Barbed reposition pharyngoplasty in multilevel robotic surgery for obstructive sleep apnoea

Anterolateral advancement pharyngoplasty versus barbed reposition pharyngoplasty in patients with obstructive sleep apnea

OBJECTIVES

To compare functional outcomes and complication rates of anterolateral advancement pharyngoplasty (ALA) versus barbed reposition pharyngoplasty (BRP) in the treatment of obstructive sleep apnea patients with palatal and lateral pharyngeal wall collapse.

STUDY DESIGN

Prospective study.

SETTING

University hospitals.

SUBJECTS AND METHODS

Forty-six patients were included in this study. Patients were divided into two groups randomly, group 1 (23 cases) underwent anterolateral advancement pharyngoplasty and group 2 (23 cases) underwent barbed relocation pharyngoplasty. According to the following criteria: both sex, age between 18 and 65 years, body mass index ≤ 32 kg/m2, Friedman stage II or III, type I Fujita, nocturnal polysomnography study diagnostic for OSA, retropalatal and lateral pharyngeal wall collapse, diagnosis with flexible nasoendoscopy during a Muller's maneuver based on a 5-point scale and drug-induced sleep endoscopy. Patients who suffered from retroglossal airway collapse were rolled out.

RESULTS

Apnea-hypopnea index decreased from 27.50 ± 11.56 to 11.22 ± 7.63 (P ≤ .001) in group 1 and from 33.18 ± 10.94 to 12.38 ± 6.77 (P ≤ .001) in group 2. Retropalatal posterior airway space increased from 9.84 ± 1.29 mm to 21.48 ± 2.8 mm (P ≤ .001) in group 1 and increased from 10.26 ± 1.2 mm to 22.86 ± 2.62 mm (P ≤ .001) in group 2. Retropalatal space volume increased from 1.9 ± 0.68 cm3 to 2.75 ± 0.7 cm3 (P ≤ .001) in group 1 and increased from 1.96 ± 0.88 cm3 to 2.82 ± 0.83 cm3 (P ≤ .001) in group 2. Surgical success was 86.95% in group 1 compared to 82.6% in group 2.

CONCLUSIONS

Both techniques appear to be effective with a high surgical success rate in the treatment of OSA patients with retropalatal and lateral pharyngeal wall collapse.

Multi-Level 3D Surgery for Obstructive Sleep Apnea: Could It Be the Future?

(1) Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway, leading to reduced or absent breathing during sleep. A nocturnal upper airway collapse is often multi-levelled. The aim of this communication is to describe a 3D multi-level surgery setting in OSA pathology, introducing new surgical approaches, such as 4K-3D endoscopic visualization for the tongue base approach with the aid of a coblator and exoscopic visualization in the palatal approach. (2) Methods: Seven patients affected by OSA underwent 3D Barbed Reposition Pharyngoplasty (BRP) surgery associated with transoral coblation tongue base reduction and nose surgery. (3) Results: No patients experienced intra-operative, post-operative or delayed complications. For OSA multi-level 3D surgery, it took less than 2 h: the median 3D system setting time was 12.5 ± 2.3 min; the overall procedure time was 59.3 ± 26 min. (4) Conclusions: The use of the 4K-3D endoscope and coblator for tongue base resectioning and of the 3D exoscope for lateral pharyngoplasty represents an excellent system in multi-level OSA related surgery that could reduce the time and the costs compared to those of robotic surgery.

Complications and side effects after barbed pharyngoplasty: a systematic review

BACKGROUND

Recently, the use of barbed pharyngoplasty (BP) has become widespread in snoring and obstructive sleep apnoea (OSA) palatal surgery, but there are no studies regarding the short- and long-term complications resulting from these different techniques. This systematic review aimed to report the complications and side effects of different BP techniques.

METHODS

An electronic search was performed on PubMed/MEDLINE, Google Scholar, and Ovid databases. The PRISMA statement was followed. Databases were searched from inception through September 2, 2021.

