Primary Endonasal DCR Without Stent: Our Experience and Case Series Analysis

Endonasal dacryocystorhinostomy is widely accepted and effective treatment option for nasolacrimal duct obstruction. It can be done with or without the use of stents. This study was carried out to evaluate the results of endonasal DCR surgery and to access efficacy of this procedure without stenting. This is a prospective clinical study conducted in Departments of ENT and Ophthalmology, L.N. Medical College and J.K. Hospital, Bhopal from October 2008 to April 2012. A total of 90 patients with epiphora as evidenced by nasolacrimal duct blockage on syringing were included in the study. These patients underwent endoscopic DCR without stenting. The cases were followed up to 18 months postoperative. Surgical success was defined as anatomical patency and symptomatic relief at the end of the follow up period. Failure was defined as no symptomatic relief, and/or acute dacryocystitis, and/or non patent lacrimal drainage system. Surgical success was observed in 80 of 90 (88.89 %) patients. Incidence of complication was low as only 6 patients had minor complication of bleeding, synechie and granulation tissue formation. It was concluded that high success rates could be achieved in case of nasolacrimal duct obstruction by endoscopic DCR. Thus, we can minimize complications, discomfort, the cost of stenting and follow up visits after endonasal DCR surgery.     

Endonasal endoscopic dacryocystorhinostomy: our experience

Objectives

To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.

Methods

Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.

Results

Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.

Conclusion

Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.     

Concept of foreign body-its past and present

Endoscopic endonasal dacryocystorhinostomy [EDCR] is considered to be a superior alternative technique to the conventional external dacryocystorhinostomy [DCR], both in primary and secondary cases. It is of particular value in children and young adults as it avoids an external scar. Sixteen cases of chronic dacryo-cystitis were treated by the endoscopic technique, including 8 revision cases of failed external approach. In all cases except one, a patent nasolacrimal fistula was noted, with a success rate of 93.7%. The authors share their experience in EDCR and review the relevant literature.     

Polypropylene in Endoscopic Dacryocystorhinostomy: A Novel Stent

Endoscopic dacryocystorhinostomy (DCR) is usually done in cases of lacrimal apparatus obstruction. The common causes of failure are that of obstruction in the common canaliculus and closure of the rhinostomy site. To overcome these problems we use stents. Stents most commonly used are that of silicon which are expensive and not readily available. As an alternative, polypropylene (Prolene; Ethicon) is used as a stent which is cheaper and readily available. This study is done to evaluate the clinical efficacy and results of stenting with polypropylene suture material in endoscopic dacryocystorhinostomy. Fifty one endoscopic DCR operations were performed between July 2013 to December 2014. After creating an aperture in the medial wall of the lacrimal sac, 3/0 prolene was inserted from lower punctum to neo ostium. The prolene was left in the lacrimal sac for 3 weeks. The patients were followed up for 3 months. In our study, most of the patients belonged to the age group of 41–60 years (47%). There was female preponderance as 64.7% were females. 47 patients (92.2%) showed very good results. Two patients (3.9%) developed granuloma for which revision surgery was done. We lost 2 patients during follow up. This modification enables an easy, safe, effective and low-cost form of DCR. Prolene is cheaper and readily available. It might be used successfully in endoscopic dacryocystorhinostomy and is promising alternative to silicone stent intubations, especially in settings with limited resources.     

