Learning Curve for Endoscopic Endonasal Dacryocystorhinostomy

Evaluation of the Educational Quality of Endonasal Endoscopic Dacryocystorhinostomy Videos on YouTube with IVORY and LAP-VEGaS Guidelines

Objective: The aim of this study was to evaluate the educational quality of endonasal endoscopic dacryocystorhinostomy (EE-DCR) videos on YouTube with Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY) and LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) guidelines and to evaluate the correlation of the 2 guidelines. Methods: EE-DCR videos were queried using search terms on YouTube. Views, likes, likes/dislikes ratio, age, and length of videos were noted. Videos were evaluated using the IVORY and LAP-VEGaS guidelines. Two IVORY scores were created: total (IVORY-1) and organ-specific (IVORY-2). The correlation analysis between video features and guideline scores was performed. Results: A total of 61 EE-DCR videos were evaluated. The mean score of LAP-VEGaS was 10.3 (±SD 2.7), the mean IVORY-1 score was 22.5 (±SD 5.5), and the mean IVORY-2 score was 10.6 (±SD 1.94). Correlation analysis revealed a statistically significant correlation between the IVORY-1 total score and the number of likes, the duration of the video, the age of the video, and the LAP-VEGaS score. Linear regression analysis showed that higher IVORY-1 scores predicted longer video duration, newer video age, and higher LAP-VEGaS scores. There was a significant association between LAP-VEGaS categories and the IVORY-1 total score (P < .001). Conclusion: The quality of EE-DCR videos is generally low to moderate. The IVORY and LAP-VEGaS guidelines were found to be correlated with each other. Both guidelines can be used to evaluate EE-DCR videos and otolaryngology surgical education videos in general. We believe that scales such as IVORY and LAP-VEGaS may be improved according to specific surgical procedures.

DCR preferences among oculoplastic surgeons: Barriers and facilitators to adoption of endoscopic DCR

OBJECTIVE

To determine the preference for dacryocystorhinostomy (DCR), patient selection criteria for endoscopic DCR, endoscopic DCR technique, and barriers to adoption of endoscopic DCR.

METHOD

Cross-sectional study conducted from May-December 2021. A survey was sent to oculoplastic surgeons. Questions on demographic characteristics, type of clinical practice, technique preferences, barriers and facilitators to adoption of endoscopic DCR were included.

RESULTS

245 participants completed the survey. Most respondents were located at an urban site (84%), were in private practice (66%), and had been in practice for more than 10 years (58.9%). Sixty one percent perform external DCR as the first line procedure for treating primary nasolacrimal duct obstruction. The most common factor influencing the surgeon's decision to perform endoscopic DCR was the patient's request (37%) followed by endonasal exam (32%). The most common barrier for not performing endoscopic DCR was the lack of experience and lack of training during fellowship (42%). The most worrisome complication for most respondents was failure of the procedure (48%), followed by bleeding (30.3%). Eighty one percent believe surgical mentorship and supervision during initial cases would facilitate endoscopic DCR learning.

CONCLUSIONS

External Dacryocystorhinostomy is the preferred technique for treating primary acquired nasolacrimal duct obstruction. Learning endoscopic DCR early during fellowship training and high surgical volume to improve the learning curve dramatically impacts the adoption of the procedure.

Experience of the First Three Years of Independent Practice Following Surgical Training: Time Taken and Long-Term Outcomes of Powered Endoscopic Dacryocystorhinostomy

PURPOSE

To describe the changes in the time taken and the long-term outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) performed by a freshly trained surgeon in the first three years following the surgical training.

METHODS

A retrospective interventional analysis was performed on all patients who underwent a primary or a revision PEnDCR from October 2016 to February 2020. Data obtained include demographics, presentation, previous interventions, pre-operative endoscopy findings, intra-operative findings, post-operative complications, and outcomes. Intra-operative features like the Boezaart surgical field scale, adjunctive endonasal procedures, and time taken for the procedure were noted. A minimum follow-up of 12 months was considered for final analysis. Statistical analysis was performed using software R (v 4.1.2).

RESULTS

A total of 159 eyes of 155 patients underwent PEnDCR, of which 141 eyes were primary surgeries. The mean age was 64.28 years, with M:F ratio being 1:2.5. The number of cases performed per year steadily increased after the first year, and so was the case with adjunctive endonasal procedures. The mean procedure time showed an average reduction by 10.80 and 12.81 minutes for surgeries with and without adjunctive endonasal procedures (p < .001). The majority (77.3%, 123/159) of the intra-operative fields were classified as Grade 3 on the Boezaart scale. The practice of post-operative mitomycin C use significantly and steadily reduced over the three years (p < .001). Bleeding and granuloma formation were the common undesirable post-operative findings and showed a significant (p < .001) decline beyond the first year. The anatomical and functional success were (96.18%, 91.72%), (95.71%, 92.14%), and (96.16%, 91.94%), respectively, at 12, 24 and 36 months follow up.

