2017-18 HSC Section 3 Green Book

Original Investigation Research

Complications After Obstructive Sleep Apnea Upper Airway Surgery

tion may have increased with the severity of OSA. It is likely that any substantial complication, such as respiratory depres- sion, would have been diagnosed quickly and treated in these intensively monitored settings. Thus, this negative associa- tion between OSA severity and operative complication can- not be applied topatientswithunrecognizedor untreatedOSA. Second, the result also cannot determine whether OSA per se increases perioperative riskbecausemost of the patients in this series had OSA, and no patients without OSA were included as controls. Third, our study is retrospective; the nature of the studymay predispose the study to recall bias, with data on rel- evant history and complications not collected. A large num- ber of potential candidates (19%) were excluded because of communication and documentation loss, which could have affected the results of the study. Fourth, operations were performed by 3 different surgeons (Z.A.A., K.A., W.I.L.). Although the principal author (Z.A.A.) was present in the op- erating theater during all of the operations, this factor could still lead to technical bias. Fifth, to avoid confounding based on differences in polysomnographic techniques, we studied only patients who underwent polysomnography at a single institution, a potential source of selection bias. Conclusions In patients withOSAundergoing upper airway surgery, the se- verity of OSA as assessed by AHI and the sites and numbers of concurrent operations performedwere not associatedwith the rate of short-termoperative complications. Both Lsat and lon- gest apnea duration more consistently predicted the opera- tive complications in our study.

complications. The choices of anesthesia, analgesics, and in- tensive care unit use in our cohort are at the discretion of the attending anesthetists; thus, it is beyond thepower of the study to give a meaningful conclusion on this point. Our data did not reveal that concurrent, multilevel sur- gery sites increased the complication risks. Mickelson and Hakim, 10 in their series of 344 UPPP surgery cases, noted a higher rate of complications in patients who underwent na- sal procedures along with UPPP compared with UPPP alone. A more recent study 39 that directly compared the complica- tions rate in simultaneous nasal andpharyngeal surgery (group 1) or pharyngeal surgery alone (group 2) to treat OSA found that performing concurrent nasal and oropharyngeal surgery for OSA was safe when compared with oropharyngeal surgery alone. The authors even suggested that, with careful selec- tion criteria, group 1 surgery can even be performed in the am- bulatory setting. 39 Many other past series found that compli- cation rates were also not associatedwith types of procedures performed and whether the surgery was a single or combina- tion surgery. 8,15,40 However, the choice of surgical approach was predetermined and not randomized in our study; there- fore, not all differences in complication rates can be attrib- uted to operative approach alone. Multiple upper airway site operations for OSA can be performed in combination or in a multistep manner, with data indicating that surgical out- comes in a simultaneous surgery group were equivalent to those in a staged surgery group. 41 The limitations of this negative finding must be acknowl- edged. First, all our patients had OSA diagnosed by polysom- nography before the operation, so most of these patients re- ceived intensive treatment andmonitoring intraoperativelyand postoperatively. The intensity of themonitoring and interven-

ARTICLE INFORMATION Accepted for Publication: September 21, 2016. Published Online: November 23, 2016. doi: 10.1001/jamaoto.2016.3268 Author Contributions: Drs Asha’ari and Ab Rahman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Asha'ari, Ab Rahman, Mohamed. Drafting of the manuscript: Asha'ari, Leman. Critical revision of the manuscript for important intellectual content: Asha'ari, Ab Rahman, Mohamed, Abdullah. Statistical analysis: Asha'ari, Ab Rahman. Administrative, technical, or material support: Asha'ari, Abdullah, Leman. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: The study was supported by grant EBW B 13-022-0907 from the International Islamic University Malaysia (principal investigator, Dr Asha’ari). Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and

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