Postoperative Fistula Formation Research Articles

Neck Dissection Timing in Transoral Robotic or Laser Microsurgery in Oropharyngeal Cancer: A Systematic Review.

ObjectiveThis review assesses the effect on intra- and postoperative patient outcomes of the timing of neck dissection in relation to transoral surgery. Outcome measures include postoperative bleeding, intra- and postoperative fistula formation, and disease-specific and overall survival.Data SourcesA search was conducted across the MEDLINE, Embase, US National Library of Medicine, and Cochrane databases with search terms in July 2021.Review MethodsArticles that conformed with specified inclusion criteria were included. Included articles were scanned for bias with the ROBINS-I tool.ResultsNineteen articles were selected for qualitative analysis, including 546 patients who had neck dissection in conjunction with transoral robotic surgery/transoral laser microsurgery (TORS/TLM). Seventy-one (18%) patients had neck dissection prior to TORS/TLM, 39 (10%) had neck dissection performed after TORS/TLM, and 281 (72%) had concurrent procedures. In patients with neck dissection before TORS/TLM, 3% experienced major postoperative bleeding, and fistula rates were 0%. In the cohort with neck dissection after TORS/TLM, 3% experienced minor postoperative hemorrhage, and 8% had intraoperative fistulae. In the concurrent cohort of patients, 1% had major postoperative bleeds and 0.3% had minor bleeds, while 4% developed intraoperative fistulas and 0.3% developed postoperative fistulas.ConclusionCurrent evidence indicated that there appears to be no correlation between timing of neck dissection and complications. This systematic review found insufficient data to comment on whether the timing of neck dissection in relation to TORS/TLM affects the outcomes of patients.

Comparative study between snodgrass urethroplasty and modified snodgrass urethroplasty for distal penile hypospadias in terms of post-operative urethrocutaneous fistula formation

Background: Hypospadias is a congenital defect involving the male urethra characterized by the absence of urethral meatus at its normal position. This anomaly is usually associated with the ventrally deficient but dorsally hooded skin. In some cases, the penis is ventrally curved. Surgery is the option for this defect. So many procedures have been developed but none is free from the development of urethrocutaneous fistula. Now-a-days, the popular Snodgrass procedure is widely practiced but still fistula occurs. Many factors are thought to be responsible for it. The most important one is defective ventral penile skin which is deficient of vascular and collagen tissues. To minimize these deficient factors, a dorsal vascular preputial flap is transferred ventrally (modified) to reduce fistula formation further. A comparative study was disigned to determine the role of dorsal vascular flap.Methods: The prospective observational study was conducted in the department of pediatric surgery, Bangabandhu Sheikh Mujib medical university, Dhaka, Bangladesh since February 2017 to May 2021.Results: A total of 40 patients with distal penile hypospadias were included in this study. They were divided into Group A and group B, 20 for each. Snodgrass procedure was for Group A and the modified Snodgrass procedure was done for group B. The outcome of both the groups was determined in terms of fistula formation. Seven patients in group-A and one patient in group B developed fistula. The results were analyzed and were found statistically significant.Conclusions: Modified Snodgrass urethroplasty has a better outcome.

Outcome of Nasal Layer Reinforcement With Autologous Dermis in Cleft Palate Repair on Postoperative Fistula Formation.

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective. A prospective study. Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021. The addition of autologous dermal graft for palatoplasty. Outcome of the study was fistula development or exposure of dermal graft. Autologous dermal graft was harvested of average dimension of 8.73 cm2 (range 5.25-18 cm2) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification). Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices.