Powered Endoscopic Endonasal Dacryocystorhinostomy with Mucosal Flaps and Trimming of Anterior End of Middle Turbinate

Endoscopic endonasal dacryocystorhinostomy (DCR), when compared to external techniques, has always had guarded acceptance primarily due to inconsistent success rates. The most common cause of surgical failure in endoscopic DCR is very high/very low mucosal incision, obstruction of neo-ostium by granulation tissue, infolding of flap or formation of synechiae between middle turbinate and the neo-ostium site post-operatively. Several techniques and modifications have been suggested by various authors over the years since the first introduction of endoscopic endonasal DCR. With the newer techniques and advancements, the success rates have become comparable or even higher than external DCR. The aim of our study was to determine the success of endoscopic endonasal DCR using the classical Wormald technique with a few modifications. A total of 37 cases of epiphora secondary to nasolacrimal duct obstruction were operated using endoscopic endonasal DCR technique. The surgical technique included classical Wormald principle of mucosal flap, removal of the overlying bone using Kerrisons punch & chisel-hammer followed by vertical incision on the sac. The medial wall of lacrimal sac was then trimmed using microdebrider, thus apposing it to the nasal mucosal flaps. The anterior end of middle turbinate was also trimmed prophylactically to prevent synechiae formation. The outcome and long term patency of the cases were evaluated. Of the 37 cases, 35 cases (94.6 %) had complete resolution of the epiphora at the end of 1 year follow up period. The two cases of failure were due to canaliculitis in one patient and extensive granulation around the neo-ostium in another. Thus the above method has very good success rate comparable to previous studies and very less chances of granulation tissue formation and blockage of neo-ostium by synechiae/flap infolding.     

A comparative study of external and endoscopic endonasal dacryocystorhinostomy — a preliminary report

This prospective study was done ta compare the results of external and endonasal dacryocys-torhinostomy (DCR). 6 patients were studied under each group. Success rate for external DCR was 93.3% and endonasal was DCR 100%. The technique, merits and disadvantages of both the procedures are discussed as well as the advantages of endonasal DCR highlighted.     

Endoscopic DCR: How To Improve The Results

Since Toti described the initial dacryocystorhinostomy (DCR) operation in 1904 many technical modifications have evolved (Becker in Ophthalmic Surg 19:419–427, 1988). Overall, three groups of procedures are currently practised; external DCR, endoscopic DCR with contact laser, and surgical endoscopic DCR without laser (Woog et al. in Am J Ophthalmol 116:1–10, 1993; Jokinen and Karja in Arch Otolaryngol 100:41–44, 1974. Many factors influence the outcome of these different approaches. The purpose of this study was to improve the long term surgical outcome in endonasal DCR. A retrospective analysis of more than 1,500 patients, who underwent primary endoscopic DCR, was done and specific small modifications were identified and applied in the next 108 cases showing an improvement in the results.     

Endoscopic dacryocystorhinostomy with conventional instruments: results and advantages over external dacryocystorhinostomy

Background

The aim of study is to evaluate the Endoscopic dacryocystorhinostomy (DCR) with conventional instruments, its results and advantage over external dacryocystorhinostomy (DCR).

Methods

The study group comprised of 127 patients who underwent consecutive endoscopic dacryocystorhinostomy. The cases operated by one team were included in the study to make the uniform analysis and its result. There were 48 males and 79 female in this study and male female ratio was 1:1.6. The mean age of the patient was 37 years (range from 16 years to 58 years). There were wide variety of cases like epiphora, lacrimal sac abscess, lacrimal sac fistula, acute dacryocystitis and road vehicular accident. All the patients had undergone non-laser, non-powered conventional instruments surgery under local anesthesia. The lighted probe was not used in any case for sac identification. The free flow of saline through newly created stoma during sac syringing was considered as successful criteria. The stent was used in two cases of road vehicular accident and in remaining 125 cases no stent was used. There were 66 cases of epiphora, 30 cases of lacrimal sac abscess, 26 cases of acute dacryocystitis, 3 cases of lacrimal fistula and 2 case of road traffic accident with multiple fractures. The average follow up period was 17 months (maximum follow up 3 years and minimum 4 months.)

Results

The success rate was 96 %.

Conclusion

The endoscopic DCR with conventional instruments is safe with very high success rate without any complications. It can be done in acute cases and very much suited for lacrimal sac abscess and lacrimal sac fistula.     