RESULTS

We included 14 prospective clinical studies consisting of 769 patients aged 23 to 81 years. The associated intra-operative complications of BP were as follows: partial thread extrusion (2.9%), self-limited bleeding (2.9%), broken needle (1.0%), and suture rupture (1.0%). Short-term complications were as follows: thread/knot extrusion (12.4%), dysphagia (5.6%), bleeding (1.5%), velopharyngeal insufficiency (1.5%), anterior pharyngoplasty dehiscence (1.2%), tonsillar haemorrhage (1.0%), excessive postnasal discharge (1.0%), barbed suture failure (0.5%), acute infection (0.2%), mucosal granulomas (0.2%), chipped tooth caused by mouth gag displacement (0.2%), and fibrous scar (0.2%). Long-term complications were as follows: foreign body sensation (7.8%), sticky mucus in throat (5.9%), dysphagia (3.6%), rhinolalia (3.1%), throat phlegm (1.1%), nose regurgitation (0.8%), dry throat (0.6%), and throat lump (0.3%).

CONCLUSION

BP is a safe technique free of significant side effects and major complications. However, in this review, patients undergoing BP were very heterogeneous in terms of characteristics of patients chosen and severity of diseases, surgical technique used (myoresective vs non-myoresective), time of follow-up, and mono level vs multilevel surgery. More studies on a larger scale with long-term follow-up are needed to confirm these promising results.

Barbed pharyngoplasty for obstructive sleep apnea: A meta-analysis

PURPOSE

The purpose of this study was to perform a meta-analysis of barbed pharyngoplasty (BP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Databases included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science and Scopus, and reference lists. Relevant articles were searched through August 2021, following the PRISMA guidelines.

RESULTS

Twenty articles with 762 participants were included. The mean success in BP as a single-level surgery was 85.2% (MD, 95% CI 77.6%, 92.7%). There was a significant reduction of oxygen desaturation index (ODI) of -11.7 (MD 95% CI -16, -7.4). The lowest oxygen saturation (LSAT) improved 8.9% (MD, 95% CI 1.3%, 16.7%). Epworth Sleepiness Scale (ESS) and snoring score significantly decreased -6.8 (MD 95% CI -8.3, -5.2) and -5.3 (MD 95% -7.9, -2.7), respectively. The apnea-hypopnea index (AHI) significantly decreased -23.9 events/h (MD, 95% CI -25.5, -22.9) with a 69% reduction. The mean surgical time was 23 min. A significant improvement of AHI, ODI, ESS, and LSAT was also revealed in BP as a multilevel surgery. Complications included suture extrusion (18%), dysphagia (20%), velopharyngeal insufficiency (15%), and dysgeusia (3%) without serious consequences. The median follow-up period was 6 months, ranged 1 to 26 months.

CONCLUSION

Barbed pharyngoplasty as a single-level or multilevel surgery is a safe and effective procedure with significant objective and subjective outcomes for OSA patients with palatal obstruction. However, randomized clinical controlled trials with multicenter cooperation and long-term study are necessary.

Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art

PURPOSE

In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed.

MATERIALS AND METHODS

We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported.

RESULTS

15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review.

CONCLUSIONS

Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures.

Combined Transoral Robotic Tongue Base Surgery and Palate Surgery in Obstructive Sleep Apnea Syndrome: Modified Uvulopalatopharyngoplasty versus Barbed Reposition Pharyngoplasty

Background: Successful surgery outcomes are limited to moderate to severe obstructive sleep apnea (OSA) syndrome. Multilevel collapse at retropalatal and retroglossal areas is often found during the drug-induced sleep endoscopy (DISE). Therefore, multilevel surgery is considered for these patients. The aim of our study was to survey surgical outcomes by modified uvulopalatoplasty (UPPP) plus transoral robotic surgery tongue base reduction (TORSTBR) versus barbed repositioning pharyngoplasty (BRP) plus TORSTBR. Methods: The retrospective cohort study was performed at a tertiary referral center. We collected moderate to severe OSA patients who were not tolerant to positive pressure assistant PAP from September 2016 to September 2019; pre-operative–operative Muller tests all showed retropalatal and retroglossal collapse; pre-operative Friedman Tongue Position (FTP) > III, with the tonsils grade at grade II minimum, with simultaneous velum (V > 1) and tongue base (T > 1), collapsed by drug-induced sleep endoscopy (DISE) under the VOTE grading system. The UPPP plus TORSTBR (n = 31) and BRP plus TORSTBR (n = 31) techniques were offered. We compare the outcomes using an Epworth sleepiness scale (ESS) questionnaire, and measure the patients’ apnea–hypopnea index (AHI), lowest O₂ saturation, cumulative time spent below 90% (CT90), and arousal index (AI) by polysomnography six months after surgery; we also measure their length of hospital stay and complications between these two groups. Results: Comparing BRP plus TORSTBR with UPPP plus TORSTBR, the surgical success rate is 67.74% and 38.71%, respectively. The significantly higher surgical success rate in the BRP plus TORSTBR group was noted. The surgical time is shorter in the BRP plus TORSTBR group. The complication rate is not significant in pain, bleeding, dysgeusia, dysphagia, globus sensation, and prolonged suture stay, even though the BRP plus TORSTBR rendered a higher percentage of globus sensation during swallowing and a more prevalent requirement of suture removal one month after surgery. The length of hospital stay is not significantly different between the two groups. Conclusion: In conclusion, BRP plus TORSTBR is a considerable therapy for moderate to severe OSA patients with DISE showing a multi-level collapse in velum and tongue base area. The BRP technique might offer a better anterior–posterior suspension vector for palate level obstruction.

