Comparison of carbon dioxide laser versus bipolar vessel device for staphylectomy for the treatment of brachycephalic obstructive airway syndrome

Abstract

Carbon dioxide (CO₂) laser and bipolar vessel sealing device (BSD) are industry standards for soft palate resection. No studies exist to directly compare these 2 techniques in a clinical setting. The purpose of this study was to describe and compare clinical outcomes for dogs that underwent CO₂ laser versus BSD staphylectomy. Medical records of brachycephalic dogs that underwent CO₂ laser (Group-L) or BSD staphylectomies (Group-B) between September 2013 and September 2017 were reviewed retrospectively. Of 60 dogs that met the inclusion criteria, 26 dogs (43%) were designated Group-L and 34 (57%) Group-B. Techniques did not differ in procedure or anesthetic time (P = 0.52 and P = 0.19, respectively) or major complication rates [intraoperative (P = 1.00), post-operative (P = 0.72), short-term (P = 1.00), and long-term (P = 0.68)]. This study suggests that patient outcomes are similar for dogs undergoing staphylectomy performed by CO₂ laser and BSD.

Introduction

Elongated soft palate (ESP) is a common abnormality among dogs with brachycephalic syndrome (BS); a syndrome which is composed of primary and secondary components. The primary components of stenotic nares, elongated soft palate, and hypoplastic trachea often lead to secondary components of everted laryngeal saccules or tonsils, tonsillar enlargement, as well as laryngeal collapse and edema due to increased airway pressure (1–4). Brachycephalic syndrome is commonly diagnosed in breeds such as the English bulldog, pug, Boston terrier, and Cavalier King Charles spaniel (2,3). Treatment for BS is primarily surgical and performed to decrease airway resistance and prevent the development of a secondary BS component (3,5).

Described surgical techniques include wedge resection of the ala nasi, staphylectomy, partial tonsillectomy and ventriculectomy, and more advanced techniques such as folded flap palatoplasty, nasal vestibuloplasty, and laser-assisted turbinectomy (5–7). Staphylectomy to correct an ESP has traditionally been performed by sharp excision followed by primary closure by suturing (5,8). Complications associated with this procedure include pharyngeal edema, dyspnea, nasal regurgitation, aspiration pneumonia, airway obstruction, and the need for temporary or permanent tracheostomy (9,10). Alternative procedures for ES have been described in an effort to reduce the incidence of postoperative complications and include the use of carbon dioxide (CO₂) and diode lasers, and electrosurgical devices such as monopoloar and bipolar cautery, bipolar vessel sealing devices, and ultrasonic energy systems (11–16).

Two of the most frequently used modalities are the CO₂ laser and bipolar vessel sealing device (BSD) (5,10). There are fundamental differences in the ways CO₂ laser and BSD generate thermal energy. The CO₂ laser works by producing focused infrared light (wavelength: 10 600 nm) that is highly absorbed by water resulting in ablation and vaporization of the tissues (11,13). The LigaSure (Covidien Energy-Based Devices, Boulder, Colorado, USA) is a commonly used bipolar vessel sealing device that uses electrothermal energy to denature collagen and elastin in blood vessel walls and seal the vessels (7,17). This device automatically adjusts the current and output voltage according to tissue impedance. To the authors’ knowledge, only 1 study has compared CO₂ laser and BSD techniques for staphylectomy in dogs (7). Neither technique resulted in significant complications in a small number of normocephalic dogs; however, postoperative evaluation was limited to 96 h (7). Several studies investigating CO₂ laser and BSD techniques have reported faster procedure times and decreased hemorrhage, swelling, and postoperative pain compared to sharp dissection (2,6,7,14). However, studies comparing clinical outcome are lacking. The purpose of the study herein was to compare clinical outcomes following staphylectomy using CO₂ laser and BSD techniques in brachycephalic dogs with elongated soft palate. We hypothesized that there would be no difference in short- or long-term complications between the 2 procedures.