Use of mitomycin C in endo-DCR

Objective: To evaluate the role of topical Mitomycin C in Endoscopic Dacryocystorhinostomy (DCR), for the prevention of stomal stenosis.Patients: Thirty patients undergoing endoscopic DCR for chronic dacryocystitis were studied prospectively. The follow up period was 12 months.Technique: Patients were divided into two groups randomly. All of them underwent endoscopic DCR. One group was subjected to topical Mitomycin C application after surgery while the control group was not.Main outcome measures: Postoperative relief of epiphora and endoscopic documentation of the patency of the stoma were the main outcome measures.Results: 80% cases of the Mitomycin C group and 86.67% cases of the non Mitomycin C group had long-term successful results. This result is not statistically significant (p> 0.2).Conclusion: Intraoperative Mitomycin C application does not alter the long-term results in endoscopic DCR. A properly and adequately performed surgery is more vital for successful result.     

Colorectal Stenting for Management of Acute Malignant Bowel Obstruction in Advanced Colorectal Cancer in Iran

Introduction: Enteral stenting is used increasingly as a palliative treatment of gastrointestinal malignant ornon malignant obstructions. This aim of this study was to evaluate the role of endoscopic stent implantation forpalliation of acute colorectal cancer obstruction in critical patients. Methods: This study was performedprospectively with 8 patients suffering clinical manifestations of acute bowel obstruction with severe co-morbiddiseases that caused them to be inoperable. They were treated by semi-elective stent insertion after primaryresuscitation. Gentle dilation of stricture with balloon or buginage was performed under fluoroscopy andcolonoscopy in gastrointestinal ward without complete preparation. Then an uncovered self-expanding metalstent was inserted over guide wire in the location of the tumor. Results: Endoscopic stent implantation could besuccessfully performed in six patients. In early days after stent insertion; general condition of patients graduallyimproved, and symptoms of acute obstruction was relieved. In two of the cases stent was inserted with difficultydue to very tortuous and complex strictures. Complications of stenting in this study were very rare. Displacementof stent after successful insertion was not seen . Of our studied patients, two died after 2 months, one after 4months and three of them after 7-8 months. The cause of death in these patients was advanced metastatic lesionin liver, lung, bone and severe underlying disease such as heart failure. Conclusion: Endoscopic stent implantationseems to be an effective and safe palliative approach for management of emergency conditions of acute colonicobstruction in inoperable patients with advanced colorectal cancer.     

Management of Traumatic Dacryocystitis and Failed Dacryocystorhinostomy Using Silicone Lacrimal Intubation Set

The aim of this work is to study the management and success rate of traumatic dacryocystitis and failed dacryocystorhinostomy (DCR) using Silicone lacrimal intubation set. A prospective study was conducted at a tertiary eye care hospital, India from February 2006 to January 2008. This study material comprised 50 patients of traumatic dacryocystitis and failed dacryocystorhinostomy. Anterior single flap external dacryocystorhinostomy with Silicon intubation was performed in all the patients. The patients were followed up at weekly intervals for 1 month and thereafter every 2 months for 1 year post operatively. Criteria determining success were based on resolution of epiphora and patency on syringing. In traumatic dacryocystitis, 21(91.3%) cases fulfilled these criteria while 23(85.2%) cases of failed DCR were successful. The overall success rate (88%) was determined with an average follow-up of 1 year. Globally, the technique was effective in 85% of cases. The results were comparable with other similar studies. This study concludes that performing a DCR in traumatic dacryocystitis and failed DCR taking into consideration the complications and chances of failure is a challenge for the surgeon. We opine that External dacryocystorhinostomy with Silicon Intubation is one of the most effective modality in dealing with such cases.     

