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UPPP (UP3) Under Attack... this time by a physician

More shocking charges against a segment of the medical profession:
"Mack Jones, MD on September 10th, 2010 2:50 pm 
A meta-analysis from one of the Scandinavian countries recently came to the conclusion (as others have in the past) that a UP3 was of no benefit in relieving OSA. 

Shouldn’t ENT surgeons stop performing this worthless surgical procedure? Shouldn’t Medicare and insurance companies stop reimbursement for this worthless surgical procedure?"

http://doctorstevenpark.com/ask-dr-park-minimally-invasive-options-...

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strong words

they are money makers that is up3
I have been saying that UPPP is worthless for the past 15 years.
It cost nearly $30,000 for the surgeries I had for OSA. What a total rip off. I was robbed by my ENT. It was totally useless. He promised me a 90% sucess. My apena was only reduced by 35%. I still have 45 occurrances an hour With a 70% oxygen saturation. These proceedures should be outlawed. I am still on bpap every night.
Sue

Carl Speas said:
It cost nearly $30,000 for the surgeries I had for OSA. What a total rip off. I was robbed by my ENT. It was totally useless. He promised me a 90% sucess. My apena was only reduced by 35%. I still have 45 occurrances an hour With a 70% oxygen saturation. These proceedures should be outlawed. I am still on bpap every night.
maybe i should

99 said:
Sue

Carl Speas said:
It cost nearly $30,000 for the surgeries I had for OSA. What a total rip off. I was robbed by my ENT. It was totally useless. He promised me a 90% sucess. My apena was only reduced by 35%. I still have 45 occurrances an hour With a 70% oxygen saturation. These proceedures should be outlawed. I am still on bpap every night.
When an ENT says that a patient is an "excellent candidate" for UPPP, that means that their insurance will cover it.
Here is the study I referred to. The quotation below is from the abstract. You can read the entire article yourself and draw your own conclusions.

SLEEP VOLUME 32, NUMBER 1/ January 1, 2009, pp 27-36. SURGERY FOR SNORING AND OSA
Effects and Side-effects of Surgery for Snoring and Obstructive Sleep Apnea--A Systematic Review, Karl A. Franklin, MD, PhD, et al.

Conclusions: "Only a small number of randomized controlled trials with a limited number of patients assessing some surgical modalities for snoring or sleep apnea are available. These studies do not provide any evidence of effect from laser-assisted uvulopalatoplasty or radiofrequency ablation on daytime sleepiness, apnea reduction, quality of life or snoring. We call for research of randomized, controlled trials of surgery other than uvulopalatopharyngoplasty and uvulopalatoplasty, as they are related to high risk of long-term side-effects, especially difficulty swallowing."
Many past meta-analyses have shown 40% success rate with the UPPP procedure. You could also argue that adeno-tonsillectomy shouldn't be done since it works in only 60% of patients. Many children will continue to have obstructive sleep apnea after having their tonsils taken out. Then there's the entire controversy over the definition of "success."

Real life compliance and tolerance for CPAP is probably less than 50%, so is CPAP not worth offering? Absolutely not. With better patient education, counseling and appropriate follow-up many more people can benefit from CPAP. Similarly, if you've exhausted all your non-surgical options and are considering surgery, you have to do it appropriately, and not just do one procedure in one part of the airway, "just to see."

If I had a choice between the patient feeling significantly better after surgery and post-op AHI in the low single digits, I choose the former. In the old days, I was too focused on getting the AHI down as low as possible. But the AHI is only one small part of the big picture. There are situations where an AHI would drop from 25 to 2 after surgery or even with CPAP, and the patient won't feel any better. For the patient, it's not considered a "success," even though from a medical standpoint, it is.

I do agree that in most cases, doing a UPPP alone won't help cure sleep apnea. However, if you have huge kissing tonsils and a small tongue with large jaws, it's likely that you'll feel much better. The challenge is in predicting who's going to respond.

Ultimately, asking if the UPPP works for obstructive sleep apnea is not a fair question, since sleep apnea is due to multiple areas of obstruction, from the tip of the nose to the tongue base. If you have three areas of clogging in a pipe, and you only unclog one area, then It's not going to work. But if the one area that you unclogged is responsible for 90% of the blockage, then opening up that one area will help greatly.

This is why addressing multiple areas simultaneously has a much higher chance of success. Various soft tissue operation have "success" rates in the 60 to 80% range. If you enlarge both upper and lower jaws (the MMA), then success rates go up to above 90%. If you bypass everything and undergo a tracheotomy, then 99%. Surgery does work, but only if performed appropriately.

