A number of factors related to the hospital, surgeon, patient, and patient's family bear consideration in deciding the timing of discharge after primary cleft lip repair. The most clinically important factor appears to be the overall preexisting medical status of the patient.

PurposePrimary surgical repair of a cleft lip is usually followed by 23-hour hospital admission. A recent article has advocated outpatient cleft lip repair with same-day discharge as a safe alternative (J Plast and Recon. Surg. 2003 Aug;112(2):381–7). Further investigation is required regarding the potential risks during the first 24 hrs after surgery.Study Design and MethodsFour directly related studies on primary cleft lip repair were designed to identify the risks and benefits of same day discharge versus 23 hr-admission: 1) A retrospective chart review of the complication rate in the first 24 hrs following 200 consecutive cleft lip repairs at two major pediatric tertiary care centers (Children’s Hospital and Regional Medical Center (CHRMC), Seattle and Hospital for Sick Children, Toronto); 2) A national survey of cleft surgeons to determine opinions about discharge practices following cleft lip repair; 3) A post-operative questionnaire for parents to determine their opinions regarding same day discharge; 4) Analysis of complication rate related to length of stay using the PHIS national database of major pediatric centers.Results1) The CHRMC chart review found 2 of 109 infants (1.8%) experienced a life-threatening complication in the first 24 hrs post-op. The Hospital for Sick Children review is still being analyzed. 2) To date, 21% of eligible respondents completed the national physician’s survey (n=129). 75% of respondents reported discharging their patients home after 23 hr admission, while 17.8% performed same day surgery. 23% reported at least one patient that developed life-threatening complications in the first 24 hrs post-op. 3) We are waiting for all questionnaires to be collected before analysis can begin. 4) The PHIS national database proposal has been submitted to the Children’s Health Initiative (CHI) for funding.ConclusionOur preliminary results indicate that up to 2% of infants experience complications in the first 24 hrs following cleft lip repair and up to 11% of surgeons recollect a complication in the first 24 hrs post-op that they felt would have had a worse outcome had the patient been discharged the same day as surgery. The current standard of practice following cleft lip surgery remains at least one night observation in hospital, with only 18% of respondents currently performing same day cleft lip surgery. Our data to date does not justify the practice of same day cleft lip repair, but we await the results of the remaining studies to examine this question further.

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A strong link exists between gastroesophageal reflux disease (GERD) and airway disease. We sought to determine the long-term results of laparoscopic antireflux surgery (LARS) for multiple airway symptoms of GERD. Methods: Between 12/15/1993 and 12/21/2002, 750 patients underwent LARS at the University of Washington. Of these patients, 230 (31%) experienced cough, hoarseness, or wheezing more than once per week and had failed medical management. We attempted to contact each patient and succeeded in 136 patients (59%). At a median follow-up of 53 months (range 19-110 mo) we determined frequency and severity of airway symptoms (cough, hoarseness, wheezing, sore throat, dyspnea), esophageal symptoms (heartburn, regurgitation, dysphagia), anti-acid medication usage, happiness with surgery, and rating of operative treatment. Results: Airway symptoms improved in the majority of patients (Table ). Typical GERD symptoms (heartburn, regurgitation) improved in 87-93% of patients. Preoperatively, almost all patients (98%) used prescription medical therapy. Forty-five patients (33%) continue to use daily prescription medication. The majority of patients (88%) were happy with the operative treatment, which was rated excellent by 78 patients (57%) and good by 33 patients (24%). Symptom Number of Patients % Pts Improved Pre-Op Freq Score* Post-Op Freq Score* p-value (Mean [138} SD) (Mean Ϯ SD) Cough 108 74 3.51 Ϯ 0.65 1.58 Ϯ 1.62 0.001 Hoarseness 82 66 2.93 Ϯ 1.09 1.45 Ϯ 1.54 0.001 Wheezing 37 69 2.86 Ϯ 1.13 1.46 Ϯ1.52 0.001 Sore Throat 41 70 2.56 Ϯ 1.10 1.10Ϯ 1.36 0.001 Dyspnea 31 65 2.84 Ϯ 1.00 1.97 Ϯ 1.66 0.01 *Frequency score: 0= never, 1= once/month, 2= once/week, 3= once/day, 4= several/day Conclusions: LARS provides long-term relief of airway symptoms in over two-thirds of patients with associated abnormal GERD, and in 90% of patients with typical symptoms of GERD. LARS should be considered for patients with proven GERD and cough, hoarseness, or wheezing, especially when medical management has failed.