surgery rona slator consultant plastic surgeon clinical director, west midlands cleft centre clapa...
TRANSCRIPT
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Surgery
Rona SlatorConsultant Plastic Surgeon
Clinical Director, West Midlands Cleft Centre
CLAPA Annual MeetingSaturday, 11th October, 2008
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The service provided…Development of that service…Problems/challenges for the
future…
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Surgery - the service
to try to restore the disrupted anatomy
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0-5 years
3 months lip repair 6-9 months palate repair
closure of fistulasurgery for speech
lip/nose revision
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5-10 years
closure of fistulasurgery for speech
8-10 years alveolar bone graft
lip/nose revision
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10-20 years
lip/nose revision
>16 years lip/nose revision orthognathic surgery
implants
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(ENT surgery for glue ear)
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But surgeons also…
Often visit newborn babies and their families
Counsel parents who have had an antenatal diagnosis of their baby having a cleft lip
Continue support for families as the children grow up
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With geneticist and paediatrician will have a role in diagnosing other anomalies and/or
developmental problems
Engage and liaise with specialists (both within and) outside the cleft team in
coordinating care
May have a major role in looking after babies with Pierre Robin Sequence with
airway/feeding problems
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Teaching/training
• Surgeons• Other members of the cleft team in training• Other specialties outside the cleft team but
also involved in the care of children with cleft lip and/or palate
Being open themselves to learning from other
specialists in the cleft team
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Development of the surgical service
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Following CSAG and reorganisation…
• Reduced numbers of surgeons involved in cleft care
• Increased time commitment of surgeons to cleft care (particularly for those involved in ‘primary’ surgery)
• All surgeons carrying out ‘primary’ lip and palate repair treating increased numbers of new babies (range in 2008, 29-77 per year)
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Developments - Surgical training
• Significantly improved and specific training (1-2 year Cleft Fellowship) for trainee surgeons wishing to become consultant surgeons carrying out primary cleft lip and palate repair.
• Currently there are talented young surgeons interested in the specialty
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Developments
• Coordination of care improved following reorganisation – all aspects of cleft care within the one team
• Longitudinal care established
• Colleagues with whom to discuss difficult or unusual surgical problems
• Other specialist disciplines within the team contribute to surgical decisions
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Developments
• Measurement of outcomes
• There is a more open culture about outcomes and intercentre audit
• And a desire to improve care by working together
• Continuing effort to move towards the CSAG inspired standards of multidisciplinary care (ENT, impact of psychology input)
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Challenges for the future
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Challenges
Developing evidence to support best surgical practice
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So, for example, order and timing of repair of lip and palate
Unilateral cleft lip and palate
Lip all of palateLip/(anterior) hard palate rest of palateLip and soft palate rest of palate
3 months 6-9 months
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An easier question?
Which sutures to use?
Still have at least one problem of outcome measure
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ChallengesOutcome measures
Speech
Facial growth
Appearance/symmetry
Well being
‘burden of care’
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plus
• Small numbers
• Workload and infrastructure to collect data
• Having equipoise for different approaches
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ChallengesAnd evidence from
Developing a better understanding of the patients’ views on surgery, particularly so called ‘secondary’
surgery.
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Challenges
Development of basic science research that might fundamentally
change the surgery needed
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Challenges - A very specialist area
Continue to attract ‘the best’ young surgeons into the field
And train them so that the ‘learning curve’ is eliminated as far as possible
Who will have wide knowledge and awareness of surgical and technical developments in all areas of surgery and elsewhere
so that these can be introduced into cleft care where appropriate
Innovation