Surgical caseload is only one variable that influences outcome

EDITOR,—Recent studies have highlighted deficiencies in the overall standard and organisation of repair of cleft lip and palate in England and Wales, but, contrary to the opinions expressed in these papers, there is no conclusive evidence that surgical caseload is a critical factor in determining outcome.1 2 In a retrospective European multicentre study the number of operations carried out by an operator was just one of several variables that may have influenced the outcome of treatment in patients with cleft lip and palate.1

Alison Williams and colleagues admit that the minimum number of primary cleft repairs that a surgeon should undertake each year is not known.2 They go on to suggest, however, that an annual caseload of 40-50 repairs would be desirable and cite a report by the Standing Dental Advisory Committee as the source of this recommendation. Unfortunately, this report has not been published and it is therefore impossible to comment on the validity of this figure.

Although there is a strong case for centralising man y specialistsurgical services, there is little evidence to support the unqualified acceptance of this process for services for cleft lip and palate. The advantages of local treatment are often dismissed as secondary considerations, but having to travel long distances regularly may present considerable problems for young families. Contrary to the views expressed by P J Sykes, it is not surgeons, managers, or purchasers but paediatricians who are often keen to instigate local services for cleft lip and palate as they are sympathetic to these problems and are concerned about the lack of coordination that often exists between local and centralised services.3 In some areas local services have been developed as a consequence of patients' dissatisfaction with the regional service.

While there is no place for “occasional” cleft lip and palate surgeons, there is no reason why local units with the necessary multidisciplinary skill cannot cooperate in an effective multicentre treatment programme and thereby provide the caseload necessary for meaningful clinical audit. This is precisely why maxillofacial surgeons involved in the primary management of cleft lip and palate in England and Wales have established a multicentre audit, based on a well defined treatment protocol. Such initiatives should be encouraged as they provide an opportunity to improve the standard of management of cleft lip and palate, which has been dominated by clinical dogma for too long.