Re: UPPP-Is it so bad?
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Re: UPPP-Is it so bad?

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Posted by sleepsurgeon on March 01, 2009 at 21:10:58:

In Reply to: Re: UPPP-Is it so bad? posted by Captin Cannuck on March 01, 2009 at 08:24:53:

Dear Captain Cannuck,

I am glad the post generated some interest and disagreement (I am sure). This was the intended purpose. Thank you for your comments and insightful questions. In order to answer your questions, I will need to start from the very beginning…. I am going to make a few statements, all of which are opinions and conclusions that I have come to with years of treating patients and after thousands of operations (as well as based on the medical literature). I have helped many patients. Many of them have told me that I have changed their life, for that, I am truly grateful and honored to be able to help them. Unfortunately, I have not helped all of them. I am continuing my research to develop new treatments for sleep apnea. For now, I feel that it is important for patients to fully understand their options and the reality of their options. That was the reason I have decided to get involved with the forum. I brought up the topic of UPPP first. I will then follow up with some MMA facts on a later post. The MMA facts are based on data from over 600 sleep apnea MMA patients. The data represents the largest series known (I have published and presented the data of 175 patients and 306 patients in the past).
First, no one can cure sleep apnea, unfortunately. I often tell my patients that curing sleep apnea is like curing aging, which is impossible. The natural history of sleep apnea is such that it gradually worsens with aging, although the rate of worsening is extremely variable between patients. Any treatment that reduces the severity is helpful. Therefore, treatment for sleep apnea is simply to reduce the severity, just like managing diabetes or hypertension.
When looking at the effectiveness of OSA treatment, one needs to look at the “gold-standard”, which is nasal CPAP. Unfortunately, nasal CPAP is not perfect (I would direct you to one of my publication-Controversy in surgical versus nonsurgical treatment of obstructive sleep apnea syndrome, J Oral Maxillofac Surg 64:1267-68, 2006.). Clearly, in order to maximize CPAP benefit, the patient needs to wear CPAP every sleeping minute. The incidence of such ideal CPAP use is NOT KNOWN but it is probably 10%-20%, at best. It is known that 18%-24% of the patients simply reject CPAP in the first place. Many patients cannot tolerate nasal CPAP, thus the CPAP compliance rate is usually quoted to be around 60%. The definition of “compliance” is defined as at least 4 hours of CPAP use per night in more than 70% of the days. This has been estimated to equate to 50% of ideal use, or near total reversal of OSA. Therefore, this is how surgical response has been defined, i.e., reducing the severity of AHI by 50% and also reducing the AHI to less than 15 or 20 per hour (or mild sleep apnea). By the way, the paper in BMJ that you have quoted (Elshaug AG et al.) is well-known to me. In fact, that paper was really based on the paper that Elshaug published earlier (Sleep, 30;461-7, 2007). Dr. Elshaug actually contacted me and sent me the article when it was first published. The success rate of 13% following UPPP you have quoted from the paper is actually based on reducing the AHI to less or equal to 5 (defined as normal, by Stanford sleep clinic years ago, I might add). The success rate of UPPP to achieve AHI reduction of 50% and/or )less than or equal to 20 is actually 55% (45% failure rate). This 55% success rate is actually quite similar to the compliance rate of nasal CPAP. When I raise this issue with Dr. Eishaug, he simply stated that the limitation of nasal CPAP is well-known. As many of you know that I am closely linked to the Stanford sleep disorders clinic. I see patients in my office as well as the clinic. I can honestly say that the first line of treatment for me is always and will be nasal CPAP. The surgery is always offered as an option when patients come to me unable to tolerate nasal CPAP or simply just absolutely do not want to use nasal CPAP. I truly believe majority of the surgeons feel the same. Surgery is simply there for patients as a second choice or what should we do for the 40% of the patients that are not treated with CPAP?
The major problem with UPPP is the technique, in my opinion. UPPP was first developed in Japan as a snoring procedure and later adapted to treat sleep apnea. I have only performed ONE traditional UPPP in my career, over 10 years ago on a special case. I DO NOT remove uvulas. On occasion, I would shorten it when it is just simply too long. The technique that I use is exactly described in my website.
The pharyngeal tissues are soft and pliable. Minor salivary glands produce saliva for lubricants. If you create lots of scars (especially with laser, sorry, Captain), you are going to result in stiffness and dryness of the tissues, thus resulting in all of the well-known side effects. Therefore, it is not that UPPP doesn’t improve sleep apnea, it is that the procedure (the way it is performed) is flawed, in my opinion. Clearly, patient selection is the key in this procedure. The varied success rate on prior studies is clearly due to the patient selection issue. When I consult patients, I adjust the potential success rate based on factors such as age, weight, anatomy, severity of sleep apnea…etc. In terms of evaluating surgical results, patient outcomes following UPPP have been reported based on pre- and post-surgical sleep study results (interpreted by sleep physicians and not by the surgeon). I don’t even look at any papers that don’t report sleep study results. Not all papers are the same and one needs to select out good versus bad papers. That was what Bill put in his book. What he was trying to say was that many surgeons simply do not evaluate their results properly and that UPPP alone (the one trick pony) is insufficient. By the way, Bill has been a true supporter of sleep apnea surgery-when properly done.

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