Endoscopic primary dacryocystorhinostomy: are silicone tubes needed? Our experience in sixty three patients

Longitudinal randomized study to evaluate the long-term outcome of endoscopic primary dacryocystorhinostomy with or without silicone tube

OBJECTIVE

Dacryocystorhinostomy (DCR) is indicated for the treatment of nasolacrimal obstruction with some authors suggesting the use of a silicone tube (stent) to maintain rhinostomy patency a long time. This study aims at comparing the results of endoscopic-DCR (En-DCR) with and without silicone stenting.

METHODS

A randomized prospective study was conducted from January 2013 to January 2018, following patients for up to 72 months. Sixty outbound patients suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction were simply randomized and assigned to En-DCR with "silicone stent tube" (SST) or "no silicone stent tube" (NSST) group. Data about the results of the two procedures were collected using Munk' and Ali' assessments. The results were statistically compared to evaluate the differences.

RESULTS

30 patients were in the SST group and 30 in NSST. In the SST group, the tube remained in place for 3-6 months (4.1 ± 1.2 months). The follow-up period was 12-72 months (48.3 ± 6.2 months). Success rates (Junk and Javed Ali assessments) were, respectively, 97% in SST and 90% NSST group, with no statistical difference (Student's test). On a long-term follow-up, SST patients had an increased risk of re-stenosis by 14 months.

CONCLUSIONS

Our results showed there were not benefit in using tube, in the opposite it increased risk of re-stenosis. Despite preliminary results, our data confirmed comparing the two methods that silicone tube should not be used.

Dacriocistorrinostomía externa, conjuntivo-dacriocistorrinostomía y cirugía de la vía lagrimal en el meato inferior

Introducción y objetivo: Realizar una revisión sobre la dacriocistorrinostomía externa (DCR-ext), sondaje de la vía lagrimal y conjuntivodacriocistorrinostomía(CDCR) empleadas ante la obstrucción de la vía lagrimal. Material y métodos : Revisión bibliográfica sobre técnicas quirúrgicas mencionadas. Discusión: La obstrucción de la vía lagrimal puede dividirse según su localización en proximales y distales. Ante obstrucciones distales, la DCR ext es la técnica gold standard con porcentajes de éxito superiores al 95%, y la CDCR en caso de obstrucciones proximales.El sondaje de la vía lagrimal es la primera indicación quirúrgica en obstrucción congénita.

Success of endoscopic dacryocystorhinostomy with or without stents: systematic review and meta-analysis

PURPOSE

To evaluate the effect of stents on the success of endoscopic dacryocystorhinostomy (DCR-EN) for treating primary acquired nasolacrimal duct obstruction (NLDO).

METHOD

A systematic review of randomized clinical trials of DCR-EN for NLDO comparing outcomes of surgeries performed with and without the use of bicanalicular stents and the complications associated with each procedure. Two authors independently searched six databases (Scopus, PubMed, EMBASE, Google Scholar, Cochrane Central Register of Controlled Trials, and Web of Science) up to May 2019. Statistical analysis and meta-analysis were performed using RevMan 5.3 software provided by the Cochrane Collaboration.

RESULTS

Twelve studies involving 997 surgeries were included in this systematic review. The meta-analysis using a fixed-effects model showed a 94% success rate with stents versus 90.6% without stent. Although stent use favors greater success of DCR-EN, the confidence interval (CI) was wide and very close to nullity line (1.01), decreasing the strength of the recommendation for stent (odds ratio: 1.62, 95% CI: 1.01-2.59, I ² = 0%). Meta-analysis of the adverse effects was not possible. A descriptive analysis was performed of the general complications related to the stents.

CONCLUSIONS

There is evidence that the use of bicanalicular stents slightly improves the success rate of DCR-EN, but the quality of evidence is low. Future prospective, randomized trials enrolling larger sample sizes may provide stronger evidence to determine whether the stent use influences the success of primary acquired DCR-EN.