Predictors of post-operative pancreatic fistula formation in pancreatic neuroendocrine tumors: A national surgical quality improvement program analysis

BackgroundPost-operative pancreatic fistula (POPF) is a serious complication following pancreas surgery. We aimed to establish factors associated with POPF specifically in patients with pancreatic neuroendocrine tumors (PNET). MethodsThe 2014–2018 American College of Surgeons National Surgical Quality Improvement Program database was querried for patients undergoing resection for PNET. The impact of patient, tumor, and operative factors on POPF formation was evaluated. Results3532 patient underwent resections for PNET. The POPF rate was significantly higher in patients with PNET (24.8%) versus non-PNET (16.4%) (p < 0.0001). Male sex (OR 1.45, 95% CI 1.11–1.89), enucleation (OR 3.14, 95% CI 1.10–8.98), pancreaticoduodenectomy (OR 1.51, 95% CI 1.13–2.03), small duct size <3 mm (OR 3.24, 95% CI 1.62–6.48), and soft gland texture (OR 1.81, 95% CI 1.18–2.77) were independently associated with POPF in PNET patients on multivariable analysis. ConclusionsPOPF is more common in patients undergoing resection for PNET and is dictated primarily by surgical approach and gland characteristics.

Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty.

The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty. A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development. Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019). The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft. Therapeutic, III.

A predictor of a postoperative fistula after double-opposing Z-plasty in bilateral cleft lip and palate patients

Furlow double-opposing Z-plasty (FDOZ) as primary palatoplasty for the bilateral cleft lip and palate (BCLP) closure often leads to a palatal fistula formation in cases with wide clefts. We examined the utility of the calculated maximum closable cleft width to determine the feasibility of a direct palatal closure without lateral incisions. In this retrospective study, we analyzed consecutive patients with a BCLP who were treated for 5 years from 2009. In sixty-three BCLP patients, the following dimensions were measured preoperatively: an actual distance between maxillary tuberosities (Actual X); actual cleft height, calculated from the line joining the maxillary tuberosities to the cleft edge (Actual Y); and actual cleft width at the hard-soft palate junction (Actual Z) and calculated maximum cleft width requiring a direct closure (CMZ). Six months postoperatively, the relationships between the fistula occurrence and actual Z/CMZ were examined. Median values (interquartile range) of Actual X, Y, and Z and CMZ were 35.0 (33.0-39.0) mm, 7.0 (6.0-8.0) mm, 10.0 (8.0-11.0) mm, and 4.6 (2.7-5.7) mm, respectively. The median age at operation was 8.0 (7.0-17.0) months. Fistulae at the hard-soft palate junction developed postoperatively in three cases with more than a 10-mm cleft width (4.76%). A receiver operating characteristic (ROC) curve analysis indicated that actual Z was a better predictor of a postoperative fistula formation than CMZ. An actual cleft width was a better predictor of the fistula occurrence than a calculated maximum cleft width after FDOZ for a BCLP repair. The low fistula rate of FDOZ suggested that FDOZ could be used to close the palate with less than a 10-mm cleft width.

Outcomes and complications of open, laparoscopic, and hybrid giant ventral hernia repair.

BACKGROUNDAn incisional hernia is a common complication of abdominal surgery.AIMTo evaluate the outcomes and complications of hybrid application of open and laparoscopic approaches in giant ventral hernia repair.METHODSMedical records of patients who underwent open, laparoscopic, or hybrid surgery for a giant ventral hernia from 2006 to 2013 were retrospectively reviewed. The hernia recurrence rate and intra- and postoperative complications were calculated and recorded.RESULTSOpen, laparoscopic, and hybrid approaches were performed in 82, 94, and 132 patients, respectively. The mean hernia diameter was 13.11 ± 3.4 cm. The incidence of hernia recurrence in the hybrid procedure group was 1.3%, with a mean follow-up of 41 mo. This finding was significantly lower than that in the laparoscopic (12.3%) or open procedure groups (8.5%; P < 0.05). The incidence of intraoperative intestinal injury was 6.1%, 4.1%, and 1.5% in the open, laparoscopic, and hybrid procedures, respectively (hybrid vs open and laparoscopic procedures; P < 0.05). The proportion of postoperative intestinal fistula formation in the open, laparoscopic, and hybrid approach groups was 2.4%, 6.8%, and 3.3%, respectively (P > 0.05).CONCLUSIONA hybrid application of open and laparoscopic approaches was more effective and safer for repairing a giant ventral hernia than a single open or laparoscopic procedure.

