99 An evaluation of predictors for success of 2-duct ligation for drooling in neurodisabilities 4 were collected at baseline and follow-up measurements so we could assess change over time and calculate treatment effect. This enabled us to identify three easily definable clinical variables that are associated with treatment success. There are, however, several limitations of the study. On the one hand, this is the largest cohort of patients that underwent 2-DL. On the other hand, the cohort still consists of a relatively small number of patients, limiting the amount of variables that could be entered in the logistic regression analyses. Patients were excluded due to missing 32-weeks follow-up which might induce a selection bias. This however included only 2 patients, so bias should be limited. Moreover, data were retrospectively collected in one institution, and we did not perform an external validation for the prediction model whichmight limit the extent towhich the results can be generalized. However, we expect that the results might be generalizable because: 1) patients are generally comparable.2 2) 2-DL is a relatively easy surgical technique for which the procedure is thoroughly described in the manuscript. 3) based on the methods, age, poor posture, and a VSSD are easy to determine in other institutions. Drooling proves refractory to 2-DL in ~ 40% of patients after 32 weeks. Age (more mature), posture (no anteflexion) and normal speech (no VSSD) are predictors for 2-DL treatment success. Clinicians could opt for a more aggressive approach (e.g. 3-duct ligation or 4-duct ligation) in case of anteflexion and a VSSD. Future studies should, however, externally validate the predictors for treatment success before the model is to be used in surgical decision making. As the effect of 2-DL is greater in moremature patients our restraint to advise surgery for anterior drooling in younger children (~ <10 years of age) is substantiated. Moreover, 2-DL interferes with SMDR which is currently the more successful treatment for drooling, so the indication should be carefully considered, especially when children are not yet mature. SMDR is, however, contraindicated in patients with progressive developmental disorders, a history of aspiration pneumonia, and posterior drooling (saliva aspiration).18,19,2 In these cases, 2-DL can be considered, but future studies should investigate the effect of 2-DL in the long-term.
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