Study of Dosage-Dependent Effects of Cytostatic Drugs Using a Fibroblast Cell Culture of the Human Nasal Mucosa

Introduction  Knowing a concentration at which cytostatic drugs are toxic for the nasal fibroblasts will enable the use cytostatic drugs in the clinical practice to prevent excessive cicatrization.

Objective  To determine the cytostatic concentrations of mitomycin С, doxorubicin, and 5-fluorouracil affecting nasal mucosa fibroblasts.

Methods  We obtained material during an endonasal dacryocystorhinostomy with the patient's informed consent. The cells were cultivated. Second- to fourth-passage cells were used in the experiments. The cells were stained for vimentin and cluster of differentiation 90 (CD90). An MTS test 3 (3-(4,5-dimethylthiazole-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium); cell viability test was performed.

Results  The cytostatic drugs have a toxic effect on cultivated fibroblasts of the nasal mucosa. This effect is dose-dependent. In terms of reducing the level of tissue fibrotisation in the nasal cavity, the most justified approach is to carry out an experimental study of the effect of mitomycin C, doxorubicin, and 5-fluorouracil at the concentrations of 0.25 mg/ml, 0.25 mg/ml, and 12.5 mg/ml respectively.

Conclusion  The authors argue that it is inappropriate to use these cytostatic drugs to conduct studies with the goal of analyzing their antifibrotic effect on the nasal mucosa at concentrations that are either lower or higher than the aforementioned ones.

A Systematic Review of Benefit of Silicone Intubation in Endoscopic Dacryocystorhinostomy

Objectives

Insertion of a silicone stent during endoscopic dacryocystorhinostomy (DCR) is the most common procedure to prevent rhinostomy closure. It has been claimed that silicone intubation improves the surgical outcomes of endoscopic DCR. However, many reports have documented an equally high success rate for surgery without silicone intubation. Accordingly, we conducted a systematic review and meta-analysis to clarify the outcomes of endoscopic DCR with and without silicone intubation and determine whether silicone intubation is actually beneficial for patients.

Methods

PubMed, Embase, and Cochrane Library databases were searched to identify relevant controlled trials evaluating endoscopic DCR with and without silicone intubation. The search was restricted to English articles published between January 2007 and December 2016. Relevant articles were reviewed to obtain information pertaining to interventions and outcomes. We also performed a meta-analysis of the relevant literature.

Results

In total, 1,216 patients included in 12 randomized controlled trials were pooled. A total of 1,239 endoscopic DCR procedures were performed, and silicone stents were used in 533 procedures. The overall success rate for endoscopic DCR was 91.9% (1,139/1,239), while the success rates with and without silicone intubation were 92.9% (495/533) and 91.2% (644/706), respectively. There was no statistically significant heterogeneity among the included studies. A meta-analysis using a fixed-effects models showed no significant difference in the success rate between endoscopic DCR with silicone intubation and that without silicone intubation (OR, 1.38; 95% CI, 0.89 to 2.12; P=0.148; z=1.45). Furthermore, there were no significant differences with regard to surgical complications such as synechia, granulation, and postoperative bleeding.

Conclusion

The findings of our meta-analysis suggest that the success rate and postoperative complication rate for endoscopic DCR is not influenced by the use of silicone intubation during the procedure.

Species-specific characteristics of the biofilm generated in silicone tube: an in vitro study

Background

To investigate characteristics of biofilm which is usually found in silicone tube for nasolacrimal duct surgery and can be the root of chronic bacterial infections eventually resulted in surgical failure.

Methods

To form a biofilm, sterile silicone tube was placed in culture media of Staphylococcus aureus, Corynebacterium matruchotii, Pseudomonas aeruginosa, or Streptococcus pneumonia. Biofilms formed on these silicone tubes were fixed with 95% ethanol and stained with 0.1% crystal violet. After staining, the optical densities of biofilms were measured using spectrophotometer on a weekly basis for 12 weeks.