An Age-BMI Compound Variable Predicts Morbidity and Mortality Following Pancreaticoduodenectomy: An NSQIP Analysis

Introduction: Pancreaticoduodenectomy (PD) is the recommended surgical therapy for periampullary lesions including pancreatic head tumors or select iatrogenic and inflammatory conditions. We sought to explore the impact of age and BMI in determining outcomes of PD. Methods: The ACS-NSQIP pancreatectomy targeted file was used to identify PDs from 2014-2019. Patients were stratified into eight different categories according to a compound age-BMI variable and risk-adjusted. Age of 65 years was set for young vs elderly. Obesity was classified as class I (BMI 30-35), class II (BMI 35-40), and class III (BMI >40). Young-normal/overweight-(BMI<30) was considered as the reference group. Results: Young-obese class I (OR 1.23, p = 0.003), young-obese class III (OR 1.54, p = 0.03), and elderly-obese class II (OR 1.51, p-value = 0.003) had statistically significant higher odds of morbidity/mortality. Young-obese class I (OR 1.95, p <0.001), young-obese class II (OR 1.59, p = 0.018), young-obese class III (OR 3.24, p <0.001), elderly-obese class I (OR 1.38, p = 0.008), elderly-obese class II (OR 1.76, p = 0.001), and elderly-obese class III (OR 1.65, p = 0.005) had statistically significant higher odds of postoperative pancreatic fistula formation. Young-obese class I (OR 1.66, p = 0.002), elderly-obese class II (OR 1.96, p = 0.001), and elderly-obese class III (OR 2.19, p = 0.007) had statistically significant higher odds of drain remaining at POD30. Conclusions: The combination of age <65 years and BMI >40 kg/m2 composite variable constitutes a significantly increased risk of postoperative morbidity/mortality and POPF formation post PD.

A novel technique for prevention of anterior fistula and facilitation of alveolar cleft repair: Gingivoperiosteoplasty with palatoplasty.

Background & Objectives:The Cleft palate is one of the most commonly encountered congenital deformity in plastic surgery clinics and can be associated with cleft lip and alveolus. Though palate repair can be associated with several complications, the most frequent and troublesome is anterior fistula formation. Various technical modifications are in practice to avoid this dreaded complication. We have started combining gingivoperiosteoplasty with palate repair to avoid postoperative anterior fistula formation and to close alveolar cleft at the same time.Methods:A prospective study was performed at the department of plastic and reconstructive surgery, Liaquat National Hospital, Karachi and selected patients were enrolled in the study after informed consent. A total of 15 patients were operated on from January 2017 to December 2020. All patients had cleft palate repair along with primary gingivoperiosteoplasty (GPP) at the age of standard palatal repair. Buccal/oral and nasal layers of the alveolus were dissected as per standard gingivoperiosteoplasty and repaired in continuation with nasal and oral layers of the palate. Postoperatively, the standard cleft palate repair protocol was followed. Follow-up was done at four weeks, 12 weeks, and six months and repair integrity was checked. Future follow-up at 4-5 years of age is planned to see the effect on alveolar collapse, bone growth, and the need for secondary bone grafting.Results:All patients were followed up regularly. None had a complication of fistula. The repairs of both palate and alveolus remained intact. Patients were kept on the follow-up to assess the need for alveolar bone grafting in the future.Conclusion:Gingivoperiosteoplasty combined with the palatal repair is a novel technique for the prevention of anterior palatal fistula.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients.

The aim of this work was to assess whether placement of a biological mesh (Permacol® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4±1.4cm vs. 6±2.9cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132). Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Comparison of outcomes between laparoscopic and open pancreaticoduodenectomy without radical lymphadenectomy: Results of coarsened exact matching analysis using national database systems.