In my opinion, it's pointless to talk about the value of the UPPP procedure without looking at it in conjunction with other areas, especially the tongue base. The most common reason why the UPPP doesn't work is that the tongue base wasn't addressed. Sometimes, even when both areas are addressed, you'll sometimes see persistent obstruction on one area. I remember reading one study where after UPPP and tongue base procedures were done, using pressure sensors, you could tell where persistent obstruction was happening. Dr. Tucker Woodson developed one particular procedure where the soft palate was pulled to the hard palate without cutting any more of the soft palate, and it worked pretty well.

It's bad enough that so may people go undiagnosed with obstructive sleep apnea, and even when diagnosed, are not given proper instructions and options for CPAP or oral appliance therapy. But there will always be some people who can't tolerate or benefit from CPAP or oral appliances, and will require surgery. Unfortunately, a UPPP is still being offered much too often as an isolated procedure. Patients have to know that if they're considering surgical therapy, it's a much more complex than just stiffening or trimming the soft palate.

To say that the UPPP is worthless perpetuates the misconception that surgery doesn't work. It won't work if it isn't done properly. It's never a black or white situation. I help many people benefit from CPAP or oral appliances. But of the small percentage of patients that end up going on to surgical options, the positive outcomes in my experience is what makes me continue to offer surgery.

But you can't think of surgery as the end-all either. Oftentimes, I'll offer nasal surgery to improve CPAP or oral appliance compliance. You start with basic, conservative options and work your way up to more aggressive treatment options. Different people have different needs. The challenge is finding what works for you without trying too many different options.
Could you expand a little more on your comment, "Then there's the entire controversy over the definition of "success?"

Steven Y. Park, MD said:
Many past meta-analyses have shown 40% success rate with the UPPP procedure. You could also argue that adeno-tonsillectomy shouldn't be done since it works in only 60% of patients. Many children will continue to have obstructive sleep apnea after having their tonsils taken out. Then there's the entire controversy over the definition of "success."

Real life compliance and tolerance for CPAP is probably less than 50%, so is CPAP not worth offering? Absolutely not. With better patient education, counseling and appropriate follow-up many more people can benefit from CPAP. Similarly, if you've exhausted all your non-surgical options and are considering surgery, you have to do it appropriately, and not just do one procedure in one part of the airway, "just to see."

If I had a choice between the patient feeling significantly better after surgery and post-op AHI in the low single digits, I choose the former. In the old days, I was too focused on getting the AHI down as low as possible. But the AHI is only one small part of the big picture. There are situations where an AHI would drop from 25 to 2 after surgery or even with CPAP, and the patient won't feel any better. For the patient, it's not considered a "success," even though from a medical standpoint, it is.

I do agree that in most cases, doing a UPPP alone won't help cure sleep apnea. However, if you have huge kissing tonsils and a small tongue with large jaws, it's likely that you'll feel much better. The challenge is in predicting who's going to respond.

Ultimately, asking if the UPPP works for obstructive sleep apnea is not a fair question, since sleep apnea is due to multiple areas of obstruction, from the tip of the nose to the tongue base. If you have three areas of clogging in a pipe, and you only unclog one area, then It's not going to work. But if the one area that you unclogged is responsible for 90% of the blockage, then opening up that one area will help greatly.

This is why addressing multiple areas simultaneously has a much higher chance of success. Various soft tissue operation have "success" rates in the 60 to 80% range. If you enlarge both upper and lower jaws (the MMA), then success rates go up to above 90%. If you bypass everything and undergo a tracheotomy, then 99%. Surgery does work, but only if performed appropriately.

In my opinion, it's pointless to talk about the value of the UPPP procedure without looking at it in conjunction with other areas, especially the tongue base. The most common reason why the UPPP doesn't work is that the tongue base wasn't addressed. Sometimes, even when both areas are addressed, you'll sometimes see persistent obstruction on one area. I remember reading one study where after UPPP and tongue base procedures were done, using pressure sensors, you could tell where persistent obstruction was happening. Dr. Tucker Woodson developed one particular procedure where the soft palate was pulled to the hard palate without cutting any more of the soft palate, and it worked pretty well.

It's bad enough that so may people go undiagnosed with obstructive sleep apnea, and even when diagnosed, are not given proper instructions and options for CPAP or oral appliance therapy. But there will always be some people who can't tolerate or benefit from CPAP or oral appliances, and will require surgery. Unfortunately, a UPPP is still being offered much too often as an isolated procedure. Patients have to know that if they're considering surgical therapy, it's a much more complex than just stiffening or trimming the soft palate.

