A critical evaluation of surgery for sleep disordered breathing

Surgical strategies for the treatment of sleep disordered breathing, although widespread and frequently used, continue to be a controversial issue. Colleagues who primarily focus on conservative treatment options point to the limitations in the available data and remind us of serious methodological concerns surrounding the current literature for surgical treatment alternatives. In accordance with the principles of evidence based medicine the best available evidence should be used to assess the efficacy of surgical treatment. While placebo-controlled trials are feasible only in selected cases, recent examples of controlled clinical trials demonstrate that well designed prospective studies are indeed possible in the field of surgical treatment. Aim of the presented review is to critically evaluate current knowledge and evidence in this field and to give examples for how to overcome methodological issues in the future. Furthermore it will be demonstrated that even the "gold standard" of conservative treatment still leaves numerous questions open in regard to primary acceptance, long term compliance and surveillance. The assessment of treatment strategies is still based primarily on the effects seen in respiratory surrogate parameters under laboratory conditions. In the future, a broad spectrum of subjective and long-term objective parameters such as cardiovascular mortality needs to be kept in mind when critically evaluating beneficial effects of any kind of treatment for sleep disordered breathing. The presented review intends to initiate an open and critical discussion on the available treatment options.