(Table 4).
DISCUSSION
Few papers in literature have investigated the improvement on quality of life after OSA treatments (19,20), therefore limited data about this topic are available in literature. Turner et al (21), have observed a statistically significance improvement (p<0.04), in terms of working memory, long-term memory, quality of life and positive attitude after CPAP treatment. In a meta-analysis study Kuhn et al.(19) proved, using the SF 36 questionnaire, a positive effect of CPAP treatment on the HR-QoL of patients with OSA.
Despite these published evidences, no studies in literature have analyzed QoL after multilevel robotic surgery for OSA and no authors have compared multilevel surgery and CPAP therapy in QoL improvement of OSA patients.
In the surgical treated patients of our study a GBI total average value of +30.4 emerged with a maximum of +75.0 and a minimum value of -16.7. The general benefit score was calculated as +31.3 (range -63.8 to +88.3), and the social benefit was +11.5 (range 0 to +66.7), whereas the physical score resulted to be +24.8 (range -16.7 to +50). These positive values over +20 points indicate an effective improvement in all aspects of the Qol.
Patients treated with CPAP showed an excellent improvement in quality of life as well (+38.6 range -20.3 to +100). However, despite a higher mean value of the total GBI in this second group, no statistical differences emerged in the total GBI score (Overall Benefit) with patients surgical treated. These results could be explained by the good clinical and respiratory outcomes obtained in both treatments analyzed(22); a significative difference between pre-treatment and post-treatment AHI values (p=0.0001) was observed in both groups of patients. Probably for the same reason, by comparing the two groups of study a not-statistically significant difference was likewise found in the general partial score (p= 0.1). Similar results have been described by Robinson et al.(23). They, in a clinical study, did not observe a statistically significant difference between CPAP and Upper Airway Surgery (UAS) in terms of general quality of life (p=0.308).
In terms of social subscale, we reported higher values in CPAP group (mean 26.9) than in TORS-multilevel surgery (mean 11.6), with a statistical difference (p= 0.0006). This subscale investigates the social support in terms of the help provided by relatives and friends in the management of daily life, in relation to the pathology and the proposed therapy. This explains the possible reason why the TORS group has reported significantly lower values in this subscale. In fact, patients treated with C-PAP require more attention in managing the disease, the related symptoms and the device itself. Therefore, they probably need more care and support from their friends and relatives. The physical score analyzes the benefit in physical health status including frequency of illness, need of medicament or medical consult. Regarding the scores of this subscale, statistical difference emerged between groups with higher values in the TORS group (mean 24.8) than in the CPAP group (mean 18.7 p<0.04). In case of surgical success(24), multilevel surgery could lead to a reduction of medical necessities and consults. Contrarily, patients that use the CPAP need constant device setting and medical consults. Furthermore, this device is characterized by poor mask comfort with a sense of pressure during the night. These aspects should not be underestimated, as they could be the cause of a poorer physical score reported in CPAP patients than in TORS subjects(25).
Although important results about the impact of CPAP and TORS on quality of life and its aspects have emerged, this study has some limitations such as its retrospective nature and the not extensive number of patients enrolled. Moreover, surgically treated patients require a longer follow-up to confirm these statements, while the mean follow up of 1.4 year described in this study is large but not sufficient to have definitive results. Further prospective large-series studies are underway to validate these outcomes.
CONCLUSIONS
Multilevel surgery and CPAP treatment have a positive impact in the quality of life in OSA patients. Both therapies appear to be equally effective in the improvement of the general quality of life (total and general GBI scores), without statistical differences among them. Data show a greater social support in patients treated with CPAP, while patients undergoing robotic multilevel surgery report a greater improvement in their physical health status.
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