followed by a two-layer closure, two-stage palate repair in BCLP and UCLP patients, and preoperative orthopedics in UCLP cases.