Materials and methods

Medical records from the Animal Medical Center from September 2013 to September 2017 were reviewed to identify dogs that underwent staphylectomy with CO₂ laser or BSD. Dogs with complete medical records and documented upper airway examination findings consistent with an ESP were included in the study. Information retrieved from the medical records included signalment, presenting complaint, clinical signs, preoperative thoracic radiographic findings, nasal and upper airway examination findings including presence and grade of laryngeal collapse, perioperative protocol, surgical methods, and outcome at follow-up appointments. Concurrent medical conditions and surgical procedures were also recorded. Dogs were excluded from the study if they had concurrent upper airway disease unrelated to BS such as laryngeal paralysis, tracheal collapse or epiglottic retroversion, had previous upper airway surgery, or if they had a concurrent illness that would significantly impact prognosis. Primary changes associated with BS included stenotic nares and elongated soft palate. A hypoplastic trachea, though independent of BS anatomic conditions, was included as a primary component as commonly described in the literature. Secondary changes included eversion of the laryngeal saccules (grade I laryngeal collapse), moderate to severe laryngeal collapse (grades II and III laryngeal collapse), enlarged tonsils, and palatine or laryngeal edema (18).

Dogs were categorized based on method of staphylectomy into 2 groups; Group-L and Group-B. Group-L dogs had the palate resected by use of a CO₂ laser as described by Clark and Sinibaldi (11). Group-B dogs had the palate resected using a BSD in a technique similar to that described by Brdecka et al (7). However, different from the technique used in that study, the dogs in Group-B underwent the procedure in sternal recumbency and the elongated soft palate was excised to the level of the caudal aspect of the tonsillar crypts. The BSD used in our study, LigaSure Small Jaw (LSJ; Covidien Energy-Based Devices) had the ability to seal and transect the tissue simultaneously, and therefore the additional step of transecting the tissue with Metzenbaum scissors as previously described (7) was not required. The device (LSJ), had the benefit of a small, curved jaw, minimal thermal spread, and a low temperature profile (17). The total and median numbers of airway procedures in addition to staphylectomy were recorded, and included wedge resection alaplasty, laryngeal sacculectomy, tonsillectomy, and procedures unrelated to the airway. Due to the retrospective nature of the study, procedure times for the staphylectomy alone were not available for comparison, and instead, a composite of all multilevel BAS surgical procedures and total anesthesia times were used as a surrogate measurement.

Intra-operative and post-operative complications following anesthesia for staphylectomy surgery were evaluated and compared between the 2 treatment groups. Complications were defined as intra-operative if they occurred from the time of sedation for upper airway examination, inclusive of the surgical procedure, to the time of extubation. Postoperative complications occurred from the time of extubation to discharge from the hospital. Short-term follow-up information was retrieved from medical records from re-examination visits 2 wk following surgery and any additional visits documented before 14 d after discharge. Long-term follow-up information was recorded as the last documented examination. Complications were further divided into major and minor complications with major complications necessitating surgical treatment (tracheostomy, revision surgery), prolonged hospitalization (aspiration pneumonia, non-cardiac pulmonary edema, hypoxia, respiratory crisis, and reintubation), or resulting in death or euthanasia. Minor complications included cough, stertor, nasal discharge, incisional infection, and regurgitation. The number of complications as well as type were compared between groups.

Statistical analysis

Numerical data were assessed for normality by the Shapiro-Wilk test. Normally distributed data in independent groups were compared using Student’s t-test, and nonparametric data of 2 groups were compared with the Wilcoxon rank sum test. Summary statistics for parametric data are presented as mean ± standard deviation (SD), and for nonparametric data are presented as median (range). Proportions of categorical data were compared using the Chi-squared test of independence, unless expected frequencies were < 5 in which case Fisher’s exact test was used. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated from 2 × 2 contingency tables. A P-value < 0.05 was considered statistically significant.

Results

A review of the medical records identified 69 dogs that underwent staphylectomy between September 2013 and September 2017. Nine dogs were excluded from the study as they had additional upper airway procedures unrelated to the primary BAS under the same anesthesia including tracheal stent placement, temporary epiglottopexy and upper airway endoscopy due to bronchopneumonia. Of the 60 dogs that met the inclusion criteria, 26 dogs (43%) comprised Group-L and 34 dogs (57%) comprised Group-B. Breeds represented included French bulldog (31/60, 52%), English bulldog (19/60, 32%), pug (8/60, 13%), bulldog mix (1/60, 2%), and shih tsu (1/60, 2%). The average age at the time of surgery was 4.3 y (range: 0.4 to 10.8 y). There was equal distribution of males and females: castrated males (n = 20), intact males (n = 10), spayed females (n = 23), and intact females (n = 7). Median body weight (BW) was 11.4 kg (range: 5.1 to 31.1 kg). There was no significant difference between Group-L and Group-B in breeds represented, mean age at the time of surgery, gender, or median body weight (P ≥ 0.13).

