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Skeletofacial reconstruction in skeletally mature patients with cleft lip/palate can be challenging because of multifaceted condition-specific anatomical features in addition to several repercussions from surgical intervention during the growing period. This surgical report presents the history and evolving philosophy of cleft-skeletofacial reconstruction at the Chang Gung Craniofacial Center, a referral center for cleft care in Taiwan. The maximization of satisfactory function and the appearance outcome-burden ratio have been the fundamental aims for this team to develop and upgrade cleft-skeletofacial reconstruction over the past 4 decades, with more than 10,000 mature patients treated. The study highlights key lessons learned in outcome-based and patient-oriented changes over time until the current approach, which focuses on patient-centered care with a comprehensive, multidisciplinary, and team-based model. Substantial advances in surgical, orthodontic, anesthetic, and computer imaging aspects have contributed to improving and optimizing the correction of a broad spectrum of facial and occlusal deformities while ensuring safety, predictability, efficiency, and stability in outcomes. Understanding the development and refinement of cleft-skeletofacial reconstruction over the time and transferring these time-tested and scientifically validated protocols and principles to clinical practice may serve as a reliable foundation to continue the advancement and enhancement of the delivery of surgical cleft care worldwide.

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Orthognathic surgery (OGS) has been successfully adopted for managing a wide spectrum of skeletofacial deformities, but patients with underlying conditions have not been treated using OGS because of the relatively high risk of surgical anesthetic procedure-related complications. This study compared the OGS outcomes of patients with and without underlying high-risk conditions, which were managed using a comprehensive, multidisciplinary team-based OGS approach with condition-specific practical perioperative care guidelines. Data of surgical anesthetic outcomes (intraoperative blood loss, operative duration, need for prolonged intubation, reintubation, admission to an intensive care unit, length of hospital stay, and complications), facial esthetic outcomes (professional panel assessment), and patient-reported outcomes (FACE-Q social function, psychological well-being, and satisfaction with decision scales) of consecutive patients with underlying high-risk conditions (n = 30) treated between 2004 and 2017 were retrospectively collected. Patients without these underlying conditions (n = 30) treated during the same period were randomly selected for comparison. FACE-Q reports of 50 ethnicity-, sex-, and age-matched healthy individuals were obtained. The OGS-treated patients with and without underlying high-risk conditions differed significantly in their American Society of Anesthesiologists Physical Status (ASA-PS) classification (p < 0.05), Charlson comorbidity scores, and Elixhauser comorbidity scores. The two groups presented similar outcomes (all p > 0.05) for all assessed outcome parameters, except for intraoperative blood loss (p < 0.001; 974.3 ± 592.7 mL vs. 657.6 ± 355.0 mL). Comparisons with healthy individuals revealed no significant differences (p > 0.05). The patients with underlying high-risk conditions treated using a multidisciplinary team-based OGS approach and the patients without the conditions had similar OGS-related outcomes.

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BACKGROUND: Subjects with obstructive sleep apnea (OSA) are vulnerable to sedation-related complications during endoscopic procedures. A significant portion of subjects undergoing routine endoscopy is at high risk of OSA, but most are undiagnosed. The purpose of this study was to estimate the prevalence of high risk for OSA among Chinese subjects undergoing deep sedation for screening gastrointestinal endoscopy and to evaluate the hypoxemia risk of these examinees stratified by Berlin Questionnaire (BQ). PATIENTS AND METHODS: We performed a prospective cohort study in subjects undergoing deep sedation with monitored anesthesia care for combined esophagogastroduodenoscopy plus colonoscopy. Subjects who were Chinese were stratified into high- and low-risk groups for OSA by administration of BQ. Deep sedation was achieved via a propofol target-controlled infusion system. Hypoxemia was defined as pulse oximetry reading of less than 90%. The frequency of hypoxemia was compared between high- and low-risk groups for OSA. RESULTS: A total of 615 Chinese subjects were recruited during the study period, and 614 subjects were included for analysis. Two hundred eighteen (35.5%) subjected were classified to be at high risk of OSA, and 396 (64.5%) were stratified to be at low risk of OSA by BQ. Hypoxemia occurred in 83 (13.5%) subjects during endoscopy procedures. The risk of developing hypoxemia in the high-risk group was significantly higher when compared to that of the low-risk group subjects (24.8% vs 7.3%; relative risk, 3.37; 95% CI, 2.22-5.13). CONCLUSION: About one-third Chinese subjects undergoing deep sedation for screening endoscopy were at high risk of OSA. Subjects at high risk of OSA are associated with an increased risk of hypoxemia in comparison to the low-risk group when undergoing deep sedation for screening gastrointestinal endoscopy.

