An Artificial Intelligence model for implant segmentation on periapical radiographs.

OBJECTIVE: To segment dental implants on PA radiographs using a Deep Learning (DL) algorithm. To compare the performance of the algorithm relative to ground truth determined by the human annotator. Methodology: Three hundred PA radiographs were retrieved from the radiographic database and consequently annotated to label implants as well as teeth on the LabelMe annotation software. The dataset was augmented to increase the number of images in the training data and a total of 1294 images were used to train, validate and test the DL algorithm. An untrained U-net was downloaded and trained on the annotated dataset to allow detection of implants using polygons on PA radiographs. RESULTS: A total of one hundred and thirty unseen images were run through the trained U-net to determine its ability to segment implants on PA radiographs. The performance metrics are as follows: accuracy of 93.8%, precision of 90%, recall of 83%, F-1 score of 86%, Intersection over Union of 86.4% and loss = 21%. CONCLUSIONS: The trained DL algorithm segmented implants on PA radiographs with high performance similar to that of the humans who labelled the images forming the ground truth.

Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access.

OBJECTIVE: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. SUMMARY OF BACKGROUND DATA: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. METHODS: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. RESULTS: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. CONCLUSIONS: Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

Diagnosis, treatment, and outcome of patients with oesophagogastric cancer during the COVID-19 pandemic: national study.

BACKGROUND: The national response to COVID-19 has had a significant impact on cancer services. This study investigated the effect of national lockdown on diagnosis, management, and outcomes of patients with oesophagogastric cancers in Scotland. METHODS: This retrospective cohort study included consecutive new patients presenting to regional oesophagogastric cancer multidisciplinary teams in National Health Service Scotland between October 2019 and September 2020. The study interval was divided into before and after lockdown, based on the first UK national lockdown. Electronic health records were reviewed and results compared. RESULTS: Some 958 patients with biopsy-proven oesophagogastric cancer in 3 cancer networks were included: 506 (52.8 per cent) before and 452 (47.2 per cent) after lockdown. Median age was 72 (range 25-95) years and 630 patients (65.7 per cent) were men. There were 693 oesophageal (72.3 per cent) and 265 gastric (27.7 per cent) cancers. Median time to gastroscopy was 15 (range 0-337) days before versus 19 (0-261) days after lockdown (P < 0.001). Patients were more likely to present as an emergency after lockdown (8.5 per cent before versus 12.4 per cent after lockdown; P = 0.005), had poorer Eastern Cooperative Oncology group performance status, were more symptomatic, and presented with a higher stage of disease (stage IV: 49.8 per cent before versus 58.8 per cent after lockdown; P = 0.04). There was a shift to treatment with non-curative intent (64.6 per cent before versus 77.4 per cent after lockdown; P < 0.001). Median overall survival was 9.9 (95 per cent c.i. 8.7 to 11.4) months before and 6.9 (5.9 to 8.3) months after lockdown (HR 1.26, 95 per cent c.i. 1.09 to 1.46; P = 0.002). CONCLUSION: This national study has highlighted the adverse impact of COVID-19 on oesophagogastric cancer outcomes in Scotland. Patients presented with more advanced disease and a shift towards treatment with non-curative intent was observed, with a subsequent negative impact on overall survival.

A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

BACKGROUND: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. METHODS: A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. RESULTS: 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. CONCLUSION: Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Primary intracranial sarcoma masquerading as a chronic subdural haematoma: illustrative case and review of an unusual phenomenon.

It is very unusual for a primary intracranial malignancy to present as a chronic subdural hematoma. This case report describes one such case in a 3-year-old girl who presented with raised intracranial pressure following a mild head injury. Imaging of her brain revealed bilateral chronic subdural hematomas with an enhancing subdural mass and multiple nodular lesions infiltrating the brain parenchyma. She underwent a craniotomy, drainage of the subdural collections and resection of the subdural mass. Histopathology revealed an undifferentiated sarcoma, and she was referred for adjuvant therapy. This case underlines the importance of evaluating paediatric subdural collections for a possible underlying malignancy, even in the background of a preceding head injury. The cause-effect relationship of sarcomas with subdural collections remains unclear because of the scarcity of available literature on the subject.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates.

