title: Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States.
abstract: BACKGROUND
  International organizations have performed palatoplasties in low- and middle-income countries for decades, often working with local providers. Few studies report long-term outcomes, especially for palatal fistulas. A fistula after palatoplasty may affect speech, socialization, and nutrition. Fistula rates on surgical missions have not been compared with rates at U.S. craniofacial centers nor have the rates of the visiting and local surgeons working on missions been compared.
  
  
  METHODS
  Fistula rates for two Ecuadorian cohorts were compared with fistula rates for a craniofacial center in the United States. In Ecuador, North American surgeons repaired one cohort (n = 46) and Ecuadorians the other (n = 82) during 2000 through 2005. Ecuadorian patients were evaluated during 2007 and 2008. The center's clinical database (n = 189) provided U.S. cohort data.
  
  
  RESULTS
  On missions, the fistula rates were 57 percent (95 percent CI, 46 to 68 percent) for Ecuadorian surgeons and 54 percent (95 percent CI, 39 to 69 percent) for North American surgeons. The rate was 2.6 percent (95 percent CI, 0.8 to 6.0 percent) at the U.S. craniofacial center. There was no difference between the two Ecuadorian cohorts' rates (p = 0.75), but they were significantly higher than those of the U.S. cohort (p < 0.001). Having a cleft lip together with cleft palate was associated with fistula formation, whereas surgeon nationality and older age at surgery were not.
  
  
  CONCLUSIONS
  The fistula rate on Ecuadorian missions, regardless of the surgeon's nationality, was significantly higher than in the United States. Further investigation into the causes of this higher fistula rate in this population is needed.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: San Francisco and Mountain View, Calif.; and Guayaquil, Ecuador From the Departments of Surgery, Pediatrics, and Anesthesia and the Division of Plastic Surgery, University of California San Francisco; the Plastic Surgery Program, Universidad Católica de Santiago de Guayaquil; and ReSurge International.
authors.forename: Rebecca G
authors.initials: RG
authors.lastname: Maine
authors.forename: William Y
authors.initials: WY
authors.lastname: Hoffman
authors.forename: Jorge H
authors.initials: JH
authors.lastname: Palacios-Martinez
authors.forename: D Scott
authors.initials: DS
authors.lastname: Corlew
authors.forename: George A
authors.initials: GA
authors.lastname: Gregory
mesh_terms: D002675:Child, Preschool; D002971:Cleft Lip / Q000601:surgery*; D002972:Cleft Palate / Q000601:surgery*; D015331:Cohort Studies; D004484:Ecuador; D005260:Female; D005402:Fistula / Q000453:epidemiology*; D006782:Hospitals, Special; D006801:Humans; D007223:Infant; D008297:Male; D008493:Medical Missions; D010159:Palate / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D014481:United States