Endoscopic treatment of malignant stenosis in home care

At our institute, we have tried to increase the patient's quality of life (QOL) by endoscopic stenting for upper intestinal stenosis due to malignant tumor, which could not be treated by surgery or chemotherapy. We report the endoscopic stenting and home therapy for those patients. The subjects were 44: (esophageal stenosis: 13 cases, biliary stenosis: 31 cases) out of 60 patients who had intestinal stenosis or obstruction, which could not be treated by surgery or chemotherapy. Esophageal stenosis was treated mainly by stenting and laser cautery, and biliary stenosis was treated by drainage using stenting. The home stay period, effective treat period, life survival period, and complications were analyzed in each case. It was found that the mean home stay period, mean effective treatment period, and mean life survival period were 3.4 months, 4.0 months, and 5.5 months, respectively, with esophageal stenosis, and 3.7 months, 4.4 months, 5.5 months with biliary stenosis. Mean home stay period/life survival period was 62% in cases of esophageal stenosis, and 67% in cases of biliary stenosis. Complications were observed in 40.0% of patients with esophageal stenting and in 12.5% with biliary stenting. Esophageal stenting showed a higher incidence of complications; however improvements in the stenting instrument will reduce the number of complications. Endoscopic stenting is thus effective for upper intestinal stenosis due to malignant tumor, especially in increasing the patient's QOL when curative therapy is not indicated, and the patient stays at home. We believe patients with uncurable malignant disease should have home treatment as early as possible.     

Endoscopic Endonasal Dacryocystorhinostomy: Best Surgical Management for DCR

EEDCR is a highly rewarding Endoscopic procedure for management of dacryocystitis when epiphora does not respond to medications or repeated syringing of nasolacrimal duct. It is a simple, less time consuming, safe but skilful, highly satisfying surgery both for the patients as well as the surgeons. There is very big advantage of EEDCR, it is close 100% successful procedure, even if there is recurrence of epiphora it is again correctable fully with no residual affects. EEDCR is far more superior to External DCR/Laser DCR and there are definite reasons for it. A total number of 578 cases have been operated by me from April 1, 2005 to March 31, 2011, only very few reoccurrences were there and they were corrected easily so much so that it can be said that it is a close 100% successful procedure and best surgical management of DACRYOCYSTITIS up to date. The successful outcome was defined as symptomatic relief from epiphora and dacryocystitis and a patent nasolacrimal duct upon syringing at the end of procedure and on follow up of patient.     

Endoscopic Septoplasty: A Retrospective Analysis of 415 Cases

Nasal obstruction is the most common complaint in nasal and sinus disease. Deviated nasal septum is a very frequently encountered and common cause. Surgical correction of a deviated septum- nasal septoplasty- is the definite treatment for septal deviation. Over the last 2 decades, the applications for endoscopy in the field of rhinology have evolved beyond functional endoscopic sinus surgery (FESS). Septoplasty which is among the three most commonly performed procedures in otolaryngology is particularly well suited to endoscopic application. Endoscopic septoplasty as a minimally invasive technique can limit the dissection and minimize trauma to the nasal septal flap under excellent visualization whose primary advantage is to decrease morbidity and post operative swelling in isolated septal deviation by limiting the excision to the area of deviation. This was a retrospective study, conducted in a tertiary care medical college hospital over a period of 5 years. The study group comprised 415 patients in and around Nashik District; who visited our tertiary health centre and were subjected to endoscopic septoplasty. Complete data records from 415 patients were available for statistical analysis. Maximum numbers of patients were in age group 20–39. The youngest patient was 7 years old and oldest was 75 years. Mean age was 32 years. The 7 years old was operated for DCR for congenital NLD block and septoplasty was adjunct procedure. Even the 75 years was operated for DCR. In the present study out of 415 cases, 256 (67.5 %) cases were male and 115 (32.5 %) cases were female. There is a male preponderance in the overall distribution of cases. In the present study of 415 patients, the most common operative procedure done was septoplasty in 260 (62.6 %), FESS with septoplasty in 38 (9.2 %) cases, septorhinopolasty in 41 (9.9 %) cases and DCR with septoplasty in 78 (18.3 %) cases. Endoscopic septoplasty facilitates good access to accomplish endoscopic DCR, FESS, and accurate and adequate septal graft harvest in severely deviated noses for septorhinoplasty. Complications like dental pain, paraestaesia, septal perforation, saddle nose deformity and persistent deviation are a rarity.     

Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting. A randomized prospective trial

BACKGROUND: Colostomy was the palliative treatment of choice in patients with malignant unresectable rectosigmoid obstruction. Palliative endoscopic treatment of malignant rectosigmoid obstruction by endoluminal self-expanding metallic stents is nowadays a well-established procedure. PATIENTS AND METHODS: Twenty-two patients, referred for treatment with diagnosis of malignant obstruction of the rectosigmoid region presenting an advanced unresectable stage, were enrolled. Patients were randomly assigned into two treatment groups (endoscopic stenting vs colostomy) according to random-number tables. The length of procedure, morbidity and mortality rate, canalization of the gastrointestinal tract, restoration of oral intake and hospital stay were assessed. RESULTS: Endoscopic group: The median length of procedure was 36 minutes. No death was observed. None of the patients reported complications. All patients resumed bowel function within 24 hours. The restoration of oral intake was achieved one day after stent placement. The median hospital stay was 2.6 days. Colostomy group: The median length of the operation was 75.4 minutes. No mortality was reported. In 1 patient (9.1%) stoma prolapse was observed 3 days after the operation. Canalization of the gastrointestinal tract was restored when colostomy was opened (on postoperative day 3). All patients were able to resume oral feedings on postoperative day 3. The median hospital stay was 8.1 days. CONCLUSION: There were no statistically significant differences between the 2 groups concerning morbidity and mortality. Endoscopic stenting was significantly more effective concerning operative time, restoration of bowel function and oral intake and median hospitalization. Our results would suggest that endoscopically placed metal stents offer an effective alternative to surgical palliation in patients suffering from unresectable malignant rectosigmoid obstruction.     

Clinical Efficacy of Endoscopic Pancreatic Drainage for Pain Relief with Malignant Pancreatic Duct Obstruction

Objective: This study was conducted to investigate the efficacy of pancreatic drainage for pain relief in advanced pancreatic cancer. Method: Seventy-one patients with pancreatic carcinoma were divided into two groups: dilated and non-dilated pancreatic ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary stenting and pancreatic stenting. Visual Analog Scale (VAS) scores, pain remission rates and survival time were evaluated during follow-up. Results: The post-ERCP VAS score of the dilated group was lower than that of the non-dilated group at 1 and 3 months post-ERCP. There was no difference at 6 months. The pain remission rate in the dilated duct group was significantly higher than that in non-dilated duct groupin 1 and 3 months post-ERCP. The median survival times were 8.17 and 8.22 months respectively. Conclusion: Endoscopic pancreatic drainage can relieve pain of advanced pancreatic cancer accompanied by safe dilation of the pancreatic duct.     

Analysis of 104 Cases of Endonasal Dacryocystorhinostomy in a Tertiary Care Hospital: A Prospective Study

To evaluate the results of endoscopic endonasal dacryocystorhinostomy performed in a tertiary care hospital. Prospective, nonrandomized, interventional clinical study. A prospective interventional study was performed on 104 patients presenting with epiphora between January 2006 and January 2010. All patients were operated by one surgeon. Out of 104 cases, 08 cases were of revision endonasal dacryocystorhinostomy (DCR). Bicanalicular silicon intubation was performed in all cases of revision endonasal DCR. Twelve patients had concomitant sinonasal disease for which septoplasty or FESS was done. The patency of nasolacrimal duct was assessed by doing syringing of lacrimal passage weekly for 1 month, monthly for 3 month, then at 6 month and 1 year. Out of 104 patients 10 patients lost follow up after surgery. Ninety four patients were followed for 1 year. On syringing, rhinostomy site was found patent in 80 patients (85.10 %), therefore they were fully satisfied. In 6 cases (6.38 %) minimal block was seen with clear fluid regurgitation, were to some extent symptomatically relieved and were found to be satisfied, whereas in 08 cases (8.51 %) syringing showed complete block. They required further management. Success rate of our study is comparable to other studies on endonasal DCR as well as external DCR, with advantages of less intra-operative bleeding, shorter operative time, better cosmesis, preservation of lacrimal pump mechanism. Other nasal pathology can be treated at the same time. Our results are clinically as well as statistically highly significant (P value < 0.0001).     

