226 SUMMARY Although hospital and community costs after 2-DL are significantly higher for 2-DL, the treatment effect after 2-DL is higher and longer-lasting. To maintain treatment effect after BoNT-A, injections are required yearly, so 2-DL might be cost-effective in the medium to long-term compared to multiple BoNT-A injections because 2-DL is equal in costs after 1.5 BoNT-A injections. Compared to BoNT-A, there seems a greater effect after 2-DL, albeit greater morbidity. Although there is greater morbidity after 2-DL, it does not seem to influence the impact of drooling on daily life gain when comparing 2-DL to BoNT-A. On the one hand, it should be stated that there is a significant degree of recurrence after 2-DL in the medium to long-term wherein a component by alternative salivary pathways is probable. On the other hand, the effect of BoNT-A is always temporary, and there is a decrease in effect after repeated injections. We do not conclude that 2-DL should substitute BoNT-A, but if there is a request for a potentially permanent solution for drooling, 2-DL could serve as the first surgical treatment option. Future research should evaluate strategies to prevent alternative salivary pathways after 2-DL. Until then, patients and caregivers should be informed of the potential for recurrence after 2-DL. Finally, one should carefully consider 2-DL in case of isolated anterior drooling because SMDR is, in our opinion, currently the superior treatment for anterior drooling that is contraindicated after 2-DL. Although the effect of subsequent SMGE after 2-DL is limited, SMGE is technically still possible after 2-DL. Future research – Ethanol submandibular duct ligation for drooling in children with neurodisabilities Aquarter of patients recurred in the periodbetweenweek 8 and 32weeks after 2-DL. Alternative salivary pathways were proposed as the leading reason for recurrence and treatment failure of 2-DL. Recent literature illustrated that intraductal ethanol infusion in the salivary gland is safe and effective for treating drooling. The last part of this thesis presents future research that evaluates the feasibility of submandibular duct ligation right after intraductal ethanol infusion into the submandibular salivary gland (Ethanol two-duct ligation) to improve treatment effect, and prevent recurrence and alternative salivary pathways after 2-DL.
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