The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair

Abstract

Background: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. Methods: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. Results: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. Conclusions: The authors’ findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Life Cycle of Orofacial Cleft Operations

“…6,7 While recommended timing guidelines for cleft operations exist, there is still considerable debate over the ideal timing for different procedures. 8,[11][12][13][14] Furthermore, national trends in the surgical timing of these orofacial procedures have yet to be described. Using the NSQIP-P database, this study characterizes the national trends in the ages for common orofacial operations with respect to advised timing recommendations.…”

“…Exclusion criteria for patients undergoing primary cleft palate repair included the CPT codes of 42225 (palatoplasty for cleft palate, attachment pharyngeal flap) and 42215 (palatoplasty for cleft palate, major revision). 8 Patients undergoing cleft lip revision or cleft palate revision were identified using the CPT codes of 40720 (secondary repair of a cleft lip and or nasal deformity) or 42215 (palatoplasty for cleft palate, major revision), respectively.…”

“…The CPT codes of 42200 (palatoplasty for cleft palate, soft and/or hard palate only) and 42205 (palatoplasty for cleft palate, with closure of the alveolar ridge; soft tissue only) were used to isolate patients who underwent cleft palate repair. Exclusion criteria for patients undergoing primary cleft palate repair included the CPT codes of 42225 (palatoplasty for cleft palate, attachment pharyngeal flap) and 42215 (palatoplasty for cleft palate, major revision) 8 . Patients undergoing cleft lip revision or cleft palate revision were identified using the CPT codes of 40720 (secondary repair of a cleft lip and or nasal deformity) or 42215 (palatoplasty for cleft palate, major revision), respectively.…”

Evidence-Based Practices in Cleft Palate Surgery

“…Two recent reports from large databases have shed light on the impact of timing on early versus late complications (ie, 30 days 31 versus 2000 days, 32 respectively). Overall, it was found that early repair was associated with worse outcomes at both endpoints.…”

“…NSQIP patients ( n = 3088) who underwent single-stage repair before 6 months of age experienced a two-fold increase in 30-day complication rates ( P = 0.04) and a four- to five-fold increase in readmissions ( P = 0.02) and reoperations ( P = 0.04) within the same timeframe (level of evidence: III). 31 With respect to 2000-day complication rates, a large database project using the IBM MarketScan Commercial Database ( n = 3046) identified that patients were more likely to require a secondary procedure if primary repair occurred before 10 months of age. However, patients were 60% less likely to require a secondary procedure if initial repair occurred between 10 and 14 months of age ( P < 0.001) and 29% less likely if initial repair occurred at more than 14 months of age ( p = 0.002) (level of evidence: III).…”