BACKGROUND: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. METHODS: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. RESULTS: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. CONCLUSION: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Towards Automatic License Plate Detection.

Automatic License Plate Detection (ALPD) is an integral component of using computer vision approaches in Intelligent Transportation Systems (ITS). An accurate detection of vehicles' license plates in images is a critical step that has a substantial impact on any ALPD system's recognition rate. In this paper, we develop an efficient license plate detecting technique through the intelligent combination of Faster R-CNN along with digital image processing techniques. The proposed algorithm initially detects vehicle(s) in the input image through Faster R-CNN. Later, the located vehicle is analyzed by a robust License Plate Localization Module (LPLM). The LPLM module primarily uses color segmentation and processes the HSV image to detect the license plate in the input image. Moreover, the LPLM module employs morphological filtering and dimension analysis to find the license plate. Detailed trials on challenging PKU datasets demonstrate that the proposed method outperforms few recently developed methods by producing high license plates detection accuracy in much less execution time. The proposed work demonstrates a great feasibility for security and target detection applications.

Painful and non-painful comorbidities associated with short- and long-term painful temporomandibular disorders: A cross-sectional study among adolescents from Brazil, Canada and France.

BACKGROUND: Temporomandibular disorder (TMD) pain is common among adolescents. The association between painful TMD and other comorbidities has been demonstrated. However, the difference between short-term (<6 months) and long-term (≥ 6 months) painful TMD is not yet clear. OBJECTIVE: The aim of this study was to assess the association between comorbidities and short- and long-term painful TMD among adolescents. METHODS: In this cross-sectional study, adolescents were recruited from Montreal (Canada), Nice (France) and Arceburgo (Brazil). Self-reported painful TMD, comorbidities, school absence and analgesic intake were assessed using reliable instruments. Multivariable logistic regression analyses were conducted to assess the study aims. RESULTS: The prevalence of short- and long-term painful TMD was estimated at 22.29% and 9.93% respectively. The number of comorbidities was associated with short- (OR = 1.71, 95%CI = 1.53-1.90) and long-term painful TMD (OR = 1.79, 95%CI = 1.55-2.08) compared to controls. Frequent headaches (ORshort-term  = 4.39, 95%CI = 3.23-5.98, ORlong-term  = 3.69, 95%CI = 2.45-5.57) and back pain (ORshort-term  = 1.46, 95%CI = 1.06-2.03, ORlong-term  = 1.69, 95%CI = 1.11-2.59) were associated with both painful TMD groups. Frequent neck pain (OR = 2.23, 95%CI = 1.53-3.26) and allergies were only associated with short-term painful TMD (OR = 1.54, 95%CI = 1.13-2.10). Frequent stomach pain was related to long-term (OR = 2.01, 95%CI = 1.35-3.26), and it was the only comorbidity significantly more frequent among the long than short-term TMD (OR = 1.82, 95%CI: 1.14-2.90). These analyses were adjusted by sex, age and city. CONCLUSION: In this multi-centre study, both short- and long-term painful TMD are associated with frequent headaches and back pain, whereas frequent neck pain and allergies are related to only short-term and frequent stomach pain with long-term painful TMD.

The impact of socioeconomic status on 30-day mortality in hospitalized patients with COVID-19 infection.

Socioeconomic status (SES) impacts outcome in a number of diseases. Our aim was to compare the outcome of hospitalized coronavirus disease 219 (COVID-19) patients in low and high SES group. Prospective cohort study of hospitalized patients with confirmed COVID-19 in three acute hospitals. Electronic case notes were analyzed for baseline characteristics and admission investigations. Scottish index for multiple deprivation (SIMD) was used to divide patients into two groups: more deprived (SIMD 1-5) and less deprived (SIMD 6-10) and results compared. Poor outcome was defined as either need for intubation and/or death. One hundred and seventy-three patients were identified, one was excluded. One hundred and eight (62.8%) were males, mean age was 68.5 ± 14.7 years. Commonest comorbidity was hypertension 87 (50.6%). One hundred and seventeen (68.0%) patients were in more deprived group. Baseline characteristics, admission blood profile and reason for admission were evenly matched in both groups. Outcomes were comparable in both groups: transfer to critical care (27.4% vs 27.3%; P = .991), intubation (18.8% vs 20.2%; P = .853), 30-day all-cause mortality (19.7% vs 14.5%; P = .416) and overall poor outcome (30.8% vs 30.9%; P = .985). Median time to discharge was 7 days longer (17 vs 10 days; P = .018) and median time to death was 4.5 days longer in more deprived group (17 vs 12.5 days; P = .388). Contrary to recent literature on COVID-19 in other geographical areas, our study suggests that the SES does not have any impact on outcome of hospitalized patients with COVID-19, however it negatively impacts length of stay.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.

