Comparing folded-flap palatoplasty and staphylectomy in brachycephalic dogs

Imagine this clinical scenario...

You are presented with a brachycephalic dog whose owner has noticed stertorous breathing, exercise intolerance, and occasional regurgitation. Your physical examination reveals stenotic nares, and an airway examination reveals an elongated soft palate, leading you to diagnose brachycephalic obstructive airway syndrome (BOAS). You identify surgical soft palate resection operations as a possible solution, with folded-flap palatoplasty and staphylectomy as two possible options. You are well-versed in the conventional staphylectomy technique but not folded-flap palatoplasty, which would require referring the owner to a specialist. You decide to consult the evidence comparing the two techniques so you can best advise your client.

The evidence

Two retrospective cohort studies were identified that directly compare folded-flap palatoplasty and staphylectomy.

Fracka et al. (2024) retrospectively studied the cases of 76 client-owned dogs who underwent upper airway surgery for BOAS between 2018 and 2022. All 76 had been diagnosed with elongated soft palate, and underwent either staphylectomy (39/76) or folded-flap palatoplasty (37/76).

80% of the cohort were Bulldogs (61/76), the median age was 25 months, and the median weight was 11kg. All staphylectomy procedures were performed using CO2. The folded-flap palatoplasty proecedures were performed with a variety of tools; 23/37 used CO2 laser, 9/37 used Metzenbaum scissors and bipolar electrocautery, and 5/37 used a combination of sharp dissection and laser treatment.

Pre, intra, and postoperative outcomes included; need for oxygen or sedation, diagnostic test results, the presence and grade of laryngeal collapse or paralysis, brachycephalic risk score, additional concurrent procedures, respiratory or cardiovascular complications, oxygen supplementation, and length of hospitalisation.

Miller et al. (2024) retrospectively reviewed the cases of 124 client-owned dogs who underwent staphylectomy or folded-flap palatoplasty surgery for elongated soft palate at a veterinary hospital in the USA between 2012 and 2019. 64/124 underwent staphylectomy and 60/124 underwent folded-flap palatoplasty.

Outcomes studied included; perioperative complications, concurrent surgical procedures, length of hospitalisation, postoperative medication use, occurrence of minor or major complications, and data from follow-up appointments.

Limitations of the evidence

The overall quality of evidence was weak. Both papers studied were retrospective cohort studies which offer a poor quality of evidence. Retrospective studies carry inherent biases due to the inability to randomise dogs between treatment groups, lack of standardisation, individual surgeons’ preferences, and inconsistent follow-up data.

Fracka et al. (2024) had a lack of standardisation of medical records, and some information was incomplete. Laryngeal evaluations were also conducted by different clinicians with differing levels of experience, making standardisation impossible. This lack of standardisation was compounded by the lack of a postoperative protocol, with treatment decisions based on individual clinicians’ preferences. The sample size was also limited which may have had the following impacts; Less reliable statistical analysis with an increased risk of type II error, and an upward bias towards complicated recovery.

Miller et al. (2024) had a small sample size for some variables such as pre and postoperative imaging, postoperative clinical signs and revision surgeries. Staphylectomy procedures were also performed with the cut-and-sew technique, and without electrocautery or laser tools that could’ve affected the outcome. There was also a limited follow-up time with a large range reported.

Summary of findings

The evidence suggests that both staphylectomy and folded-flap palatoplasty can be used to treat BOAS in dogs with good outcomes and does not suggest a significant difference in complications and discharge time between the two. However, this must be considered in line with the limitations outlined above.

Fracka et al. (2024) found that 14/76 dogs experienced minor postoperative complications, and 16/76 experienced major postoperative complications. Of the 16 dogs that experienced major complications, 11 had undergone staphylectomy and 5 had undergone folded-flap palatoplasty. The following factors were identified as being associated with a complicated recovery, but the type of surgery was not considered in this analysis; increasing age, higher laryngeal collapse grade, and longer duration of anaesthesia.

The median duration of postoperative hospitalisation was 1.5 days, with 73/76 dogs surviving to discharge. Two dogs were euthanised for persistent severe dyspnoea in the 1–2 days following surgery, but this was not linked to the type of surgery.

Miller et al. (2020) found that 27/124 dogs experienced minor complications, the occurrence of which was not different between the two surgical procedures. 5/124 dogs experienced major complications which were relatively evenly distributed between both surgery types. Two dogs were euthanised within two weeks of surgery, two dogs received a tracheostomy procedure postoperatively and were euthanised within two weeks of surgery, and one underwent a tracheostomy procedure within two weeks of surgery but was not euthanised. In all cases of euthanasia, this was carried out due to severe and persistent respiratory distress postoperatively.

The median length of hospital stay was one day for both procedures. 7/124 dogs underwent further soft palate surgeries after follow-up appointments. Three of them had initially had a staphylectomy and four had initially had a folded-flap palatoplasty.

Conclusion

The existing evidence comparing the outcomes and length of hospitalisation after use of staphylectomy and folded-flap palatoplasty to treat BOAS is weak, but suggests that both produce good outcomes, result in a hospitalisation length of 1 to 1.5 days, and come with a small risk of serious complications. Further blinded, randomised control studies are required to assess whether a specific technique can result in less complications and earlier discharge times.

In lieu of strong evidence, clinicians should take the context of each individual patient into account when choosing between the two, and consider factors such as; patient age, the presence and severity of comorbidities such as laryngeal collapse, and expected surgical time.

The full knowledge review is available here: https://doi.org/10.18849/ve.v10i3.716 

Disclaimer

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise; patient’s circumstances and owner’s values; country, location or clinic where you work; the individual case in front of you; and the availability of therapies and resources.