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PURPOSE: The objective of this study was to evaluate the efficacy of hypotensive anesthesia in reducing intraoperative blood loss, decreasing operation time, and improving the quality of the surgical field during orthognathic surgery. A systematic review and meta-analysis of randomized controlled trials addressing these issues were carried out. MATERIALS AND METHODS: An electronic database search was performed. The risk of bias was evaluated with the Jadad Scale and Delphi List. The inverse variance statistical method and a random-effects model were used. RESULTS: Ten randomized controlled trials were included for analysis. Our meta-analysis indicated that hypotensive anesthesia reduced intraoperative blood loss by a mean of about 169 mL. Hypotensive anesthesia was not shown to reduce the operation time for orthognathic surgery, but it did improve the quality of the surgical field. Subgroup analysis indicated that for blood loss in double-jaw surgery, the weighted mean difference favored the hypotensive group, with a reduction in blood loss of 175 mL, but no statistically significant reduction in blood loss was found for anterior maxillary osteotomy. If local anesthesia with epinephrine was used in conjunction with hypotensive anesthesia, the reduction in intraoperative blood loss was increased to 254.93 mL. CONCLUSIONS: Hypotensive anesthesia was effective in reducing blood loss and improving the quality of the surgical field, but it did not reduce the operation time for orthognathic surgery. The use of local anesthesia in conjunction with hypotensive general anesthesia further reduced the amount of intraoperative blood loss for orthognathic surgery.

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BACKGROUND: Although previous studies have reported soft-tissue management in surgical treatment of Sturge-Weber syndrome (SWS), there are few reports describing facial bone surgery in this patient group. The purpose of this study is to examine the validity of our multidisciplinary algorithm for correcting facial deformities associated with SWS. To the best of our knowledge, this is the first study on orthognathic surgery for SWS patients. METHODS: A retrospective chart review included 2 SWS patients who completed the surgical treatment algorithm. Radiographic and clinical data were recorded, and a treatment algorithm was derived. RESULTS: According to the Roach classification, the first patient was classified as type I presenting with both facial and leptomeningeal vascular anomalies without glaucoma and the second patient as type II presenting only with a hemifacial capillary malformation. Considering positive findings in seizure history and intracranial vascular anomalies in the first case, the anesthetic management was modified to omit hypotensive anesthesia because of the potential risk of intracranial pressure elevation. Primarily, both patients underwent 2-jaw orthognathic surgery and facial bone contouring including genioplasty, zygomatic reduction, buccal fat pad removal, and masseter reduction without major complications. In the second step, the volume and distribution of facial soft tissues were altered by surgical resection and reposition. Both patients were satisfied with the surgical result. CONCLUSIONS: Our multidisciplinary algorithm can systematically detect potential risk factors. Correction of the asymmetric face by successive bone and soft-tissue surgery enables the patients to reduce their psychosocial burden and increase their quality of life.

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BACKGROUND: In recent years, patient-controlled epidural analgesia (PCEA) has been developed as an attractive alternative to continuous epidural infusion (CEI) for labor pain control. PCEA is still not popular for labor pain control in Taiwan and disparities may exist between different ethnic and cultural groups toward the attitude of labor pain control. The aim of this study was to investigate whether there were any differences between PCEA and CEI in the maintenance of epidural analgesia for Taiwanese parturients undergoing spontaneous delivery. METHODS: We collected data of 179 parturient requests for epidural labor analgesia. They were allocated into two groups with PCEA (n = 81) or CEI (n = 98) for maintenance with the same solution of 0.08% ropivacaine and 2 microg/mL fentanyl mixture. The demographic characteristics, epidural maintenance methods, dosage requirements, obstetrical outcomes, intervention of inadequate analgesia or side effects, and the quality of labor analgesia of parturient were also analyzed. RESULTS: There were no differences in demographic characteristics, duration of 1st and 2nd stages, delivery methods, fetal Apgar scores, local anesthetics usage, and analgesic qualities between the PCEA and CEI groups. There were also more requirements for intervention by the anesthesiologist due to inadequate analgesia in the CEI group. CONCLUSION: The results of this study provided further evidence that PCEA is a highly effective method of the control of labor pain, which was highly accepted by women in labor. In a busy obstetric unit, this could potentially improve parturient satisfaction and reduce the workloads of clinicians and nurses.