BACKGROUND: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. AIMS AND METHODS: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. RESULTS: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. CONCLUSION: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

Empowerment of Parents of Children With Cleft Lip and Palate by Objective Scoring of Patient Information Websites.

BACKGROUND: Whether a new diagnosis or for ongoing care, the Internet is now an established and massively frequented resource for parents and patients with cleft lip and/or palate. The purpose of this study was to assess the correlation between the first 50 ranked websites for cleft lip and palate via the Google search engine versus those ranked with an objective patient information scoring tool. METHODS: The first 50 websites ranked by Google were recorded for the search items "Cleft Lip," "Cleft Palate" and "Cleft Lip and Palate." Quality assessment was performed using the DISCERN score, an objective and validated patient information website scoring tool. The Google rank was compared to the DISCERN rank to assess for correlation. The top five websites for each search item were then ranked by blinded cleft health professionals for quality. RESULTS: Based on Google ranking, 36% of websites were the same across the search terms used. The DISCERN ranking scores demonstrated no evidence of positive or negative correlation when compared to Google ranking. In the top 10 DISCERN ranked websites for each search item, 4 websites appear in the top 10 Google rankings. CONCLUSION: This is the first study that demonstrates that high-quality information on cleft lip and palate is available on the Internet. However, this may be difficult and confusing for parents and patients to access due to the ranking system used by internet search engines. Cleft healthcare professionals should be aware of these problems when recommending websites to families and patients.

Urgent Versus Standard Colonoscopy for Management of Acute Lower Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospitalization. However, the optimum timing of colonoscopy following patient presentation remains unclear. This systematic review and meta-analysis aims to evaluate the effect of urgent versus standard colonoscopy timing on management of acute LGIB. MATERIALS AND METHODS: Medline, EMBASE, CENTRAL, and PubMed were searched up to January 2020. Randomized controlled trials were eligible for inclusion if they compared patients with hematochezia receiving urgent (<24 h) versus standard (>24 h) colonoscopy. Nonrandomized observational studies were also included based on the same criteria for additional analysis. Pooled estimates were calculated using random effects meta-analyses and heterogeneity was quantified using the inconsistency statistic. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RESULTS: Of 3782 potentially relevant studies, 4 randomized controlled trials involving 463 patients met inclusion criteria. Urgent colonoscopy did not differ significantly to standard timing with respect to length of stay (LOS), units of blood transfused, rate of additional intervention required, or mortality. Colonoscopy-related outcomes such as patient complications, rebleeding rates, and diagnosis of bleeding source did not differ between groups. However, meta-analysis including nonrandomized studies (9 studies, n=111,950) revealed a significantly higher rate of mortality and complications requiring surgery in the standard group and shorter LOS in the urgent group. Overall GRADE certainty of evidence was low in the majority of outcomes. CONCLUSIONS: Timing of colonoscopy in acute LGIB may not significantly affect patient outcomes. Timing should therefore be decided on a case-by-case basis.

Dog-Bite Injuries to the Craniofacial Region: An Epidemiologic and Pattern-of-Injury Review at a Level 1 Trauma Center.

