Learning Curve in External DCR – A Trainee’s Perspective

et al. 2020

Am J Rhinol�Allergy

Background Epiphora is a common ophthalmologic sign that is most commonly caused by distal acquired lacrimal obstruction. Recent data have demonstrated that external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR) can be considered the treatments of choice. However, different post-surgical medical therapies are available and are currently used to improve surgical outcomes, although no direct comparison has been performed. Objective To analyse the influence of post-surgical medical treatments on END-DCR and EXT-DCR outcomes. Methods A structured search was conducted using the U.S. National Library of Medicine (PubMed), EMBASE, SCOPUS, and Cochrane databases with a final search performed in May 2020. The research identified papers published later than 2000 with at least 50 single clinician procedures performed in EXT-DCR and END-DCR. Articles that studied acute infections, revision cases, mixed cohort studies of acquired and congenital obstruction, and tumour were excluded. The influence of systemic antibiotic/steroids, local application of mitomycin C, nasal/ocular antibiotic, nasal/ocular steroids and nasal decongestants was analysed. Results In total, 11,445 papers were selected, 2,741 of which were reviewed after screening, and 18 included after full text review (0.6% of the initial articles reviewed) which involved 3,590 procedures. Considering the low number of publications on EXT-DCR, statistical analysis of post-surgical therapy was not feasible. In END-DCR, the analyses were performed only for nasal steroids (p = 0.58), oral antibiotics (p = 0.45) and nasal decongestant (p = 0.27), which demonstrated no meaningful influence. Given the variable association between adjunctive medical therapies, pharmacologic molecular heterogeneity and modality/concentration of application, these results should be considered critically. Additionally, no differences were seen for application of silicone stenting, whereas, no statistical analysis was performed for mitomycin C. Conclusions Given the high success rate of EXT-DCR and END-DCR and the heterogeneity of literature data, the effective influence of post-surgical medical therapy is difficult to identify. Future large prospective randomized studies could help in detecting the optimal adjunctive therapy for these surgeries.

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Impact of Post-Surgical Therapies on Endoscopic and External Dacryocystorhinostomy: Systematic Review and Meta-Analysis

et al. 2020

Am J Rhinol�Allergy

“…All included articles were published later than 2000 and provided a clear functional success rate based on single-clinician procedures; in fact, as recently demonstrated, an experienced surgeon can positively influence the END-DCR outcome. 16-18…”

Section: Resultsmentioning

confidence: 99%

“…Regarding the last point, as highlighted in recent literature, the lacrimal surgical learning curve can influence outcomes so that an experienced clinician may diminish a potential bias. [16][17][18] Exclusion criteria were as follows: the study (1) comprised a mixed cohort of congenital and acquired etiology, (2) analyzed surgical success only in secondary cases, (3) did not clearly define the surgical success rate, (4) included oncologic pathologies, or (5) was primarly based on surgery performed for acute infections (dacryocystitis).…”

Section: Search Methods For the Identification Of Studiesmentioning

confidence: 99%

Influence of Surgical Techniques on Endoscopic Dacryocystorhinostomy: A Systematic Review and Meta‐analysis

Otolaryngol.--head neck surg.

et al. 2020

Objective Endoscopic endonasal dacryocystorhinostomy (END-DCR) has increased as a valid alternative to the classic external approach to treat distal lacrimal obstruction. Different surgical varieties of the END-DCR approach have been proposed with no clear understanding of the best surgical technique. Data Source A comprehensive research was performed in PubMed, Embase, SCOPUS, and Cochrane databases with a final search on March 2020. Review Methods The aim of this search was to identify relevant END-DCR procedures performed with mechanical (Mecn-END-DCR) and powered (Pow-END-DCR) approaches to compare their functional success rate. In addition, the influence of mucosal flaps was evaluated. Articles were selected only if they were published later than 2000 and had at least 50 single-clinician surgical procedures performed. Excluded articles included acute infections, cancers, mixed cohort study, and revision cases. Results A total of 11,445 publications were identified and 2741 reviewed after screening; 15 articles were included after full-text review (0.6% of the initial articles reviewed). The mean success rate was 91.34% (95% CI, 87.1%-94.3%) for Pow-END-DCR and 89.5% (95% CI, 86.5%-91.9%) for Mecn-END-DCR with no significant difference between the surgical approaches ( P = .43). For mucosal flaps performed during END-DCR, the mean success rate was 89% (95% CI, 86%-91%) if mucosal flaps were used and 92% (95% CI, 88%-95%) if they were not used, with no statistical difference present ( P = .14). Conclusions Our analyses suggest that there are no differences in outcomes between mechanical and powered approaches in END-DCR and that mucosal flap preservation is not essential to achieve a superior END-DCR outcome.

“…The latter criterion was applied since, as recently highlighted, an experienced surgeon can positively influence the surgical outcomes of DCR, reducing bias based on the surgeon's skill. [8][9][10] Exclusions criteria were: (I) language other than English; (II) mixed cohort study of acquired and congenital obstruction; (III) did not clearly describe an outcome; (IV) analysed surgical outcomes only in revision cases; (V) included surgeries performed for tumour; (VI) included surgeries performed for infections. However, due to the lack of data, very few exceptions to these criteria were made and clearly stated (Table 1).…”

Section: Methodsmentioning

confidence: 99%

Role of anaesthesia in endoscopic and external dacryocystorhinostomy: A meta-analysis of 3282 cases

European Journal of Ophthalmology

et al. 2021

Distal acquired lacrimal obstruction is a common adulthood pathology whose primary treatment is represented by EXT-DCR and END-DCR. When considering their influencing factors, the role of the type of anaesthesia applied during these surgeries has a major role. The aim of this study is to systematically analyse the influence of general and local/regional anaesthesia on the final success rates of EXT-DCR and END-DCR. Primary EXT-DCR and END-DCR articles published later than 2000 with at least 50 single clinician procedures were selected. Exclusion criteria included acute dacryocystitis, tumours, studies focussing on revision surgeries, surgeries with adjunctive procedures, not clearly demarcated surgeons, mixed cohort study of acquired and congenital disorders. This systematic review was conducted in accordance with MOOSE guidelines; where feasible, a meta-analysis of the collected results was conducted. As a result, 11,445 articles were selected of which 2741 were examined after screening, and 16 included after full text review (0.6% of the initial papers). Among all papers included, the number of EXT-DCR was not enough to provide a solid analysis of the effect of anaesthesia; conversely, a significant difference of success rate was noted between local anaesthesia + sedation (85.1%, IC 77.8%–90.4%), and general anaesthesia (90.8%, IC 88.8%–92.4%) in END-DCR ( p = 0.048). In conclusion, END-DCR performed with general anaesthesia should be considered as the solution of choice; however, local anaesthesia, eventually associated with a sedation, can be used as an alternative in selected cases. No meaningful conclusions could be drawn for EXT-DCR, due to the lack of data.