Barbed suture Extrusion and Exposure in palatoplasty for OSA: What does it mean?

PURPOSE

Analyze Extrusion&Exposion (E&E), its implications in the functional, anatomical results and subjective discomfort in OSA patients treated with Barbed Reposition Pharyngoplasty (BRP).

MATERIALS AND METHODS

488 patients treated with BRP or multilevel TORS. Stratafix wire was used in 230 patients, V-Loc in 258. E&E, timing and localization evaluated at follow-up. Polygraphy used to assess the impact of E&E on functional results, PPOPS questionnaire used for subjective discomfort.

RESULTS

E&E in the entire group was 18,4%, with significant difference between Stratafix and V-Loc wire (p = 0,002), but not between BRP alone and multilevel surgery (p = 0,68). 28,9% of extrusion happened within the first seven days, 76,7% between seven days and two months, 5,5% after two months. Symptomatic clinical profile has been seen in 62,2%, asymptomatic one in 37,8% of patients. 35,5% of E&E were localized in tonsillar bed, 46,7% in soft palate and 20% in other sites. Mean delta-AHI of E&E patients was -15,87 ± 16.82 compared with one of those who did not have E&E was -16.34 ± 22,77 (p = 0,38). Mean PPOPS of 183 patients analyzed was 12,32 ± 4,96. Mean PPOPS of extruded group was 12,94 ± 4,68 and 11,92 ± 5,11 in not extruded one (p = 0,166).

CONCLUSIONS

E&E are suture-type sensitive (V-Loc > Stratafix), reported more frequent when BRP is performed alone than BRP-TORS with no statistical significance. 76,7% of the E&E occur after patient discharge and within 2 months. About half of the E&E were localized in soft palate. There is no need to fear Extrusion&Exposition because it does not affect in a negative way subjective and PSG outcome.

Barbed Reposition Pharyngoplasty versus Expansion Sphincter Pharyngoplasty: A Meta-Analysis

OBJECTIVE

This study was to compare barbed reposition pharyngoplasty (BRP) and expansion sphincter pharyngoplasty (ESP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Relevant 907 articles were searched from various databases until August 2020, including PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science and Scopus, and reference lists.

RESULTS

Four studies with a total of 208 participants were included. The mean reduction of apnea-hypopnea index (AHI) in the BRP group was 74.03% and the mean reduction of AHI in the ESP group was 60.17%. The mean success rate in the BRP group and the ESP group was 84.96% and 79.87%, respectively. The mean difference (MD) of the change in AHI between groups was not significantly different (MD = -1.24 event/hr, 95% CI [-11.86, 9.36], P = .82). There was no significant difference in postoperative AHI, postoperative Epworth Sleepiness Scale, pain, hospital stay, time to oral diet, and the change in oxygen desaturation index in both groups whereas the analgesic requirement was lower in the BRP group. Operative time was lower in the BRP group (MD = 21.72 minutes, 95% CI [18.85, 24.60], P < .0001).

CONCLUSION

The outcomes in both procedures are comparable in the improvement of OSA with palatal collapse. BRP is superior to ESP in term of surgical time. However, randomized clinical controlled trials with multicenter cooperation and long-term follow-up are essential to further demonstrate the efficacy of these procedures. Laryngoscope, 131:1420-1428, 2021.