Nineteen dogs (32%) were presented for elective surgery, and at the time of presentation had no to mild stertor. Twenty-six dogs (43%) were presented for elective surgery (not currently in respiratory crisis) with a history of moderate to severe clinical signs (dyspnea, exercise intolerance, collapse, cyanosis, hyperthermia). Nine dogs (15%) were presented in acute respiratory crisis and 6 dogs (10%) were hospitalized for other reasons not attributed to the upper airway but had an acute respiratory crisis necessitating upper airway surgery for extubation. Nineteen dogs (32%) had a history of chronic vomiting and regurgitation and 9 dogs (15%) had a history of aspiration pneumonia. There were no statistically significant differences between groups concerning presenting complaint, history of vomiting or regurgitation, or incidence of aspiration pneumonia (P ≥ 0.67).

Preoperative thoracic radiography was performed for 57 (95%) of the dogs. Five (9%) dogs were diagnosed with aspiration pneumonia and 7 (12%) dogs had radiographic evidence of hiatal hernia. Radiographs were also evaluated by a Board-certified radiologist for the presence of a hypoplastic trachea. There was no significant difference between the groups in preoperative aspiration pneumonia (P = 0.07) or hiatal hernia (P = 1.00).

Of the 60 dogs, the median number of primary components for BAS was 2 (range: 1 to 3) with ESP noted in all dogs, stenotic nares in 50 dogs (83%) and hypoplastic trachea in 7 dogs (12%). The median number of secondary components of BAS was 1 (range: 0 to 4). Secondary components included everted laryngeal saccules in 53 dogs (88%), moderate to severe laryngeal collapse in 11 dogs (18%), enlarged tonsils in 7 dogs (12%), and palatine or laryngeal edema in 9 dogs (15%). There was no significant difference between the groups in median number of primary or secondary (P ≥ 0.14) components of BAS.

All dogs received perioperative gastrointestinal protectants (proton pump inhibitor) and an anti-emetic. Forty-eight dogs (80%) received 1 or more doses of dexamethasone (DexaJet SP; Biomeda-MTC Animal Health, Cambridge, Ontario), median dose: 0.1 mg/kg BW, range: 0.01 to 0.5 mg/kg BW, during the peri-operative period for the prophylactic treatment of upper airway inflammation. There was no significant difference between the groups (P = 0.33). Fifty-five (92%) dogs underwent multilevel surgery to address additional components of BAS including wedge resection alaplasty in 46 (77%), laryngeal sacculectomy in 47 (78%), and tonsillectomy in 8 dogs (13%). The median number of upper airway BS-related surgeries for both groups was 3 (range: 1 to 4); however, in total Group-L underwent significantly more multilevel surgical procedures than Group-B (P = 0.01). Additional procedures unrelated to the respiratory tract performed under the same anesthetic event were recorded in 23 dogs (38%), and included laparoscopic ovariectomy, open ovariohysterectomy, prescrotal castration, episioplasty, hiatal hernia repair, upper gastrointestinal endoscopy and biopsies, subcutaneous mass removal, combined laparoscopic ovariectomy and renal biopsy, tail amputation, head and bulla computed tomography, tracheobronchoscopy, and pacemaker placement. There was no statistical significance between the groups in terms of additional procedures unrelated to the upper airway (P = 0.10).

For Group-L, the median procedure time was 32.5 min (range: 10 to 80 min) and anesthesia time was 67.5 min (35 to 295 min). For Group-B, the mean procedure time was 27.5 min (range: 10 to 60 min) and anesthesia time was 58.5 min (range: 20 to 210 min). There was no significant difference in procedure or anesthesia time between the groups (P = 0.52 and P = 0.19, respectively). The median length of hospitalization was 2 d (range: 1 to 11 d) with no significant difference between the groups (P = 0.67). The final cost of surgery and hospitalization was not significantly different between the groups (P = 0.01) with a median of $3131 US$ (range: $850 to $19 640 US$) for Group-B and $3475 US$ (range: $1430 to $11 645 US$) for Group-L.

