Is transoral robotic surgery a safe and effective multilevel treatment for obstructive sleep apnoea in obese patients following failure of conventional treatment(s)?

Abstract

A best evidence topic was written according to a structured protocol. The question addressed was whether TransOral Robotic Surgery (TORS) is a safe and effective multilevel treatment for Obstructive Sleep Apnoea (OSA) in obese patients following failure of conventional treatment(s). A total of 39 papers were identified using the reported searches of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing treatments for OSA - primarily CPAP - though highly effective are poorly tolerated resulting in an adherence often lower than 50%. As such, surgery is regaining momentum, especially in those patients failing non-surgical treatment (CPAP or oral appliances). TORS represents the latest addition to the armamentarium of Otorhinolaryngologists - Head and Neck Surgeons for the management of OSA. The superior visualisation and ergonomics render TORS ideal for the multilevel treatment of OSA. However, not all patients are suitable candidates for TORS and its suitability is questionable in obese patients. In view of the global obesity pandemic, this is an important question that requires addressing promptly. Despite the drop in success rates with increasing BMI, the success rate of TORS in non-morbidly obese patients (BMI = 30-35kgm-2) exceeds 50%. A 50% success rate may at first seem low, but it is important to realize that this is a patient cohort suffering from a life-threatening disease and no option left other than a tracheostomy. As such, TORS represents an important treatment in non-morbidly obese OSA patients following failure of conventional treatment(s).

Robotic Head and Neck Surgery: History, Technical Evolution and the Future

“…More recently, it has been deployed in the management of carcinoma of unknown primary tumours [22] as well as for transoral robotic total laryngectomy [23]. In addition to malignant disease, TORS has been shown to be a valuable treatment for obstructive sleep apnoea (OSA) due to the excellent access it offers, and it represents an ideal tool for targeted multilevel surgery in patients who do not tolerate continuous positive airway pressure (CPAP) [24][25][26].…”

Transoral Robotic Surgery for Obstructive Sleep Apnoea-Hypopnoea Syndrome

“…Patients should satisfy all of the following criteria for TORS to be considered as a treatment for OSAH: (1) moderate-to-severe OSA confirmed by polysomnography (defined as AHI ≥15 h -1 ), (2) failure to comply or refusal of all other treatment modalities including CPAP, and mandibular advancement device, (3) BMI < 35 kg/m 2 , and (4) predominant base of tongue collapse with or without epiglottic collapse evaluated by drug-induced sleep endoscopy [8,18].…”

“…This heterogeneity makes it difficult to evaluate the true effectiveness of robotic surgery in isolation [8]. Moreover, the majority of studies is limited in terms of both patient numbers and/or follow-up time and commonly includes cases performed at the beginning of surgeons' learning curves.…”

“…Transoral robotic surgery (TORS) represents the latest addition to the armamentarium of otorhinolaryngologists -head and neck surgeons for the treatment of OSAH [8]. Its superior visualisation and ergonomics make TORS an ideally suited minimally invasive surgical treatment for addressing all levels involved [8].…”

“…Its superior visualisation and ergonomics make TORS an ideally suited minimally invasive surgical treatment for addressing all levels involved [8].…”