Different barbed pharyngoplasty techniques for retropalatal collapse in obstructive sleep apnea patients: a systematic review

BACKGROUND

The use of barbed sutures (BS) for the treatment of retropalatal collapse and vibration in patients suffering from snoring and obstructive sleep apnea (OSA) has significantly increased in the last few years. Many surgeons have discovered the advantages and unique properties of the BS and allowed the popular surgical pharyngoplasty techniques to be updated and improved.

METHODS

A systematic review was performed to identify all the clinical studies concerning the different barbed pharyngoplasty (BP) techniques used for the treatment of palatal collapse in snoring and OSA patients. A qualitative analysis of data extracted was conducted.

RESULTS

We included 12 studies of which 10 are prospective and 2 retrospective: 9 single-arm studies on the efficacy of a specific BP technique, 1 randomized clinical trial on the comparison between BP and control groups, and 2 studies on the correlation between two different BP techniques. To date, in the literature, 5 different types of BP techniques have been described: barbed snore surgery, barbed reposition pharyngoplasty, barbed expansion sphincter pharyngoplasty, barbed suture suspension, and barbed soft palate posterior webbing flap pharyngoplasty. All the studies showed an overall improvement in the primary efficacy parameters investigated (apnea-hypopnea index, oxygen desaturation index, and Epworth sleepiness scale) in each of the surgical techniques performed without any major complications.

CONCLUSIONS

Given the extreme heterogeneity of the studies analyzed, it is necessary to perform more randomized and control studies on large samples aimed to define the best BP technique based on its effectiveness, surgical success rate, patient's compliance, and complications.

Lateral pharyngoplasty techniques for obstructive sleep apnea syndrome: a comparative experimental stress test of two different techniques

PURPOSE

To show the different effects of expansion sphincter pharyngoplasty (ESP) and barbed reposition pharyngoplasty (BRP) on muscle tension and muscle fiber tearing using a comparative experimental stress test with a frog thigh muscle model.

METHODS

Frog thigh muscle was used for this experimental study. A Barbed suture was used to simulate the BRP pharyngoplasty whereas a Vicryl 3-0 suture was used to simulate the ESP technique. The other extremity of the suture was attached to traction scales. The traction scales were used to measure the weight relative to the amount of force required to obtain muscle breaking. Both surgical techniques were simulated on the frog muscle. Traction was performed until muscle breaking was observed, measuring the value of force needed to obtain muscle rupture.

RESULTS

Specimen muscle breakdown in the ESP simulation occurred with an average value of 0.7 kg of traction force. Contrarily, specimen muscle breakdown in the BRP simulation with Barbed suture occurred with an average value of 1.5 kg of traction force CONCLUSION: During simulation of the ESP technique, specimen muscle breakdown occurred with an average value of traction force lower than in the BRP technique. During traction the multiple lateral sustaining suture loops of BRP could ensure greater stability then the single pulling tip suture of ESP with minor risk of muscle fiber damage.

Treatment-emergent central sleep apnoea after surgery for obstructive sleep apnoea

Central sleep apnoea (CSA) is a lack of drive to breathe during sleep, which can occur in physiologic as well as in pathologic conditions. A particular type of CSA, defined treatment-emergent CSA (TECSA), may occur after the treatment of obstructive sleep apnoea syndrome (OSAS), either with CPAP or surgery. TECSA is transitory and seems to be related to the severity of OSAS. We describe a 51-year-old man affected by severe OSAS who developed severe, transient CSA immediately after upper airways surgery. We believe that CSA was triggered by the sudden variation in nocturnal arterial PCO₂, which decreased from 52.3 mmHg before surgery to 42.0 mmHg after surgery. It is conceivable that, due to long-lasting severe OSAS, our patient lowered his chemosensitivity to PCO₂. Consequently, the resolution of obstructive apnoeas and the restoration of normal nocturnal values of PCO₂ may have reduced the nocturnal PCO₂ to the point of being inadequate to stimulate ventilation.

Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea

OBJECTIVES

The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients.

DESIGN

Prospective study.

SETTING

Multicentre study.

PARTICIPANTS

Patients suffering from obstructive sleep apnoea.

MAIN OUTCOMES MEASURES

Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS).

RESULTS

111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001).

CONCLUSIONS

Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.