PURPOSE: The purpose was to determine the incidence, etiologic factors leading to injury, and demographic composition of patients sustaining dog-bite injuries of the craniofacial region at a regional referral level 1 trauma center. These findings may assist primary and affiliated health care providers, educators, and policy makers in developing and implementing strategies to prevent serious dog-bite injuries, particularly in the individuals most vulnerable-children and elderly persons. PATIENTS AND METHODS: We performed a retrospective observational and descriptive review of dog bite-related injuries solely managed by the Section of Maxillofacial Surgery at Charleston Area Medical Center in West Virginia. Patient information was derived from an existing database on dog-bite injuries of the craniofacial region, electronic health records, and animal encounter records. RESULTS: We reviewed 182 patient records distributed among several breed categories. The results showed a disturbing trend toward more severe injuries, especially in younger children, and a reversal in gender, with girls bitten more than boys. Young children incurred more extensive facial injuries, including fractures. The data showed that compared with other dog breeds, pit bull terriers inflicted more complex wounds, were often unprovoked, and went off property to attack. Other top-biting breeds resulting in more unprovoked and complex wounds included German shepherds, Rottweilers, and huskies. Management of facial wounds took place more often in the operating room, especially in younger children, with increased hospital stays. Of the patients, 19 (10.4%) had fractures and 22 (12%) underwent a rabies vaccination protocol. CONCLUSIONS: This study showed a disturbing trend toward more severe dog-bite injuries in young children and a greater incidence of bites in girls than in boys among several biting breeds of dogs. The public health implications of aggressive biting breeds and risks of severe injury in the home environment were discussed.

Transcranial Doppler waveform changes due to increased cerebrovascular resistance and raised intracranial pressure in a patient with cirrhosis: A difference in shapes, not in numbers.

We report and discuss a case that illustrate the clinical utility of transcranial Doppler (TCD) ultrasound in a patient with cirrhosis. A 43-year-old female presented with acute decompensation of cirrhosis with hepatic encephalopathy, requiring mechanical ventilation. TCD showed low diastolic flow velocities and high pulsatility index (PI) consistent with increased cerebrovascular resistance (CVR). The flow velocities and PI normalized over a period of few days and correlated well with neurological improvement after treatment. Subsequently, the patient developed a large intracerebral hemorrhage with mass effect. The TCD measurements in intracranial hypertension were similar to those with cirrhosis and hepatic encephalopathy. However, the windkessel notch in the systolic phase of TCD waveform, related to the distensibility of arterial wall, was absent during raised intracranial pressure (ICP). The absence of a windkessel notch may help to differentiate a high downstream resistance due to raised ICP from increased CVR.

Comorbid conditions associated with painful temporomandibular disorders in adolescents from Brazil, Canada and France: A cross-sectional study.

BACKGROUND: Painful temporomandibular disorder (TMD) is common among adolescents. Presence of painful comorbidities may worsen painful TMD and impact treatment effectiveness. OBJECTIVE: The aim of this study was to assess the association between painful TMD and comorbidities. METHODOLOGY: In this cross-sectional study, adolescents were recruited in Montreal (Canada), Nice (France) and Arceburgo (Brazil). Reliable instruments were used to assess painful TMD and comorbidities. Multivariable logistic and linear regression analyses were conducted to assess the study aims. RESULTS: The prevalence of self-reported painful TMD was estimated at 31.6%; Arceburgo (31.6%), Montreal (23.4%) and Nice (31.8%). Painful TMD was more common among girls than boys (OR = 1.96). Painful TMD was associated with a higher number of comorbidities (OR = 1.77); Arceburgo (OR = 1.81), Montreal (OR = 1.80) and Nice (OR = 1.72). A stronger association was found between painful TMD and headaches (OR = 4.09) and a weaker one with stomach pain (OR = 1.40). Allergies were also related to painful TMD (OR = 1.43). CONCLUSION: Painful TMD was associated with comorbidities. Headaches were consistently associated with painful TMD. Other associations were modified by sex and/or covariates related to the cities where participants were recruited.

Angiotensin converting enzyme inhibitors do not increase the risk of poor outcomes in COVID-19 disease. A multi-centre observational study.

