Failure analysis in sleep apnea surgery

Guilleminault et al. (1) coined the term “obstructive sleep apnea” (OSA) to describe patients with disrupted nocturnal breathing. In 1969, Kuhlo et al. (2) performed the first tracheotomy to bypass upper airway obstruction, which represented the first definitive surgical intervention in OSA. In 1979, Fujita et al. (3) introduced uvulopalatopharyngoplasty (UPPP) for treatment of OSA. In 1981, Sullivan et al. (4) published the first study of continuous positive airway pressure (CPAP) for nonsurgical treatment of OSA. As with tracheotomy, CPAP eliminates excessive daytime sleepiness (EDS) and cardiopulmonary sequelae of OSA (5) including normalization of blood pressure (6). Only complete compliance with CPAP was shown to be sufficient to derive treatment benefits from this therapy (7). Problematically, incomplete compliance with CPAP was prevalent (8-10). Despite increased compliance with auto-titrating CPAP, a substantial proportion of patients remained ineffectively treated (11). This led to a shift in attention toward surgical treatment for OSA. In a meta-analysis, Sher et al. (12) noted success of UPPP in 41% of all patients; however, in patients with tongue-base obstruction UPPP was successful in only 6% of the cases. This finding is further supported by Isono et al. (13) who demonstrated that collapsibility at the level of the retroglossal airway is the most significant determinant of UPPP outcome.