The overall major complication rate was 14/60 (23%) including 5 dogs (5/26, 19%) from Group-L and 9 dogs (9/34, 26%) from Group-B. There was no significant difference between the groups in major or minor complications in the intraoperative, post-operative, short-term, or long-term periods (P ≥ 0.68). No significant difference was demonstrated between the groups in major complications necessitating additional surgical interventions (P = 1.00), prolonged hospitalization (P = 0.51), or resultant death or euthanasia (P = 0.22). Patients that underwent major complications throughout the study period are further described in Tables 1 and 2.

Table 1.

Patient variables and major complications for Group-L.

	Patient number
	1	2	3	4	5
Signalment	4-year-old French bulldog	2-year-old French bulldog	11-year-old French bulldog	10-year-old French bulldog	5-year-old French bulldog
Preoperative variables
Presenting complaint	Elective	Elective, history of respiratory crisis	Hospitalized, other	Hospitalized, other	Elective, history of respiratory crisis
Vomiting/regurgitation	None	None	None	Chronic	None
Aspiration pneumonia	None	None	None	Historical, not current	None
Laryngeal collapse	None	None	None	Grade II	None
Procedure variables
Upper airway related	Staphylectomy Rhinoplasty	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Rhinoplasty Tonsillectomy	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Rhinoplasty Sacculectomy
Additional	None	None	Transjugular pacemaker placement	Tracheobronchoscopy	Episioplasty
BAS time (min)	29	19	13	26	43
Anesthesia time (min)	64	49	295	160	160
Major complications
Intraoperative	None	None	None	None	None
Postoperative	None	None	Asp. Pneumonia Hypoxemia Reintubation	Hypoxemia Aspiration pneumonia Reintubation Tracheostomy	Hypoxemia Reintubation
Short-term	Revision	None	None	None	None
Long-term	None	Respiratory crisis Revision	None	Respiratory crisis Death/euthanasia	None

Table 2.

Patient variables and major complications for Group-B.

	Patient number
	1	2	3	4	5
Signalment	6-year-old Pug	1-year-old French bulldog	11-year-old English bulldog	4-year-old French bulldog	9-year-old Pug
Preoperative variables
Presenting complaint	Hospitalized, other	Elective	Elective, history of respiratory crisis	Elective, history of respiratory crisis	Hospitalized, other
Vomiting/regurgitation	Chronic	None	None	Chronic	None
Aspiration pneumonia	Historical and concurrent	None	None	None	Historical
Laryngeal collapse	Grade III	Grade III	None	None	None
Procedure variables
Upper airway related	Staphylectomy Sacculectomy	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Rhinoplasty Sacculectomy Tonsillectomy	Staphylectomy Rhinoplasty Sacculectomy
Additional	None	None	Endoscopy and biopsies	Endoscopy and biopsies	None
BAS time (min)	14	26	20	20	24
Anesthesia time (min)	57	125	68	55	60
Major complications
Intraoperative	None	None	Hypoxemia	None	None
Postoperative	Hypoxemia Death/euthanasia	None	Reintubation Tracheostomy	Hypoxemia Reintubation	Hypoxemia Aspiration pneumonia Death
Short-term	n/a	None	Hypoxemia Respiratory crisis Aspiration pneumonia Revision Tracheostomy	Hypoxemia Aspiration pneumonia	n/a
Long term	n/a	Respiratory crisis NCPE Laryngeal collapse progression	Hypoxemia Death/euthanasia		n/a
	Patient number
	6	7	8	9
Signalment	10-year-old English bulldog	6-year-old English bulldog	11-year-old English bulldog	7-year-old English bulldog
Preoperative variables
Presenting complaint	Respiratory crisis	Respiratory crisis	Respiratory crisis	Respiratory crisis
Vomiting/regurgitation	None	None	None	Chronic
Aspiration pneumonia	None	None	Historical and concurrent	None
Laryngeal collapse	None	Grade IV	None	None
Procedure variables
Upper airway related	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Rhinoplasty	Staphylectomy Rhinoplasty Sacculectomy	Staphylectomy Sacculectomy
Additional	None	None	None	None
BAS time (min)	40	10	30	20
Anesthesia time (min)	45	130	50	20
Major complications
Intraoperative	None	None	None	None
Postoperative	Hypoxemia Death/euthanasia	Respiratory crisis Death/euthanasia	Hypoxemia Reintubation	None
Short-term	n/a	n/a	None	None
Long-term	n/a	n/a	None	Hypoxemia Respiratory crisis Laryngeal collapse Aspiration pneumonia Tracheostomy

BAS — Brachycephalic airway syndrome; NCPE — Noncardiogenic pulmonary edema. n/a — Not available.

