Keywords
Introduction
Velopharyngeal insufficiency (VPI) is a consequence of incompetent velopharyngeal sphincter closure during speech. Approximately 20% of the patients with history of cleft palate repair develop VPI
2
. Management is a multidisciplinary-dependant approach; and surgery is indicated only after speech therapy modalities have been exhausted. the posterior pharyngeal flap is the most commonly deployed surgical intervention against VPI3
.The posterior pharyngeal flap is not devoid of complications, as 5% of the patients are destined to experience complications like respiratory distress, dehydration, flap dehiscence, and bleeding
4
. The most common and serious thereof are the acute respiratory complications, which take place during the first 24 hours postoperatively. Hence, pharyngoplasty patients are routinely admitted to the intensive care unit (ICU) in some centres for close monitoring before transfer to the ward. Notwithstanding, we believe that this is unnecessary. Herein, we present our experience with such cases and propose our indications for ICU admission in cleft palate patients who undergo pharyngoplasty.- Jw S
- Jl J
- Bt M
- K A
- Ja T
Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database.
Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc [Internet]. 2016 Sep; 53 ([cited 2022 Nov 9]Available from:)
Materials and methods
In this retrospective analysis, all patients who underwent superiorly-based posterior pharyngeal flap surgery for treating VPI in the duration from 2011 to 2018 in our center had their medical records reviewed for clinical and demographic data, including age, gender, associated syndromes, type of the cleft palate according to Veau classification, post-operative complications, the requirement for ICU admission, and the length of hospital stay. Only cleft palate cases following pharyngoplasty due to VPI with complete clinico-demographic data and perioperative outcomes were included. All surgeries were done by a single surgeon (AA).
The decision for postoperative monitoring in the floor or ICU was based on the surgeon's judgement. Admission to the floor for postoperative monitoring was based on the ability of the patient to independently maintain patent airway without a serious desaturation. Collected data was recorded and analysed using SPSS (BM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). Observational values were presented in numbers and percentages; and measures of dispersion were calculated. Institutional review board approval was obtained.
Results
In a span of seven years, 38 patients underwent pharyngeal flap surgery for VPI. Mean age was 13.4 years and more than half (57.9%) were females. No associated syndromes were present in 81.5% of the cases while 31.6% had Veau type-III cleft palate. None of our patients had associated medical conditions such as neuromuscular disorders, cardiac, or pulmonary diseases.
Patients’ postoperative outcomes are depicted in Table 1. There were no incidents of serious postoperative complications, including death, flap dehiscence, profuse bleeding, or airway compromise requiring re-intubation. Only two patients (5.3%) were admitted to ICU for postoperative monitoring; one patient experienced a difficult extubation whereas the other patient suffered from a postoperative respiratory distress. The average length of ICU admission was one day, while the mean length of stay for all other patients (admitted to surgical ward) was 1.3 ± 0.7 (Minimum= 1 day; maximum= 4 days).
Table 1Postoperative data.
| Parameter | Value, percentage | Measures of dispersion |
|---|---|---|
| Postoperative admission | Surgical ward: 36, 94.7% | |
| ICU: 2, 5.3% | - | |
| Hospital admission duration | - | Mean= 1.3 days |
| SD= 0.7 day | ||
| Minimum= 1 day | ||
| Maximum= 4 days | ||
| Postoperative immediate complications | Respiratory distress: 1, 2.6% | |
| Difficult extubation: 1, 2.6% | - |
Abbreviations: ICU: Intensive care unit; SD: Standard deviation.
Discussion
The premise behind the pharyngeal flap is to create a mucosal flap that connects the soft palate to the posterior pharynx, whereby the mucosal wall is static with two lateral ports for ventilation, decreasing airflow through the velopharyngeal opening. The two main acute perioperative complications of this technique are airway obstruction and bleeding(4).
At our centre, patients undergoing the aforementioned procedure are routinely observed for an hour in the recovery bay, specifically looking for signs of airway compromise, before being sent to the ward if they do not suffer from cardiopulmonary adverse events, in which case they are admitted to the ICU for strict monitoring until vital signs normalize, before being sent to the ward.
The expenses of a single day admission to theICU are three to five times more compared to a single day admission to the ward. At our centre, the cost of care at the ICU ranges between $1,300- $2,100 per patient a day, while the cost of care is 50% less in the ward. Therefore, limiting ICU admissions could help in saving resources. At the centres under the Ministry of Health in Saudi Arabia, the average cost of medical care for a patient a day in the ICU ranges between $1460-$1860
5
.Conclusion
Posterior pharyngeal flap surgery is indicated for cleft palate patients with velopharyngeal insufficiency; and the postoperative care is an integral part of the management course. While many centres routinely admit patients to the ICU immediately following the surgery, our data support the practice of sending the patients to the ward unless an acute postoperative complication arises. This is especially true as continuous pulse oximetry monitoring can be conducted by the nurses in the ward. Syndromic patients or those with cardiopulmonary complications should be strictly monitored in the ICU before shifting to the ward. As the sample size is small in this study, caution is required prior to large scale implementation of our conclusion.
Funding
None.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
References
- Velopharyngeal dysfunction.Semin Plast Surg. 2012 Nov; 26: 170-177
- Clinical Outcomes of Primary Palatal Surgery in Children with Nonsyndromic Cleft Palate with and without Lip.BioMed Res Int. 2015; 2015185459
- Pharyngeal flap outcomes in nonsyndromic children with repaired cleft palate and velopharyngeal insufficiency.Plast Reconstr Surg. 2010 Jan; 125: 290-298
- Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database.Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc [Internet]. 2016 Sep; 53 ([cited 2022 Nov 9]Available from:)
- King Saud Medical City Intensive Care Unit: A critical and cost-focused appraisal.Saudi Crit Care J. 2019; 3: 19
Article info
Publication history
Accepted:
February 19,
2023
Received:
July 24,
2022
Publication stage
In Press Accepted ManuscriptIdentification
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© 2023 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
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