One of my greatest challenges as a sleep apnea surgeon is what to do when patients require additional surgery because the first one didn’t work. With all surgical options for sleep apnea, there is always a small but significant number of patients when surgery helps partially or not at all.
Patients know this before going into surgery. Rarely, you can also have complications. There are a number of technical reasons why this may happen, but the remainder of this discussion will focus on the dilemma that the patient and I face when presented with the possible need of more surgery. When initial operation didn’t work, I can’t help but to feel a sense of remorse as their surgeon feeling like I’ve let them down somehow. By all accounts, I did everything by the book.
In a recent movie I saw called “Bridge of Spies,” Tom Hanks plays James Donovan, a high powered New York lawyer, who unsuccessfully defends a Russian accused of spying during the cold war. He escalates the case to the Supreme Court, arguing successfully that the accused should not be executed in case they need a bargaining chip with the Soviets. Sure enough, an American pilot gets shot down and stands trial in Russia for spying.
The American government is contacted by the Soviets through someone in East Berlin to inquire about a possible trade. About the same time, an American student is captured and detained in East Berlin. Donovan is determined to negotiate the release of both captives in exchange for the convicted soviet spy.
Ultimately, Donovan easily wins the freedom of the American pilot. In everyone’s eye, this was a fair and equitable trade and something that was more than anyone could have asked for. But he couldn’t let this go. He kept pushing for the East Germans to free the American student at the risk of jeopardizing the deal he made with the Soviets for the American pilot’s freedom if not at the risk of his own life. He was accused of being an extremist. He fought with a dilemma of feeling like maybe he’s doing this to stroke his own ego or because he knew this is the right thing to do no matter what the cost.
My Dilemma as a Surgeon
Throat surgery is usually considered only after trying everything else for sleep apnea patients, including CPAP, dental devices, nasal surgery, diet and lifestyle modifications. Whenever the first surgery doesn’t help, patients will sometimes initiate the discussion, asking about the possibility of further surgery. In most cases secondary surgery helps.
But what about patients who undergo multiple procedures without success? Some patients go through 3, 5 or even 10 surgical procedures before coming to see me. Whenever I ask my sleep colleagues, the general response is to avoid doing any more surgery on these type of patients.
Is the Patient Crazy?
Whenever I see a long list of past surgical procedures, I admit that my first reaction is to recommend not doing any more surgery. What more can I possibly offer when even some of the top sleep surgeons in the country can’t help? Whenever I run these situations by my colleagues, I’m told consistently to avoid doing any more surgery, but I can see from the tone of their voice and facial expressions that they think the patient is addicted to surgery.
One way I’ve dealt with this situation is to recommend a second opinion. Some people end up going for two, or even three opinions. Invariably, they get conflicting recommendations and comes back even more confused and frustrated.
This brings up the question that all surgeons have to face: How far do you go to help your patients? Is there ever a limit to the number of surgical procedures, especially if you have a reasonably good idea what the problem is? Does having undergone ten operations automatically disqualify you from further surgery? Is it unrealistic to expect surgeons and patients to expect a “cure” after the first procedure?
Addicted to Surgery?
I thought that I could find all the answers since we are the “experts.” Patients are looking to us as their last hope. We as a profession should to able to help patients who have exhausted all their other options. But what should I do when my own profession tells me to withdraw care on certain patients that are “addicted” to surgery?
I searched amongst my colleagues, the research literature, and Google for some answers, but was unable to find any helpful suggestions. However, over the years, I began to see some insight from an unexpected source: my patients.
Something Besides Brain Damage
I began to see a pattern with certain patients that seem to be “addicted” to surgery. These people were relentless in their pursuit of a great nights’ sleep. Some patients were able to localize where the blockage was happening, but were oftentimes dismissed by their doctors. In other cases, sleep physicians were puzzled when the AHI dropped from 60 to 1, but they didn’t feel any better. One common explanation by sleep doctors is that there may have been some brain damage or nerve damage in the throat that can’t be cured with surgery.
However, whenever I examine these patients in the office or under general anesthesia, I see obvious persistent obstruction behind the soft palate, tongue base, or both. The previous procedure wasn’t strong enough. Sometimes, the epiglottis falls back or the soft palate flips back up in the nose during nasal exhalation. The latter mentioned conditions can’t be picked up by sleep studies. You can also see complete obstruction to breathing, but the pauses are so short that the sleep study doesn’t register any apneas or hypopnea. Oftentimes these patients are told that they don’t have any more sleep apnea and that their symptoms are either due to brain damage for some other unknown problem.
The Possible Difference Between Success and Failure
Whenever these patients decide to go on for more surgery, many patients end up finding the holy grail: a great night’s sleep. It may not be perfect, but it’s so significant, that some patients are in tears. Not all patients will ever reach this point, but in general, the more aggressively the patient pursues more surgery, the better the result.
Contrary to what’s generally believed by the sleep medicine community, in my experience, surgical failure does not lead to lessening the chances that you can use CPAP. Oftentimes, suboptimal surgery will allow patients to better benefit from CPAP and/or dental appliances. Extremely high CPAP pressures can be lower, making it more comfortable to use, and oral appliances may help better since there’s more space behind the throat structures.
Sleep Apnea Surgery Is Not A One Time Deal
Patients and doctors still have the mentality that you need one good option to treat your sleep apnea. This is what ultimately breeds unnecessary competition between the various sleep professionals. What I’m finding is that for best long-term results, you need to consider mixing and matching multiple options, with periodic adjustments and even switching primary treatment options every few years.
For obstructive sleep apnea, most patients can do well with only one procedure, but some patients will require more than one surgical procedure. One way of looking at this is to consider surgery for cleft palate, reconstructive procedures for children born with no ears, or patients with severe facial burns. In each of these situations, you start off with the knowledge that you’ll most likely need multiple surgical procedures, mixed along with physical therapy, hearing tests, psychologists, and various other supportive options that are usually needed.
If your initial surgery was successful but stopped working after a few weeks, most people will say that the surgery didn’t work. However, the fact that it did help significantly, even if only temporarily, means that you addressed the right area of blockade, but the surgery was not aggressive enough. At this point, an examination in the office or sleep endoscopy usually reveals what more needs to be done.
Questioning My True Motives
Tom Hank’s character struggled with whether or not to “go for it” placing both captives and even his own life at risk. He could have taken the easy way out and settled for only the pilot. In the same way, the easiest and safest option for me is to tell the patient that I don’t think anything more can be done. But if I know that there’s persistent obstruction behind the soft palate and there’s a chance that more surgery can help, what’s the right thing to do? Settle for good enough and go back to CPAP, or agree to further surgery with no guarantees of success? Am I offering further surgery because it’s in the patient’s best interests, or to boost my own ego as a sleep apnea surgeon?
Granted most patients won’t ever have to face this dilemma. But this situation happens often enough for me to question my own motives every time it happens. Unfortunately, there are no textbooks, research studies, experts or other resources to help me with this particular issue. Until something comes along, the only resource I have to to develop a strong relationship with my patients, and come to an individual decision based on the available evidence and mutual trust.
If you are faced with this situation as a patient, would you rather that your surgeon play it safe or would you rather that he or she did everything possible? What do you think?