The entire population was further assessed for variables associated with the development of major complications. Two preoperative variables were associated with an increased risk of major complications; English bulldog breed [odds ratio (OR): 5.83; 95% confidence interval (CI): 1.3 to 26.1; P = 0.03] and the development of respiratory distress following hospitalization for a concurrent disease process (OR: 8.8; 95% CI: 1.4 to 54.9; P = 0.02). There was no significant difference between Group-L and Group-B in preoperative variables associated with major complications (P < 0.13) (Table 3). The overall mortality rate for the study was 6/60 (10%) with all cases of death/euthanasia occurring within the post-operative and long-term periods. Two major complications were negatively associated with an increased risk of death/euthanasia throughout the study period; aspiration pneumonia (OR:17; 95% CI: 2.3 to 123.02; P = 0.01) and placement of a temporary tracheostomy (OR: 26.5; 95% CI: 1.9 to 359.2; P = 0.02). Of the 3 dogs that underwent placement of a temporary tracheostomy tube, all 3 had aspiration pneumonia and 2 subsequently died or were euthanized. There was no difference between Group-L and Group-B in complications associated with death/euthanasia (P < 0.17) (Table 4). Though not associated with an increased risk of death/euthanasia, revision surgery was performed in 3/60 (5%) dogs including 2 from Group-L and 1 from Group-B. Two of the revision surgeries were performed secondary to a respiratory crisis and the third case of revision surgery was performed secondary to owner reported exercise intolerance in the short-term period. There was no significant difference between the groups in the performance of revision surgery (P = 0.57).

Table 3.

Preoperative variables significantly associated with major complications for Group-L and Group-B.

Preoperative variable	Total (N = 60)	Group-L (N = 26)	Group-B (N = 34)
Bulldog breed (n = 19)	19/60 (32%)	6/26 (23%)	13/34 (38%)
Major complication (n = 5)	5/19 (26%)	0/6 (0%)	5/13 (38%)
Hospitalized, other (n = 6)	6/60 (10%)	2/26 (7.7%)	4/34 (12%)
Major complication (n = 4)	4/6 (67%)	2/2 (100%)	2/4 (50%)

Table 4.

Major complications significantly associated with death/euthanasia for Group-L and Group-B.

Major complication	Total (N = 60)	Group-L (N = 26)	Group-B (N = 34)
Aspiration pneumonia (n = 6)	6/60 (10%)	2/26 (7.7%)	4/34 (12%)
Tracheostomy (n = 3)	3/6 (50%)	1/2 (50%)	2/4 (50%)
Death/euthanasia (n = 3)	3/6 (50%)	1/2 (50%)	2/4 (50%)
Tracheostomy (n = 3)	3/60 (5%)	1/26 (4%)	2/34 (6%)
Death/euthanasia (n = 2)	2/3 (67%)	1/1 (100%)	1/2 (50%)

Discussion

The results of this study indicate that the clinical outcome and procedure time for staphylectomy in dogs are similar between CO₂ laser and the LigaSure. To the authors’ knowledge this is the first study to provide a direct clinical comparison between CO₂ laser and BSD-assisted staphylectomy in a population of brachycephalic dogs. While the results demonstrate no statistical difference between the 2 groups in total procedure times and anesthesia times (P = 0.52 and P = 19, respectively), there were more multilevel surgical procedures performed in Group-L (P = 0.01) even with the exclusion of patients that received staphylectomy alone (P = 0.01). It may be inferred that surgeries in Group-L were faster, given a greater total number of multilevel procedures and similar total procedure and anesthesia times; however, further prospective studies are necessary for a direct comparison. Surgical times for staphylectomy performed by CO₂ laser in the literature have been variable. Davidson et al (19) reported a mean staphylectomy procedure time of 309 s (range: 210 to 450 s). Dunie-Merigot (12) reported surgical times of 510 s when combined staphylectomy and extended palatoplasty techniques were used in brachycephalic dogs with upper airway obstructive syndrome. Brdecka et al (7) reported shorter surgical times for staphylectomy performed by a bipolar sealing device (mean 67.5 +/− 14.1 s, range: 45 to 90 s) compared with the CO₂ laser (mean: 174.5 +/− 76.5 s, range: 90 to 313 s) in normal dogs. The medical records used for the current study reported only total surgical time and did not differentiate between individual procedure times in multilevel surgeries.