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STUDY OBJECTIVE: To evaluate the correlation between accepted screening tests for difficult tracheal intubation and ease of intubation with a lightwand blind technique. DESIGN: Prospective study. SETTING: Anesthetic rooms of a university hospital. PATIENTS: 122 female, ASA physical status I, II, and III patients requiring tracheal intubation for elective surgery. INTERVENTIONS: After receiving a standardized anesthetic induction, patients first underwent direct laryngoscopy to determine Cormack laryngoscopy grade, then tracheal intubation was performed using a transillumination method. MEASUREMENTS AND MAIN RESULTS: Patient demographics, Mallampati class (MC), mouth opening (MO; cm), and thyromental distance (TMD; cm) were all measured and the values recorded. Body mass index (BMI; kg/m2) was calculated for each patient. Laryngoscopy grades obtained by laryngoscopy were also recorded. Times to intubation were measured by a chronometer and failures were recorded. Patients were then allocated to groups according to the measured parameters: BMI > or = 30 kg/m2, BMI < 30 kg/m2; TMD > or = 6 cm, TMD < 6 cm; MO > or = 3, MO < 3; MC I, MC II, MC III, MC IV, and Laryngoscopy Grade (LG) 1, LG 2, LG 3, LG 4. Intubation times at the first attempt were compared within the groups for each variable. The total results of 119 patients were studied; overall success was 99%, and mean time to intubation at the first attempt was 9.2 +/- 4.9 seconds. Although time to intubation was prolonged with increasing Mallampati and laryngoscopy scores, and in the TMD < 6 cm and BMI > or = 30 kg/m2 groups, only the MC III and BMI > or = 30 kg/m2 groups represented a statistically significant difference of prolongation. Mean time to intubation in the MC III and BMI > or = 30 kg/m2 groups were 13.2 +/- 5.4 (p = 0.011) and 14.8 +/- 1.7 (p < or = 0.001), respectively. CONCLUSION: Mallampati class III airway significantly increases time to intubation when the transillumination technique is used. BMI > or = 30 kg/m2 is another factor that interferes with the ease and success of intubation with this technique.

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BACKGROUND: Caudal epidural block (CEB) has become increasingly important for pediatric analgesia in recent years. However, data regarding CEB in adult ambulatory surgery are scarce. The aim of this study was to verify whether CEB could be applied as a simple, safe and economic method of anesthesia for adult patients undergoing minor gynecologic procedures (MGP). METHODS: One hundred and seventy-two female patients were enrolled in this study. Each patient received a 20-mL bolus of 1.5% lidocaine caudal epidural injection. The efficacy of CEB was evaluated. Types and duration of surgery, success rate, sensory level of analgesia, caudal epidural depth, complications and duration in the postanesthesia care unit (PACU) were also under investigation. RESULTS: No side effects occurred and only few hemodynamic changes were noted in the study. All patients experienced excellent surgical anesthesia except seven patients, who required rescue supplement opioids (4.1% of failure rate). The success rate of CEB was 95.9% (165/172). Duration of anesthesia and surgery were 46.66 +/- 11.76 min and 23.08 +/- 9.54 min, respectively. The highest sensory dermatome level reached below T10. The average epidural depth was 3.06 +/- 0.23 cm. No postoperative anti-emetic was given in the study. Only three patients required postoperative narcotics. Four patients had spontaneous voiding before discharge. The average PACU stay was 74.30 +/- 10.80 min. CONCLUSION: Single-dose CEB with 1.5% lidocaine 20-mL was an easy and simple technique. It provided satisfactory anesthesia for MGP and did not prolong patients' discharge time. CEB may be another choice of anesthetic technique in such cases of clinical practice.