Laparoscopic pancreaticoduodenectomy has recently been covered under Japan's insurance system for patients not requiring lymph node dissection. Only high-volume hospitals that meet specific criteria are permitted to perform laparoscopic pancreaticoduodenectomy. Although open and laparoscopic pancreaticoduodenectomy outcomes with lymph node dissection have been described previously, procedures performed without lymph node dissection have not been compared using a nationwide database. This study aimed to review the results of laparoscopic pancreaticoduodenectomy and compare them to those of open pancreaticoduodenectomy (OPD) using records from a nationwide database. We collected patient demographic and medical data of 2900 patients who underwent pancreaticoduodenectomy (laparoscopic, n=162; open, n=2738) without lymph node dissection between 2016 and 2018 from the National Clinical Database in Japan. Coarsened exact matching was used to match patients in the laparoscopic and open pancreaticoduodenectomy groups. In-hospital mortality was not observed in the laparoscopic pancreaticoduodenectomy group. The rate of conversion to an open procedure was 6.8% (11 cases). After 1:1 matching, we obtained 141 pairs of patients for comparison. The mortality rate was comparable in the laparoscopic and open pancreaticoduodenectomy groups (0.0% vs 0.7%, respectively; P=1.00). The laparoscopic approach showed more favorable results in terms of median blood loss. Postoperative pancreatic fistula formation and complications were comparable between the two groups. Our results indicate that laparoscopic pancreaticoduodenectomy could be introduced successfully, and the outcomes achieved by the institutions included in our study were comparable to those of open pancreaticoduodenectomy.

Effect of intraoperative secretin on operative outcomes in pancreatic resection: A randomized controlled trial

BackgroundObjectives: We performed a randomized, double-blind, placebo-controlled trial to determine if using Secretin intra-operatively to identify leaks and subsequently target operative intervention would decrease the frequency of clinically significant post-operative pancreatic fistula formation. MethodsPatients undergoing pancreaticoduodenectomy or distal pancreatectomy were randomized to receive intra-operative Secretin or placebo intra-operatively following the completed pancreaticojejunostomy or closure of the cut remnant stump. If a potential leak was identified, targeted therapy with directed suture placement was performed. Results170 patients were randomized; 83 receiving placebo and 87 receiving Secretin. The rate of clinically significant fistula formation was 3% (3/87) in the Secretin group and 6% (5/83) in the placebo group (p = 0.489). The rate of biochemical leak was 29% (25/87) in the Secretin group and 19% (16/83) in the placebo group (p = 0.157). There were no Grade C post-operative fistula in either group. Of the 9% of patients in the Secretin group who had a targeted intra-operative intervention, none developed a clinically significant fistula. Adverse events were similar between groups. ConclusionsCompared to placebo, intra-operative Secretin administration was not associated with an overall reduction in clinically significant pancreatic fistula formation. However, patients with an intra-operative leak identified by Secretin may benefit from intervention (clinicaltrials.gov: NCT02160808).

Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

The aim of the present study was to investigate the incidence of postoperative fistula formation from a hybrid cleft palate repair compared to that from two well-established techniques.We performed a modified technique, Sommerlad-Furlow (SF), which combined the repositioning of the levator veli palatini muscles as described by Sommerlad with the double opposing Z-plasty of Furlow to lengthen the soft palate. A retrospective cohort study was conducted to evaluate patients who underwent cleft palate repair utilizing SF, Sommerlad, or Furlow techniques with the incidence of palatal fistula as the target endpoint.A total of 1,164 patients were included in the present study and underwent the following techniques: 603 cases with SF, 244 cases with Furlow, and 317 cases with Sommerlad. In addition to not requiring relaxing incisions, SF advantages included a consistently lower fistula rate compared to that of the Sommerlad technique, as well as the lowest fistula rate in patients with both hard and soft palate clefts without a cleft lip (OR:2.62 95% CI: 1.35, 5.09). However, the differences among the three techniques did not reach statistical significance in terms of a bilateral or unilateral cleft lip/palate, or in patients with a soft palate only or a submucosal cleft palate(OR: 2.22,95% CI:0.77, 6.37).Based on the results of our study, the Somerlad-Furlow technique should be preferred whenever possible.

Laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastasis

Authors present the case of a laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastatic lesion of the uncinate process. A 43-year old female patient was admitted with a lesion in the uncinate process detected by abdominal ultrasound performed for mild epigastric pain she has been suffering from for 3 months prior to admission. Her past medical history is significant for right nephrectomy performed 9 years ago for clear cell renal cell carcinoma, which was confirmed by the histopathology report. A multidisciplinary investigation was performed. Pancreatic protocol CT-scan revealed a 2 cm hyper-enhancing round-shaped tumor, located within the uncinate process. Considering the CT-scan characteristics of the lesion and the past medical history of the patient, a clear cell renal cell metastasis was suspected. Transabdominal US-guided fine-needle aspiration biopsy (US-FNAB) was performed. Immunohistochemical examination using CD10 confirmed the suspicion. A laparoscopic pancreatic enucleation was planned with possible Whipple procedure in case the enucleation would turn out to be unfeasible due to such factors as intensive bleeding from an intrapancreatic vessel, unclear borders of the tumor, and high risk of postoperative pancreatic fistula formation. Nevertheless the attempt to perform enucleation succeeded. The postoperative course was uneventful. The drain was removed on postoperative day 3 after amylase level control. Final histopathological examination revealed a clear cell renal cell carcinoma (RCC) metastatic lesion to the pancreas with clear surgical margins. The purpose of the video is to demonstrate the feasibility of laparoscopic pancreatic enucleation, which is an organ-preserving procedure and is accompanied with better long-term results.

Retrospective Study Over the Hypospadias Surgery in a Single Tertiary Center.

Hypospadias surgery is a common activity in every department for pediatric surgery, increased incidence of this condition contributing this aspect. For this purpose permanent review of the data of cases is probably necessary, in order to promptly evaluate short and long term results. Material and methods. The authors are presenting this retrospective clinical and statistical study, enrolling 149 patients, hospitalized and operated in the Department of Pediatric Surgery and Orthopedics, between 2009 and 2018. several parameters were taken into consideration: moment of conception, type of hypospadias, associated malformations, use of meatoplasty, age at meatoplasty, age at urethroplasty, type of urethroplasty, postoperative incidents and complications. Results. Most of the patients included in the study were classified as anterior type of hypospadias, associated malformations were present in 20,13% of the patients, and 80% of the associated malformations belonged to the urogenital system. Over 60% of the cases underwent meatoplasty as a tactical procedure. Mathieu was the most appreciated procedure (74,5%) for urethroplasty and over a half of the patients were operated after the age of 3 years. Early and late postoperative fistula formation was noted in 18,12% of cases. Conclusions. Better parameters to assess the exact type of hypospadias are needed to be introduced. Also, clear protocols for preoperative work-up in detection of other abnormalities, especially genito-urinary. Meatoplasty as a tactical procedure is having unclear influence for urethroplasty. Decreasing the age at urethroplasty should be the next goal. Some surgeons should really get overspecialized for this type of surgery.

Preoperative anthropomorphic radiographic measurements can predict postoperative pancreatic fistula formation following pancreatoduodenectomy

BackgroundPostoperative pancreatic fistulae (POPF) are a major contributing factor to pancreatoduodenectomy-associated morbidity. Established risk calculators mostly rely on subjective or intraoperative assessments. We hypothesized that various objective preoperatively determined computed tomography (CT) measurements could predict POPF as well as validated models and allow for more informed operative consent in high-risk patients. MethodsPatients undergoing elective pancreatoduodenectomies between January 2013 and April 2018 were identified in a prospective database. Comparative statistical analyses and multivariable logistic regression models were generated to predict POPF development. Model performance was tested with receiver operating characteristics (ROC) curves. Pancreatic neck attenuation (Hounsfield units) was measured in triplicate by pancreatic protocol CT (venous phase, coronal plane) anterior to the portal vein. A pancreatic density index (PDI) was created to adjust for differences in contrast timing by dividing the mean of these measurements by the portal vein attenuation. Total areas of subcutaneous fat and skeletal muscle were calculated at the L3 vertebral level on axial CT. Pancreatic duct (PD) diameter was determined by CT. ResultsIn the study period 220 patients had elective pancreatoduodenectomies with 35 (16%) developing a POPF of any grade. Multivariable regression analysis revealed that demographics (age, sex, and race) were not associated with POPF, yet patients resected for pancreatic adenocarcinoma or chronic pancreatitis were less likely to develop a POPF (10 vs. 24%; p = 0.004). ROC curves were created using various combinations of gland texture, body mass index, skeletal muscle index, sarcopenia, PDI, PD diameter, and subcutaneous fat area indexed for height (SFI). A model replacing gland texture with SFI and PDI (AUC 0.844) had similar predictive performance as the established model (p = 0.169). ConclusionA combination of preoperative objective CT measurements can adequately predict POPF and is comparable to established models relying on subjective intraoperative variables. Validation in a larger dataset would allow for better preoperative stratification of high-risk patients and improve informed consent among this patient population.