CONCLUSION

Several intra-operative and post-operative parameters of PEnDCR patients showed improvement beyond the first year of independent practice. The success rates were well-maintained in the long term.

Assessment of Rhinostomy Parameters in Endonasal Dacryocystorhinostomy

Epiphora is a bothersome condition seen in chronic dacryocystitis. The mainstay of treatment is surgical, that is creating an opening to establish a drainage pathway. With the advent of endoscope, endonasal DCR has gained popularity. Use of silicone stent in endonasal DCR has added advantage in improving the surgical outcome. And the use of DOS system in improving the success rates of endonasal DCR: (Mohammad et al. in Clin Ophthalmol 8:2491-2499, 2014) a total of 35 patients with chronic dacryocystitis were subjected for endonasal DCR with silicone bicanalicular stent. Patients were followed up at an interval of 1 week, 3 weeks, 6 weeks and 6 months post surgery. DCR ostium parameters were evaluated using DOS system. Silicone stent removal was done at sixth week and evaluated for success. The success rate in our study was 89%. The DOS score of the patient with successful surgery had a score of more than 30 and in the failed cases the score was between 22 and 28. The success rate of the procedure primarily depends on the ostium parameters and the position of the silicone stent. The DOS scoring system can be suitable tool in evaluating the same.

Sinus Plain Film Can Predict a Risky Distance from the Lacrimal Sac to the Anterior Skull Base: An Anatomic Study of Dacryocystorhinostomy

Background: Removal of the surrounding bone during dacryocystorhinostomy may present a higher risk of skull base injury in patients with frontal sinus aplasia. We used sinus plain films to predict cases with a greater risk of a reduced skull base distance in dacryocystorhinostomy. Methods: Sinus plain films and computed tomography data from patients were retrospectively evaluated. The frontal sinus was classified as normal, hypoplastic, or aplastic according to Waters’ view. Correlations of the frontal sinus roof-supraorbital margin (F-O) and the frontal sinus roof-nasion (F-N) distances on plain film with the closest lacrimal sac-anterior skull base (LS-ASB) distance measured on computed tomography images were assessed. Results: We evaluated 110 patients. In total, 16 (11.8%) patients had frontal sinus aplasia, of whom 6 (2.7%) had bilateral and 10 (9.1%) had unilateral aplasia. Sides with frontal sinus aplasia based on Waters’ view had a shorter median LS-ASB distance than normal or hypoplastic sides. The F-O and F-N distances in Waters’ view were significantly positively correlated with the computed tomographic LS-ASB distance. The F-O margin and F-N distance thresholds for predicting an LS-ASB distance < 10 mm, considered a risky distance, were 11.6 and 14.4 mm, respectively, with sensitivities of 100% and 91.7%, and specificities of 76% and 82.7%, respectively. Conclusions: The LS-ASB distance is closer on aplastic frontal sinus sides. Waters’ view on plain sinus films can provide a fast and inexpensive method for evaluating the skull base distance and sinonasal condition during planning for dacryocystorhinostomy.

Effect of surgeon-related factors on outcome of retinal detachment surgery: analyses of data in Japan-retinal detachment registry

The purpose of this study was to investigate the effects of surgeon-related factors on the surgical outcome of pars plana vitrectomy (PPV) and scleral buckling (SB) surgery on eyes with a rhegmatogenous retinal detachment (RRD). This was a nationwide, multicenter, observational study of the data in the Japan-RD Registry. Registered cases that had undergone surgery for a RRD by 128 accredited surgeons in 26 institutions were studied. The surgeon-related factors that significantly affected surgical success and visual outcomes of simple RRD treated by PPV or SB at 6 months postoperatively were analyzed and compared. Among 3446 registered cases, 2533 cases met the inclusion criteria with 1896 in the PPV group and 637 cases in the SB group. The median total number of lifetime cases was 150 and the rate of surgeries/year was 22. Multivariate regression analyses showed that the number and rate of surgeries/year were not significantly associated with the surgical outcome in the PPV group. However, surgeons with a higher average annual number of surgeries had significantly better surgical outcomes in the SB group (P = 0.038). Analyses of a nationwide registry showed that SB but not PPV surgeries require sufficient experience and case numbers to acquire and maintain skills to treat RRDs successfully.

Can preoperative lacrimal endoscopic evaluation change the paradigm of conventional lacrimal surgery?

PURPOSE

To evaluate the effectiveness of preoperative lacrimal endoscopic evaluation (LEE) of lacrimal duct system (LDS).

