Uvulopalatopharyngoplasty Procedure Safe and Effective

People with obstructive sleep apnea (OSA) repeatedly stop breathing during their sleep, often for a minute or longer, as many as hundreds of times during a single night. In patients with this condition, there is complete obstruction of the airway (obstructive apnea). OSA occurs in approximately two percent of women and four percent of men over the age of 35. The disorder can be deadly, leading to high blood pressure and other cardiovascular problems. Some 12 million Americans have complete or partial obstruction of the airway.

Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure performed for obstructive sleep apnea (OSA). The operation entails removal of excess tissue at the back of the throat (tonsils, uvula and part of the soft palate). The anatomic and physiologic abnormalities associated with OSA pose additional risks of complication during and after the surgery. Fear of postoperative edema or swelling further raises the concern for complications during the procedure. For example, respiratory complications can occur with airway obstruction leading to respiratory arrest and reintubation or emergent tracheotomy, an event within hours of surgery. For cardiovascular complications, OSA patients may be especially vulnerable to myocardial infarction after surgery. Finally, patients undergoing UPPP, particularly those undergoing concurrent tonsillectomy, are at risk for postoperative hemorrhage.

Nevertheless, these serious perioperative complications appear to be uncommon. However, data supporting this contention come from single-site case series with a limited number of patients. It is difficult to estimate rates accurately with these small studies of rare events. For example, three studies suggest a mortality rate of one to two percent, while the last three argue that there is no real mortality risk. There is a similar limitation on the estimates of the incidence of serious complications, and the figures for the more-recent studies are lower as well. By pooling these case series, the crude mortality rate appears to be 0.41 percent (4/977) and serious complication rate 3.5 percent (34/977). However, the contributing case series vary widely on the definition of complication, period of evaluation and setting for surgery.

The purpose of this original study was to calculate the 30-day incidence of serious complications and mortality in a large, multi-site cohort of UPPP patients. The authors of "Incidence of Serious Complications After Uvulopalatopharyngoplasty (UPPP)" are Eric J. Kezirian MD MPH, Edward M. Weaver MD MPH, Bevan Yueh MD MPH, and Richard A. Deyo MD MPH, all from the University of Washington School of Medicine, Seattle, WA; and Shukri F. Khuri MD, and Jennifer Daley MD, both from the Brockton/West Roxbury VA Medical Center West Roxbury, and Harvard Medical School, Boston, MA; and William Henderson, PhD, from the University of Colorado Health Sciences Center, Denver, CO. Their findings will be presented at the annual meeting of The Triological Society http://www.triological.com/default.htm meeting May 4-6, 2003, at the Gaylord Opryland Hotel, Nashville, TN.

Methodology: This was a retrospective cohort study of all patients undergoing UPPP, defined by CPT code 42145 or 42299, at any Veterans Affairs (VA) medical center in the United States from 1991 -- 2001. Patients were excluded if they had concomitant neck dissection or ablative surgery, which are indicators of oncologic resection.

The primary outcome of interest was the incidence of serious 30-day perioperative complications, including death. Fifteen specific life-threatening complications were identified. These outcomes were grouped according to system: death; respiratory (including reintubation), pneumonia, prolonged ventilation (>48 hours), emergent tracheotomy, or pulmonary edema; cardiovascular including cardiac arrest, myocardial infarction, cerebrovascular accident, or pulmonary embolism; and other complications including hemorrhage >4 units of packed red blood cells, coma, wound infection or systemic sepsis.

Overall incidence of 30-day complication was calculated as the number of patients with at least one complication per UPPP done. Rates were calculated for each system (e.g., number of patients with a respiratory complication per UPPP done) and for specific complications. Because multiple complications may occur in a single patient, the sum of the system-specific complication rates would be greater than the overall rate.

Results: There were 3,130 patients with a procedure code for UPPP, after exclusion of oncology patients as described above. The overall incidence of 30-day serious complications (including death) was 1.7 percent (54/3130). Respiratory complications comprised the largest subcategory, occurring in 1.1% of all cases. Other complications included pneumonia, hemorrhage, reintubation and cardiac disorders.The rates of complication and death showed no systematic relationship to patient age group.

Conclusions: This study provides the largest and first multi-site cohort of UPPP patients examined for this purpose. The rate of acute serious complications (including death) after palate surgery is low.