190 GENERAL DISCUSSION by the smaller 2-DL cohort size or selection bias, as SMDR is contraindicated in posterior drooling, unsafe oral intake, and progressive neurodisabilities, whereas 2-DL is not. In 25 minutes of operative time, 2-DL is a relatively short procedure compared to SMDR, which takes about an hour and a half. It also carries a slightly lower (4%) risk of serious surgical AEs compared to SMDR and SMGE (8%) in the short to mediumterm follow-up.48, 51 2-DL is performed in an out-patient setting in contrast to SMDR and SMGE for which, in our institute, admission is required for three to four, and two days, respectively. In conclusion, on the one hand, the efficacy of 2-DL seems inferior to SMDR and SMGE. On the other hand, 2-DL is a short procedure performed in an outpatient setting with a more limited risk of AEs. Direct comparison between 2-DL and SMDR is troublesome because SMDR is generally performed in ‘better’ patients with safe swallowing, adequate posture, and non-progressive neurological disease. Positioning of 2-DL in the invasive interventions for drooling As mentioned, treatment for anterior drooling should be multidisciplinary because treatment options depend on various clinical variables and the wishes and preferences of patients and caregivers. With the findings in the current thesis, we can inform patients and caregivers of the advantages and disadvantages of 2-DL. Future research should evaluate strategies to prevent alternative salivary pathways after 2-DL, but until then, patients and caregivers could either chose for 2-DL; a short procedure, performed in an out-patient setting with limited risk on AEs, but a greater chance of recurrence and where after SMDR is contraindicated. Alternatively, patients could opt for SMGE or SMDR; more extensive procedures with multiple-day admissions and a slightly greater risk of severe adverse events, but with a larger effect and smaller chance of recurrence. Future research should evaluate which of these procedures preserves an optimal balance between the burden of the procedure, drooling relief, impact of drooling
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