DESIGN

Retrospective comparative case series METHODS: From March 2016 to February 2020, the charts of patients chosen to undergo endoscopic dacryocystorhinostomy (EDCR) or silicone tube intubation (STI) were reviewed retrospectively. Group 1 included patients that underwent EDCR, and group 2 included patients that underwent STI. Preoperative LEE was performed for all patients. In group 1, we compared the functional success rate for patients who had been converted to STI with the patients who had undergone EDCR. In group 2, we compared the functional success rate of STI with those who had had STI without LEE.

RESULTS

In group 1, 19 (54.3%) eyes were converted to STI following LEE, and the functional success rate was 84.2%, which is not significantly different from that of the EDCR group following LEE (p = 0.608). The functional success rate of EDCR without LEE was not different from that of STI following LEE (p = 1.000). In group 2, five eyes (26.3%) were converted to EDCR following LEE. The group undergoing STI following LEE showed a significantly higher functional success rate (95.7%) than the group without LEE (66.6%, p = 0.023).

CONCLUSION

Preoperative LEE enables direct visualization of the LDS and helps to obtain more accurate diagnosis. This allows for the best surgical option based on LEE findings, which can contribute to better results. Therefore, LEE would be expected to change the paradigm of the classical management of LDS.

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

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.

Influence of Indwelling Lacrimal Drainage Tube on the Curative Effect of Endonasal Endoscopic Dacryocystorhinostomy

Endonasal endoscopic dacryocystorhinostomy (EES-DCR) has gradually become the main surgical method for treating chronic dacryocystitis. Whether the placement of the lacrimal drainage tube during the operation can improve the operation’s success rate is an issue. This study observes the effect of an indwelling lacrimal drainage tube on the curative effect of EES-DCR in patients with chronic dacryocystitis. The cure rate of the Lacrimal duct drainage tube non-indwelling group A was 93.8% (46/49). The 3 cases failed because of the nasal cavity’s inflammation, which resulted in the adhesion of the anastomotic stoma and the middle turbinate. The cure rate of the Lacrimal drainage tube indwelling group B was 85.7% (42/49). The 7 cases failed because of the excessive proliferation of the tissue around the anastomosis, the hyperplasia of granulation tissue, the shedding of the lacrimal duct drainage tube, the crack of the lacrimal duct, and the premature removal of the lacrimal duct drainage tube caused the contraction of the mucosa around the anastomosis, resulting in the anastomosis obstruction. There was no obvious difference between the two groups (P > 0.05). At 6 months, 46 cases of the EES-DCR group A had gradually epithelialized anastomoses without granulation tissue growth with the follow up time extension. In the EES-DCR group B, 42 cases of anastomoses were gradually epithelialized without granulation tissue growth. Nasal endoscopic dacryocystorhinostomy combined with an indwelling lacrimal duct drainage tube can be used to treat chronic dacryocystitis, but an indwelling lacrimal duct drainage tube has no significant effect on the efficacy of chronic dacryocystitis.

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

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.

Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system

BACKGROUND

Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field.

MATERIAL AND METHODS

Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering^® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal.

RESULTS

Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation.

CONCLUSION

The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

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

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.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Laser-assisted dacryocystorhinostomy in nasolacrimal duct obstruction: 5-year follow-up

AIM

To evaluate the long-term sucess rate of laser-assisted dacryocystorhinostomy (L-DCR) in patients with nasolacrimal duct obstruction (NDO).

METHODS

Forty-one eyes of forty patients aged between 21-85y (mean 56.7y) who underwent L-DCR for the treatment of NDO were included in this retrospective, non-randomized study. The follow-up time was 72mo. Functional sucess was defined as the disappearance of epiphora under normal conditions and the presence of a patent ostium on lacrimal irrigation. Anatomical success was defined as a patent lacrimal passage on syringing besides continuing epiphora. Surgical failure was defined as persistent epiphora and closed ostium.

RESULTS

Twenty-seven of 40 patients (67.5%) were female and 13 of 40 patients (32.5%) were male. The NDO was right-sided in 17 (42.5%) patients and left-sided in 22 (55%) patients whereas 1 (2.5%) patient had undergone bilateral surgery. In 11 (27.5%) patients there were additional nasal abnormalities requiring simultaneous surgical approach. The average time for L-DCR was 26.50±4.9min (16-39min) and the average total amount of laser energy used was 287±27.9 J (239-367 J). At the 5y follow-up, anatomical sucess rate was 75.0% (30 patients) and functional success rate was 65.0% (26 patients), whereas surgical failure was seen in 25% (10 patients). Revision of surgery was performed in 10 cases (25.0%); failure of revision surgery was seen in 2 cases (5.0%).

CONCLUSION

Transcanalicular L-DCR is a reliable and fast procedure in the treatment of NDO. It can be alternative to external DCR which is accepted as the gold standard currently. The functional and anatomical success rate is higher in the first months and years, but still satisfactory at fifth year.