"Long term speech outcomes after using the Sommerlad technique for primary palatoplasty: a retrospective study in the Wilhelmina Children's Hospital, Utrecht."

OBJECTIVES: After cleft lip and/or palate (CL/P) repair, children may develop velopharyngeal insufficiency (VPI) leading to speech imperfections, necessitating additional speech correcting surgery. This study examines the incidence of VPI and speech correcting surgery after Sommerlad's palatoplasty for CL/P, and its association with various clinical features. MATERIALS AND METHODS: A retrospective cohort study was performed in the Wilhelmina Children's Hospital in Utrecht and child records from 380 individuals with CL/P registered from 2008 to 2017 were retrospectively reviewed. Inclusion criteria comprised the diagnosis of CL/P, primary palatoplasty according to Sommerlad's technique, and speech assessment at five years or older. Association between cleft type and width, presence of additional genetic disorders and postoperative complications (palatal dehiscence, fistula) were assessed using odds ratios and chi squared tests. RESULTS: A total of 239 patients were included. The VPI rate was 52.7% (n = 126) and in 119 patients (49.8%) a speech correcting surgery was performed. Severe cleft type, as indicated by a higher Veau classification, was associated with a significant higher rate of speech correcting surgeries (p = 0.033). Significantly more speech correcting surgeries were performed in patients with a cleft width >10 mm, compared to patients with a cleft width ≤10 mm (p < 0.001). Patients with oronasal fistula underwent significantly more speech correcting surgeries than those without fistula (p = 0.004). No statistically significant difference was found in the incidence of speech correcting surgery between patients with and without genetic disorders (p = 0.890). CONCLUSIONS/CLINICAL RELEVANCE: Variations in cleft morphology, cleft width and complications like oronasal fistula are associated with different speech outcomes. Future research should focus on creating a multivariable prediction model for speech correcting surgery in CL/P patients.

Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis.

OBJECTIVES: In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome. MATERIALS AND METHODS: A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model. RESULTS: One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11). CONCLUSIONS: A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair. CLINICAL RELEVANCE: Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.

Computer-Assisted Surgical Anatomical Mapping of the Antebrachial Cutaneous Nerves: An Anatomical Study with a Proposition for Alternative, Cutaneous Nerve-Sparing Anterior Elbow Incisions.

It is common practice to assess the distance from nerves to anatomical structures in centimeters, but patients have various body compositions and anatomical variations are common. The purpose of this study was therefore to assess the relative distance from cutaneous nerves around the elbow to surrounding anatomical landmarks by providing a stacked image that displays the average position of cutaneous nerves around the elbow. The aim was to research possibilities for adjusting common skin incisions in the anterior elbow so that cutaneous nerve injury may be avoided. Methods: The lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) were identified in the coronal plane around the elbow joint in 10 fresh-frozen human arm specimens. Marked photographs of the specimens were analyzed using computer-assisted surgical anatomical mapping (CASAM). Common anterior surgical approaches to the elbow joint and the distal humerus were then compared with merged images, and nerve-sparing alternatives are proposed. Results: The arm was divided longitudinally, from medial to lateral in the coronal plane, into 4 quarters. The LABCN crossed the central-lateral quarter of the interepicondylar line (i.e., was somewhat lateral to the midline at the level of the elbow crease) in 9 of 10 specimens. The MABCN ran medial to the basilic vein and crossed the most medial quarter of the interepicondylar line. Thus, 2 of the quarters were either free of cutaneous nerves (the most lateral quarter) or contained a distal cutaneous branch in only 1 of 10 specimens (the central-medial quarter). Conclusions: The Boyd-Anderson approach, which is often used to access anteromedial structures of the elbow, should be placed slightly further medially than traditionally advised. The distal part of the Henry approach should deviate laterally, so that it runs over the mobile wad. In distal biceps tendon surgery, the risk of cutaneous nerve injury may be reduced if a single distal incision is placed slightly more laterally (in the most lateral quarter), as in the modified Henry approach. If proximal extension is required, LABCN injury may be prevented by using the modified Boyd-Anderson incision, which runs in the central-medial quarter. Clinical Relevance: Cutaneous nerve injury may be prevented by slightly altering the commonly used skin incisions around the elbow on the basis of the safe zones that were identified by depicting the cumulative course of the MABCN and LABCN using CASAM.

Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage.

BACKGROUND: Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication. METHODS: All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage. RESULTS: Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2). CONCLUSION: Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.