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We report an unusual cause of acute total airway obstruction after aspiration of a dislodged tube that was separated from its metallic connector. A 5-year-old boy had an emergence agitation and bucking to the endotracheal tube with a vigorous bite before extubation of the trachea. The whole uncuffed endotracheal tube was aspirated deep into the lower trachea causing laryngotracheal obstruction. The patient showed sudden oxygen desaturation and was then in an immediate life-threatening airway obstruction. We could not rescue oxygenation and were unable to establish a patent airway. Mask ventilation failed to relieve the progressive of hypoxemia. Immediate extraction of the tube using a pair of Magill's forceps before irreversible exacerbation was performed. We discuss our experience and the importance of prompt decision making and management for the extraction of the dislodged tube.

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Prader-Willi syndrome (PWS) is a sporadic disorder of chromosome abnormalities with an estimated prevalence of 1 in 15,000. It mainly affects the central nervous system, and often involves the hypothalamus. Both general and regional anesthesia for these patients is difficult mainly due to morbid obesity. Other common problems include hypotonia, disturbance in thermoregulation, arrhythmia, cor pulmonale, diabetes mellitus, behavior problems, and convulsions. We report on 2 pediatric patients with PWS receiving general anesthesia. The first patient experienced life-threatening episodes of severe hypoxemia in the postanesthesia care unit (PACU) as well as in the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (CPAP) was suggested by the pediatric pulmonary medicine specialist, and thereafter the patient's condition improved. The clinical course of the second patient was uneventful except for transient intermittent episodes of bronchospasms during emergence. In addition, we discuss differences between these 2 cases and our strategy for the prevention of perioperative complications for PWS patients in the future.

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BACKGROUND: This randomized, prospective study was designed to evaluate the role of various anesthesias in postoperative urinary retention and hesitancy in micturition in patients receiving hemorrhoidectomy on ambulatory basis. METHODS: In a randomized order, 128 ambulatory patients, ASA physical status I or II, were divided into two groups to receive hemorrhoidectomy under epidural or local anesthesia. In all patients, the intraoperative intravenous fluid given was limited to 200 ml +/- 2 ml/kg/h of Ringer's lactate solution. Patients were requested to void urine voluntarily before discharge. The incidences of postoperative urinary retention and hesitancy in micturition were evaluated by telephone interview 24 hours after surgery. RESULTS: Neither the incidence of urinary retention, nor the incidence of hesitancy in micturition was significantly different between the two groups. Patients with age over 50 had a significantly higher incidence of hesitancy in micturition than younger patients. The incidence of hesitancy in micturition seemed higher in male patients (31.3%) than that in females (15.6%), but the difference was not statistically different (P = 0.0585). CONCLUSIONS: With judicious intraoperative fluid restriction and voluntary voiding before discharge, epidural anesthesia does not increase the incidence of postoperative urinary retention or hesitancy in micturition following ambulatory hemorrhoidectomy.

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PURPOSE: To describe a practical method of aiding nasotracheal intubation in a cleft palate patient with previous pharyngoplasty using a suction catheter under tactile guidance. Problems of airway management in these patients are also discussed. CLINICAL FEATURES: A 26-yr-old woman presented for elective Le Fort maxillary osteotomy. She had a history of cleft lip and palate and subsequent palatoplasty and pharyngeal flap. She had no symptoms of upper airway obstruction or obstructive sleep apnea. Preoperative examination revealed a hypernasal voice and patent nasal passages. Anesthesia was induced and the patient paralyzed. An attempt to pass a 6.5-mm cuffed endotracheal tube through the right nostril met with resistance. A suction catheter was introduced into the nostril, while a finger was positioned over the flap and the velopharyngeal port, until its tip rested against the flap, the catheter coiled and a small loop could be palpated past the patent velopharyngeal port. The catheter was then hooked into the oropharynx. The endotracheal tube was "railroaded" over it and advanced into the glottis. There was minimal bleeding and no desaturation during the procedure. CONCLUSION: Preoperative determination of the type of pharyngoplasty is essential to understand the anatomy of the patent velopharyngeal port. A history of pharyngeal flap infection, hyponasal voice or upper airway obstruction suggests possible port stenosis. We describe a tactile guided technique that is useful and practical. Use of a flexible suction catheter of small external diameter minimizes the potential for trauma, bleeding and creation of false passages.

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