Results

Staphylococcus aureus group and Pseudomonas aeruginosa group formed significantly more amounts of biofilms compared to the control group. The maximum optical densities of the two groups were found on week 3–4 followed by a tendency of decrease afterwards. However, the amounts of biofilms formed in other groups of silicone tubes were not statistically significant from that of the control group.

Conclusions

Bacterial species that could form biofilm on silicone tube included Staphylococcus aureus (week 3) and Pseudomonas aeruginosa (Week 4). It is important to first consider that the cause of infection around 1 month after silicone tube intubation can be Staphylococcus aureus and Pseudomonas aeruginosa.

The benefit of silicone stents in primary endonasal dacryocystorhinostomy: a systematic review and meta-analysis

OBJECTIVE

To critically evaluate the evidence comparing success rates of endonasal dacryocystorhinostomy (EN-DCR) with and without silicone tubing and to thus determine whether silicone intubation is beneficial in primary EN-DCR.

DESIGN

Systematic review and meta-analysis.

SEARCH STRATEGY

A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of various MeSH. The date of last search was January 2016. This review was limited to randomised controlled trials (RCTs) in English language. Risk of bias was assessed using the Cochrane Collaboration's risk of bias tool. Chi-square and I² statistics were calculated to determine the presence and extent of statistical heterogeneity.

EVALUATION METHOD

Study selection, data extraction and risk of bias scoring were performed independently by two authors in concordance with the PRISMA statement.

RESULTS

Five RCTs (447 primary EN-DCR procedures in 426 patients) were included for analysis. Moderate interstudy statistical heterogeneity was demonstrated (Chi² = 6.18; d.f. = 4; I² = 35%). Bicanalicular silicone stents were used in 229 and not used in 218 procedures. The overall success rate of EN-DCR was 92.8% (415/447). The success rate of EN-DCR was 93.4% (214/229) with silicone tubing and 92.2% (201/218) without silicone tubing. Meta-analysis using a random-effects model showed no statistically significant difference in outcomes between the two groups (P = 0.63; RR = 0.79; 95% CI = 0.3-2.06).

CONCLUSIONS

Our review and meta-analysis did not demonstrate an additional advantage of silicone stenting. A high-quality well-powered prospective multicentre RCT is needed to further clarify on the benefit of silicone stents.

Comparison of Endoscopic and External Dacryocystorhinostomy Results and Analysis of Patients' Satisfaction

Objective

Comparison of endoscopic and external dacryocystorhinostomy (DCR) results and evaluation of patients' satisfaction.

Methods

Forty six (35 females and 11 males) patients who underwent endoscopic DCR and 43 (37 females and six males) who underwent external DCR were included. Surgical success was objectively and subjectively assessed. The nasolacrimal duct was irrigated by a saline solution, and the saline solution was objectively visualized by endoscopy from the nose. Subjective assessment was performed asking the patients' epiphora. In addition to evaluating the success of the operation, satisfaction and result surveys were administered to the two groups.

Results

There was no statistically significant difference between the two groups in terms of age and sex (respectively p=0.486, p=0.23). However, the number of females was higher than the number of males in the two groups, and the difference was statistically significant (endoscopic-DCR p=0.01, external-DCR p=0.001). There was no statistically significant difference between the two groups in terms of postoperative bleeding and punctum damage. The success rate was 84.7% in the endoscopic DCR group and 90.6% in the external DCR group. There was no statistically significant difference in the success rate between the two groups (p=0.397). The survey results revealed that there was no statistically significant difference between the two groups in terms of patient satisfaction (p=0.397).

Conclusion

The results of many studies in the literature show operation success rates between the two groups that are similar to ours. Both techniques have advantages and disadvantages. Independent of the preferred procedure, our results show that functional success mainly determines patient satisfaction.