Buccal fat pad in cleft palate repair- An institutional experience of 27 cases

ObjectivesThe purpose of this paper is to consider the anatomical basis and surgical technique along with the utility of buccal fat pad (BFP) for the reconstruction in cleft lip and palate patients. MethodsWe reviewed 27 cases of CLAP treated with BFP over three year period in our institution which included 2 cases of primary palatoplasty & 25 cases of secondary palatoplasty. Inclusion criteria consisted of patients operated by a single surgeon with a minimum follow up of 2yrs. Exclusion criteria included all syndromic cleft lip and palate patients. Predictor variables recorded were demographic characters, follow up period, type of cleft, type of surgical procedure, site & dimension of the fistula. Outcome variables of the study were post-operative fistula formation, post-operative hemorrhage & speech assessment. ResultsThe study included 8 female & 19 male patients with mean age group 3.75 ± 1.75yrs. Cleft of soft palate & Lt. CLAP were the most common type of cleft. The surgical technique used was: BFP with V–Y pushback palatoplasty for primary palate repair, BFP with Furlow's technique for VPI correction, and BFP in conjugation with rotation flap, straight-line closure or redohardpalatoplasty for fistula closure. All cases showed satisfactory healing with favorable speech assessment outcomes for 18 patients (67%). ConclusionBFP along with other types of flap is the choice of treatment in cases of moderate defect owing to its favorable anatomic location & high vascularity. The size limitation of the BFP must be known to permit a successful outcome.

Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair.

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in "early" versus "standard" cleft palate repair in a cohort of patients treated at a single craniofacial center.A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. "Early repair" is defined as palatoplasty before 6-months of age (108 patients). "Standard repair" is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors' data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.

The Effect of Buccal Fat Pad Graft in the Palatoplasty and the Risk Factor of Postoperative Palatal Fistula.

The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation. Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated. Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036). The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.

Effects of a Perioperative Safety Checklist on Postoperative Complications Following Surgery for Gastric Cancer: A Single-Center Preliminary Study.

Objective. A Perioperative Safety Checklist (PSC) for gastric cancer (GC) was established to evaluate the effects of PSC on the clinical outcomes of GC. Methods. This single-center preliminary observational study conducted at a tertiary referral hospital included patients with GC who underwent surgery from January 1, 2016, to June 30, 2016, treated without PSC (allocated to the control group) and those who underwent surgery between January 1, 2017, and June 30, 2017, managed according to the PSC designated as the PSCGC (Perioperative Safety Checklist for Gastric Cancer) group. Results. Overall, 1072 cases were enrolled, 556 cases in PSCGC group and 526 cases in control group. After matching, there were 474 patients in each group. PSC intervention led to significant reductions of the incidence of postoperative intestinal fistula formation (P = .034), the incidence of unplanned secondary surgery (P = 0.039), and the total hospitalization expenses (P < .001). Total completion rate of all 14 checklists items was 79.1%. Intraoperative blood loss in the complete and partial implementation groups was significantly lower than the complete nonimplementation group (P = .002), whereas hospitalization cost showed an opposite trend, which was significantly higher in the incomplete nonimplementation group (P = .015). Conclusion. PSC implementation was associated with a decreased incidence of gastrointestinal fistula formation, unplanned secondary surgery, and hospitalization cost in patients with GC. However, it had no effect on the in-hospital mortality, the incidence of postoperative complications during hospitalization (ie, incision complications and lung infections), unplanned secondary admission, and the duration of postoperative hospital stay.