The second goal of the current study was to compare the 2 procedures in terms of complication rates. The intraoperative, post-operative, short-term, and long-term complication rates were similar between the 2 groups. While Group-B had more major complications at each time point, the difference was not significant. During the intraoperative period, Group-L had no major complications. Group-B had a single patient that became hypoxemic during surgery and required reintubation and placement of a temporary tracheostomy tube in the post-operative period. Of the 10 patients that experienced major complications during the postoperative period, 3 were from Group-L (3/26, 12%) and 7 from Group-B (7/34, 21%). In further comparing complications between the groups, 1 patient from Group-L (1/26, 4%) and 2 patients from Group-B (2/30, 7%) experienced major short-term complications. Long-term complications occurred in 2 patients from Group-L (2/26, 8%) and 3 from Group-B (3/30, 10%). Mortality rates follow a similar trend as postoperative rates were lower for Group-L (0/26, 0%) compared with Group-B (4/34, 12%), although these differences were not significant.

The ideal procedure for staphylectomy would provide consistent hemostasis with minimal local inflammation, edema, and complications. The current study failed to demonstrate superiority when comparing the CO₂ laser with LigaSure and it appears that each method should be evaluated for its potential advantage and disadvantages specific to the patient, surgeon, and facility.

Post-operative dyspnea can occur in up to 20% of patients following upper airway surgery that is related to pharyngeal and laryngeal inflammation and edema, which can further contribute to airway resistance (9,10). In comparing the CO₂ laser with LigaSure there is no clear advantage of one modality over the other in post-operative inflammation evaluated histologically in one study (7). In the current study, severe post-operative dyspnea (reported as hypoxia) occurred in 9 patients, and of these patients, 4 ultimately died or were euthanized. Our study failed to demonstrate a statistically significant difference between the groups in terms of post-operative complications.

Another possible contributing factor to the perioperative complication rate is the high rate of aspiration pneumonia in the study (6/60, 10%). In a study by Ree et al (9), both perioperative metoclopramide use (OR: 16; P = 0.0172) and postoperative radiographic evidence of pneumonia reported in 5% of dogs (OR: 49.99; P = 0.0059) were associated with development of major complications (euthanasia/death and need for temporary tracheostomy tube placement). At our institution, metoclopramide has been routinely administered in the perioperative period. The current study showed, similarly, that patients which developed aspiration pneumonia alone (OR: 17; P = 0.0103) or in addition to placement of a temporary tracheostomy tube (OR: 26.5; P = 0.0243) were at much greater risk for mortality. Lorinson et al (20) also reported aspiration pneumonia as a significant risk factor for the development of major complications in the postoperative period. In that study, postoperative aspiration pneumonia was reported in 11% of dogs with the overall mortality rate associated with aspiration pneumonia being 6.25%; however, in bulldogs aspiration pneumonia appeared to be more severe with a 12.5% mortality rate (20). In our study, English bulldogs were significantly more likely than any other brachycephalic breed to develop a major complication (OR: 5.83; P = 0.03). Brachycephalic breeds have increased negative intrathoracic pressure as a result of increased respiratory effort which predisposes them to gastroesophageal reflux and subsequently aspiration pneumonia (6,20,21).

Limitations of the current study include those associated with retrospective studies including a lack of standardization in the amount of soft palate resected and anatomic landmarks used for staphylectomy. The goal of staphylectomy is to shorten the soft palate by resection of the caudal portion to prevent obstruction to the rima glottidis during inspiration (2,10,11). A reported complication of excessive staphylectomy is pharyngonasal regurgitation secondary to over-shortening the soft palate (9,10). Future studies should be conducted to determine if there are differences between ease of use and precision in performing staphylectomy with the CO₂ laser versus LigaSure. In addition, staphylectomy is used to shorten the soft palate but does not address underlying soft palate hyperplasia that may contribute to the upper airway obstruction. A recent study determined a correlation between the thickness of the soft palate and severity of brachycephalic obstructive clinical signs (6). This study also demonstrated that the soft palate of French bulldogs is significantly thicker than that of pugs (6).

The current study showed similar outcomes and safety for CO₂ laser and BSD-assisted staphylectomy. Both procedures were equally effective in speed of the procedure, minimal intraoperative complications and favorable clinical outcomes. CVJ