To say that the UPPP is worthless perpetuates the misconception that surgery doesn't work. It won't work if it isn't done properly. It's never a black or white situation. I help many people benefit from CPAP or oral appliances. But of the small percentage of patients that end up going on to surgical options, the positive outcomes in my experience is what makes me continue to offer surgery.

But you can't think of surgery as the end-all either. Oftentimes, I'll offer nasal surgery to improve CPAP or oral appliance compliance. You start with basic, conservative options and work your way up to more aggressive treatment options. Different people have different needs. The challenge is finding what works for you without trying too many different options.
it's really so very sad for the patients that have this surgery [UPPP}, not knowing any better and truly trusting in their dr. to help them do what's best. I am one of those patients. I had the surgery in 2007 because my sleep dr. thought I was not going to ever be able to adapt to using the c-pap machine.
I trusted him and I trusted the surgeon who promised me a 90% success rate! I now have severe sleep apnea, I had mild before the surgery, i still can't seem to have much success using the c-pap machine, so I am much worse than I was before the surgery.
I makes me very, very, sad!!!
Betty, I'm so, so sorry you've gone through all this, with the hope that you'd feel and BE better. The trust issue is so critical in these serious matters.

Did you have an opportunity to seek a second opinion before proceeding? It seems as if many people, (and I tend to be one), lean toward trusting their MD's advice, but some don't even know they have an OPTION to seek second, third, fourth second opinions prior to agreeing to a surgical procedure. I'm absolutely NOT an expert on these complex surgeries, but given the differing thoughts of MDs in general, and a few on SG specifically, it seems to me that ALL physicians have a duty to encourage patients to speak with other specialists and gather as much information re: options and opinions about success rates as possible, before subjecting them to surgery.

It may be easy for a (hopefully) well-meaning MD to encourage a surgical solution to the complex problems related to OSA, but the patient is the one who lives with the result of that (over?) confidence. To me, that nearly DICTATES that patients be very well-informed, via many experienced sources, prior to making a decision re: surgery.

Betty is probably one of many patients who now live with not only the disappointment/sadness of an unsuccessful surgery, but with the reality that the very surgery that was supposed to help has indeed contributed to the exacerbation of their condition.

Perhaps these situations can be better avoided by people, both professionals and patients, have upfront, searching conversations/disagreements which explore the many options available and their efficacy.

Mack, I applaud your bringing this apparently controversial subject to SG and placing it in the forefront of our thoughts. Confrontation of entrenched ideas is never easy to approach, much less dive into, but as far as I'm concerned, it's a critical piece of OSA treatment that bears close examination by ALL of us, whether we're surgery candidates or not.

***SO HERE'S MY (unsolicited!!!) PUBLIC SERVICE ANNOUNCEMENT FOR THE DAY:

Dr. Steven Park is presenting a free teleconference tonight, September 14th, @ 8:00 p.m. EST, on this very topic. I've attended a # of these teleconferences and have ALWAYS come away with helpful information re: this bad boy of a disease called OSA. Even if it's not a personal issue, the education is well worth the one-hour's time you'll spend tuning in.

To register, email *doctorstevenpark.com* to get to his website to sign up. Or you can chase him down on SG and let him know you'd like to sign in tonight.

Betty, again, my heart is with you. I'm so glad you're here on SleepGuide 'cause it's THE best place to get the support you no doubt need at this point in your treatment process. Lotsa good people here have your back and will listen to anything you need to talk about.

Susan McCord

betty mills said:
it's really so very sad for the patients that have this surgery [UPPP}, not knowing any better and truly trusting in their dr. to help them do what's best. I am one of those patients. I had the surgery in 2007 because my sleep dr. thought I was not going to ever be able to adapt to using the c-pap machine.
I trusted him and I trusted the surgeon who promised me a 90% success rate! I now have severe sleep apnea, I had mild before the surgery, i still can't seem to have much success using the c-pap machine, so I am much worse than I was before the surgery.
I makes me very, very, sad!!!
(
x

betty mills said:
it's really so very sad for the patients that have this surgery [UPPP}, not knowing any better and truly trusting in their dr. to help them do what's best. I am one of those patients. I had the surgery in 2007 because my sleep dr. thought I was not going to ever be able to adapt to using the c-pap machine.
I trusted him and I trusted the surgeon who promised me a 90% success rate! I now have severe sleep apnea, I had mild before the surgery, i still can't seem to have much success using the c-pap machine, so I am much worse than I was before the surgery.
I makes me very, very, sad!!!

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