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#84

"Surgical Outcomes"

SUMMARY     The authors make the important point that most outcome data on surgical treatment of obstructive sleep apnea (OSA) comes from short-term follow-ups of less than one year after surgery. There exists little data concerning longer-term results.     In this study, patients were followed up over a year after surgery, which consisted of anterior maxillomandibular osteotomy and advancement (cutting the upper and lower jawbones and pushing it forward) plus genioglossus (tongue muscle) advancement and hyoid bone suspension. In previous shorter-term follow-up at 6 months after surgery, this procedure resulted in a 95% success rate, similar to that of CPAP.     The patient group in the study consisted of 40 patients treated over a ten-year interval, between 1985 and 1995. They were predominantly male (33/40), averaged 46 years of age with a wide spread of ages, had an average Body Mass Index of 31 (obese), an average Respiratory Distress Index (RDI) of 71, indicative of severe OSA, though again with a wide spread, and an average lowest oxygen saturation (LSAT) of 68%, also severe with a wide spread.     On short-term follow-up six months after surgery, all patients reported marked improvement in their excessive daytime sleepiness, which was previously severe. There was marked improvement in both RDI (9) and LSAT (86%), comparable to their results using CPAP (8 and 87%).     Long-term follow-up took place a minimum of one year after surgery, ranging from 12 to 146 months postoperative and averaging 51 months, about 4 years postoperative. At this point, 36 patients ((90%) continued to have successful results, reporting their excessive daytime sleepiness still under cotnrol, with RDIs averaging 8 and LSATs 87%, essentially the same as at six months follow-up. There had been a small but statistically significant weight gain in the meantime.     However, at the long-term follow-up, 4 patients (10%) had relapsed, with recurrence of excessive daytime sleepiness, and worsening of average RDI and LSAT from 6 months (RDI increased from 10 to 43; LSAT decreased from 88% to 82%).     Early complications of the surgery included wound infection in 2 patients, tooth injury in 1, aspiration in 1, and facial numbness in 36 (sic). Later on, only 5 continued to have numbness.     The authors pointed out that the great majority of their patients continued to do just as well at long-term as at short-term follow-up, despite gaining weight. Among the four patients who relapsed in the long-term, two had severe weight gain, one had a decrease in the degree of advancement, and one had only mild worsening of RDI but recurrence of excessive daytime sleepiness, requiring CPAP.     They considered the long-term complication rate low, the persistent numbness in 12% being well tolerated. The single patient who experienced early aspiration, related to the hyoid suspension, led to their modifying their surgical procedure.     Initial facial skeletal deformity of some degree was present in 75% of their patients, in which cases they observed generally improved appearance after surgery. Among those 10 patients without such deformities, measures were taken to "soften" the esthetic impact of the surgery, and only two patients had initially negative reactions, that cleared up with time.

A central point made by this study is that results of this specialized surgical procedure for sleep apnea--available only at a minority of advanced treatment center, like Stanford--were almost as good a few years after surgery as they were several months after surgery. This is very important, since other procedures, like the UPPP, may have much less persistent effects on sleep apnea. Furthermore, this study employed thorough follow-up evaluations, including sleep studies, whereas some earlier studies depended mainly on patient self-report.     The authors preface their own report with brief reference to a few publications on the effectiveness of other surgical procedures, especially the notoriously ineffective UPPP. This deserves a bit more detail. Several reviews of multiple studies found UPPP to accomplish improvement--not cure--in only 50% of patients who underwent this operation, with complete control in only 30%. Contrast this with the 90-95% total success rates reported with the much more extensive procedures used by the authors.     Do bear in mind that these are complex procedures, far from available everywhere from every surgeon, generally expensive and covered only partially by insurance. Despite the limited complications, the surgery is by no means routine or minor.     Among the numerous queries I receive by e-mail, the issue most frequently referred to is that of surgery. Not only do I warn people about UPPP and other "routine and minor" procedures having limited effectiveness for OSA, sometimes relieving one its principal symptoms, snoring, without resolving the underlying obstructive process, sometimes actually aggravating OSA and hindering later CPAP response, sometimes leading to initial improvement followed by relapse. On the other hand, I do believe that the procedures described by these authors represent treatments as effective as CPAP, with some advantages for some patients over CPAP. However, they do not represent something to proceed with lightly. In fact, the complexity is such that I have made little effort to detail them--I believe the lay reader would find this aspect of the research report one of the features of surgical literature that deters efforts at understanding.

"Sleep. . .Oh! how I loathe those little slices of death. . ." Henry Wadsworth Longfellow, 1807-1882

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