Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4538_Библиотеки_им_академика_М_И_Перельмана

The rst therapeutic attempts of OSAS date back to the beginning of the 1980s of the last century and were CPAP treatment and the palate surgery. CPAP immedi­ately proved to be an effective therapy as opposed to surgical therapy, which was initially characterized by the high frequency of undesirable side effects (open rhino­lalia and leakage of liquids and solids from the nose during swallowing) and by the low percentage of positive results. Initial failures were primarily due to the use of extensive resective-demolition techniques, in which surgery was directed only at the medial region of the palatine pillars and uvula. At the end of the 1990s, the limita­tion of a resective surgery of the soft palate with the unnecessary sacrice of the uvula, whose resection involved the loss of the constant humidication of the pha­ryngeal mucosa, with great disappointment of the patients, began to be understood. It was only at the beginning of the 2000s that the international scientic community began to understand the importance of the pharyngopalatal muscles in maintaining the patency of the upper airway. The rationale for the use of more conservative sur­gical techniques was consolidated because of the advantages of putting them under tension by anchoring them—through sutures—to rigid structures, such as the ptery­goid raphe, so as to better expand the airway lumen in a minimally invasive, more physiological way and without having to demolish the muscles. The growing knowl­edge of the pathophysiology underlying obstructive sleep apnea has led to the devel­opment of new surgical procedures, increasingly conservative, but all aimed at combating both anteroposterior and lateral collapse. These include Anterior Pharyngoplasty-CAPSO modied; Lateral Pharyngoplasty; Expansion Sphincter Pharyngoplasty; Functional Expansion Sphincter Pharyngoplasty; Barbed Roman Blinds Technique; Barbed Anterior Pharyngoplasty-BAPh; Barbed Reposition Pharyngoplasty (BRP). The goal of all these techniques was to increase the respira­tory space of the airway lumen without sacrice of the muscles, but only by pulling them anteriorly or laterally in order to stabilize the walls of the oropharyngeal sphincter. Since the early 2000s, the DISE (drug-induced sleep endoscopy), a dynamic endoscopic examination of the rst airways that simulates the nocturnal condition as it is performed during a pharmacologically induced sleep and in supine position, has become widespread. This examination has allowed a better under­standing of OSA pathophysiology, since it has allowed to identify the structures directly involved in snoring and apneic obstructions, to be treated surgically. As a result of DISE, the selection of patients who are candidates for surgical therapy has been improved because it is possible to characterize the collapse of the oropharyn­geal walls responsible for airway lumen closure (latero-lateral, antero-posterior, circular). An important conceptual and technological innovation in palatal surgery for OSAS was born in 2011 from the idea of Prof. Mario Mantovani to use the “Barbed Sutures.” These are surgical sutures, resorbable, self-locking, that do not require knots to approximate the anatomical structures involved. Another great advantage of the barbed sutures is to ensure a homogeneous distribution of the tensile- modulative forces over the entire extension of the suture thread and not con­centrated only in correspondence of the knots and therefore in a few points as with

In a signicant number of OSA patients selected for surgery, more than one site must be treated in order to restore a functional airway. The most common combina­tion is nose and palate, but sometimes also tongue base and or epiglottis are included. When more than one site is operated on, the overall procedure must be considered a multilevel procedure.