BACKGROUND AND AIMS: Hypertension is associated with an increased risk of severe outcomes with COVID-19 disease. Angiotensin Converting Enzyme (ACE) inhibitors are widely used as a first line medication for the treatment of hypertension in the UK, although their use was suggested in early reports to increase the risk associated with SARS-CoV-2 infection. METHODS: A prospective cohort study of hospitalised patients with laboratory confirmed COVID-19 was conducted across three hospital sites with patients identified on the 9th April 2020. Demographic and other baseline data were extracted from electronic case records, and patients grouped depending on ACE inhibitor usage or not. The 60-day all-cause mortality and need for intubation compared. RESULTS: Of the 173 patients identified, 88 (50.8%) had hypertension. Of these 27 (30.7%) used ACE inhibitors. We did not find significant differences in 60-day all-cause mortality, the requirement for invasive ventilation or length of stay between our patient cohorts after adjusting for covariates. CONCLUSION: This study contributes to the growing evidence supporting the continued use of ACE inhibitors in COVID-19 disease, although adequately powered randomised controlled trials will be needed to confirm effects.

Impact of the COVID-19 pandemic on core surgical training.

BACKGROUND AND AIMS: COVID-19 pandemic has caused significant disruption in training which is even more pronounced in the surgical specialties. We aim to assess the impact of COVID-19 pandemic on core surgical training. METHODS: All core surgical and improving surgical trainees in West of Scotland region were invited to participate in an online voluntary anonymous survey via SurveyMonkey. RESULTS: 28 of 44 (63.6%) trainees responded, 15 (53.6%) were CT1/ST1. 14 (50.0%) working in teaching hospital and 15 (53.6%) working in general surgery. 20 (71.4%) felt that due to the pandemic they have less opportunity to operate as the primary surgeon. 21 (75.0%) have not attended any outpatient clinics. 8 (28.6%) did not have any form of access to the laparoscopic box-trainer. 20 (71.4%) felt their level of confidence in preforming surgical skills has been negatively impacted. 18 (64.3%) found it difficult to demonstrate progress in portfolio. 21 (75.0%) trainees have not attended any teaching. 10 (35.7%) trainees have been off-sick. 8 (28.6%) trainees have felt slightly or significantly more stressed. CONCLUSION: COVID-19 pandemic has an unprecedented negative impact on all aspects of core surgical training. The long term impact on the current cohort of trainees is yet to be seen.

What We Do: Greater Palatine Medializing Foraminal Osteotomy for Repair of the Wide Cleft Palate.

Wide cleft palates (>15-mm gap) present a number of challenges to the surgeon tasked with their repair ( Bardach, 1999 ). Eliminating the need for secondary surgery due to fistula formation can reduce additional anesthetic and scarring risks and optimize early speech development. Greater palatine foraminal osteotomy is a useful surgical adjunct that allows additional medial movement of oral mucoperiosteal flaps to aid in tension-free closure of the oral layer. We use a technique similar to that described by Seibert in 1995 with a few modifications. Closure of the nasal layer in these wide clefts can be achieved using a sphenoid flap, a technique recently published by our unit ( Khan et al, 2018 ).

Use of the Sphenoid Flap in Repair of the Wide Cleft Palate.

OBJECTIVE: In wide palatal defects, closure of the nasal layer can prove a considerable challenge. Mobilizing nasal flaps posteriorly usually facilitates soft palate closure. However, the defect is often too wide within the hard palate; hence, bilateral vomerine flaps are frequently required. Despite this, there is often a small defect in the nasal layer at the posterior septum (typically equating to the hard-soft palate junction), which has to be left to heal by secondary intention with the resulting increased risk of fistula formation and the potential deleterious long-term effect on speech due to cicatricial migration of the reconstructed levator sling anteriorly. We describe our experience in the use of the sphenoid flap to obtain tension-free primary closure of the nasal layer. METHODS: A retrospective multi-center study assessing all sphenoid flap procedures undertaken at both Birmingham Children's Hospital and Great Ormond Street Hospital. Key demographic and medical data was collected pre-, peri-, and postoperatively across the 2 sites. RESULTS: A total of 66 patients underwent the use of a sphenoid flap to aid closure of the nasal layer. The average age at time of repair was 9.7 months. More than half (55%, n = 36) were isolated cleft palates, and 35% (n = 23) were BCLPs. Forty-two percent of all patients had Robin sequence. The average cleft width was 14.4 mm. The overall fistula rate was 25.8% (n = 17). CONCLUSIONS: We describe the operative technique, indications, and our experience in the use of the sphenoid flap in wide cleft palate repair.