Role of interventional radiography in the treatment of the hepato-pancreato-duodenal area,complicated by obstructive jaundice

We assessed the role of interventional radiological procedures used in the treatment of patients with hepatopancreatobiliary cancer complicated by obstructive jaundice. Between 1990 and 2000, 71 patients underwent percutaneous transhepatic biliary drainage (PTBD): external drainage--18 (group A); external-internal drainage or stenting (group B), and external-internal drainage or stenting plus chemoinfusion or chemoembolization of the hepatic artery--15 (group C). Mean survival (M(SD) calculated for patients who died was 2.1(0.5 mo for group A; (pb,c(0.01), 7.9(6.7 mo (group B), and 16.6(14.8 mo for group C (NS with B). The actual one-year survival was 10, 25, and 45%, respectively. External-internal PTBD and stenting are safe effective palliative procedures for patients with malignant obstructive jaundice. Survival in patients with hepatopancreatobiliary cancer doubled after chemoinfusion or chemoembolization, without grave complications or lethality.     

Nonoperative urinary diversion for malignant ureteral obstruction

The management of malignant ureteral obstruction (MUO) has undergone major changes due to the availability of percutaneous drainage techniques and new ureteral stents for endoscopic insertion. These procedures are less morbid than conventional surgical techniques so that the indications for urinary diversion due to untreated or relapsing malignancy have to be reconsidered. During the period of technological change from 1978 to 1984, 135 patients with unilateral (37) or bilateral (98) MUO were managed. Open nephrostomy is now almost never necessary. Initial retrograde ureteral stenting (RS) was successful under local anaesthesia in 41% of patients. Forty-seven had percutaneous nephrostomy (PN), nine of whom underwent antegrade ureteral stenting (AS) and elimination of external appliances. Twenty-nine patients underwent miscellaneous open procedures mostly in the earlier years, with a 57% morbidity rate compared to the minimal morbidity associated with the newer techniques. The overall mean survival post diversion was 9.9 months, which is significantly longer than that reported using open procedures. MUO can now be successfully relieved with little morbidity and frequently without the use of external urine collection devices. The relative ease of diversion can complicate decision making in patients with progressive renal failure due to bilateral MUO.     

Endoscopic techniques to diagnose and manage biliary tumors.

Malignancies of the bile duct are often suspected in patients with abnormal serum hepatic enzyme levels and obstruction of the biliary system. Although cross-sectional imaging can provide evidence for biliary obstruction and a malignancy arising from the bile duct, a definitive diagnosis is often obtained through the use of endoscopic procedures. Endoscopic retrograde cholangiopancreatography (ERCP), the most commonly performed procedure for cholangiocarcinoma, can provide a tissue diagnosis through brush cytology of the bile duct. Relief from biliary obstruction can be provided with temporary plastic stenting or permanent metal stenting. Photodynamic therapy guided by ERCP may provide improved palliation from biliary obstruction in the future. Endoscopic ultrasonography complements the role of ERCP and may provide a tissue diagnosis through fine-needle aspiration and staging through ultrasound imaging. High-resolution ultrasound images can provide detailed information regarding the relationship between a mass and the bile duct wall. Despite these advances in endoscopic techniques and imaging of the bile duct, a tissue diagnosis often remains elusive in many patients. In the future, molecular markers will be employed to improve the sensitivity for the detection of malignancy in bile duct samples obtained through brushing, aspiration, and biopsy.