Sunday, September 25, 2005 - 2:55 PM

Teaching Residents Primary Cleft Palate Repair with Low Fistula Rates

John A. Van Aalst, MD, Sumeet S. Teotia, Kim S. Uhrich, C. Scott Hultman, Gerald M. Sloan, MD, H. Wolfgang Losken, and SB Dean, MD.

Purpose: Low fistula rates after palatoplasty can be achieved in an academic setting with a defined, significant resident participation.

Methods: All patients requiring palate repairs performed from 1996 2004, representing the tenure of four craniofacial surgeons, were identified. Though both velopharyngeal insufficiency (VPI) and fistula rates are traditionally used as benchmarks for successful palatoplasty, we chose absence of fistula as a measure of success and as the entry-point for successfully teaching residents to perform palatoplasty. Craniofacial Team charts were retrospectively reviewed to determine the presence of fistulas. A fistula was identified as any post-operative aperture posterior to the incisive foramen. Palate repair case numbers for all residents were tabulated during this time period; minimum Residency Review Committee (RRC) numbers for palatoplasty is six. Resident participation in cases was also documented. A change in teaching philosophy occurred in 2001: residents initially performed most or all of the procedure under attending supervision; since 2001, residents have performed half the procedure under attending supervision.

Results: 221 palate repairs were identified with a fistula rate of 19.9% (44/221). At the mid-point of the study, following reassessment of training philosophy, fistula rates decreased from 32.5% (39/120) between 1996 2000 to 3.96% (4/101) from 2001 -2004. Graduating resident cleft palate cases rose from an average of 17.9 (1996 - 2000) to 24.4 (2001 - 2004). All residents were above the minimum RRC requirements (range, 8 26 from 1996 to 2000 and 13 37 from 2001 to 2004). Chi-square analysis of fistula rates with change in teaching philosophy was significant (p<.01);student t-test analysis of resident case numbers and fistula rates approached statistical significance (p=.066).

Conclusion: The balance between patient care and teaching need not compromise either: Low fistula rates after palatoplasty are as important for patient care as they are for teaching purposes. We recognize that fistula rates following palatoplasty are influenced by multiple confounding variables, including attending surgeon, type and width of the cleft, techniques utilized and post-operative care. However, resident level of participation and case numbers also play a role. Low fistula rates can be achieved with significant resident participation. The numbers for minimal competency in palate repair among residents, however, is likely higher than the RRC recommendation of six, and closer to twenty; yet, this number remains ill-defined.

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