Principles and techniques to reduce the incidence of fistula: a review of over 1000 cleft palate repairs by a single surgeon.

Abstract

Fistula is a significant complication following cleft palate repair. This study presents the lowest incidence of post-operative fistula in a patient cohort of its size. The series provides an opportunity to describe the techniques and principles that we believe are important to reduce the rate of fistulae. This is a retrospective review of prospectively collected data of 1041 consecutive cleft palate repairs performed by a single surgeon. The number of post-operative fistulae (defined as any oronasal communication excluding any residual intentionally unrepaired alveolar clefts) was determined. Regression analysis was performed to determine the factors that impact the risk of developing a fistula. Nine patients developed a post-operative fistula representing an incidence of 0.86%. All patients who developed a fistula had a straight-line repair (n=882). None of the patients who underwent a Furlow palatoplasty developed a fistula (n=159). Veau type (OR of 2.88, p=0.04) and the use of buccal myomucosal flaps (OR of 19, p=0.02) were associated with a risk of developing a fistula. Five of the nine patients who developed a fistula had a Veau 4 cleft. This study presents a large series with a fistula rate that compares favorably to the published literature. The authors present the principles and techniques believed to reduce post-operative fistula rates: appropriate pre-operative management, respect for tissue, minimizing tension, and careful post-operative management. Detailed surgical videos are presented.