Simplified dacryocystorhinostomy (DCR) with suturing of anterior flaps only

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Objective: To determine the efficacy of external DCR, suturing of anterior flaps with excision of posterior flaps and intubation. Design: Quasi Experimental. Materials and Methods: This study was conducted at Department of Ophthalmology Unit-1 Dow University of Health Sciences, Civil Hospital Karachi and a private clinic. 110 patients of chronic dacryocystitis with nasolacrimal duct block (NLD) were operated over a period of 31/2 years from Feb 2009 to June 2012. All patients were operated under general anesthesia by a single surgeon. Only the anterior mucosal flap of lacrimal sac and nasal mucosa were sutured together with excision of posterior flaps and silicone intubation was done. Tube was removed after a period of 3 months. Patients were followed postoperatively every month for a period of 6 month. Results: A success rate of 95.45% was achieved with symptomatic relief of epiphora. Conclusion: External DCR with suturing of anterior flaps with excision of posterior flaps and intubation is a highly successful procedure with 95.45% success rate and is relatively an easy procedure as compared to suturing of both anterior and posterior flaps.

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... We hypothesized that this approach would simplify and speed up the procedure without adversely affecting patient outcomes. Although most modified Ex-DCR procedures involve excision of the posterior flaps [9,10] the anterior flaps were deemed to be a superior choice for excision in this study as they are more accessible and thus easier to remove. ...
... Ex-DCR approach wherein the anastomosis is created by suturing the anterior lacrimal and nasal mucosal flaps after excising the posterior flaps [8][9][10]. The procedure described in the present study serves as a logical extension of such research. ...
... Nevertheless, existing research seems to indicate that modifications to the conventional Ex-DCR approach-like the one outlined in the present study-do not adversely affect patient outcomes, even if they do not have a clear statistical advantage [8][9][10]14,15]. Moreover, such modifications may have other benefits in terms of shortening operating time and reducing the technical difficulties associated with suturing the anterior lacrimal sac and nasal mucosal flaps [8,10,12]. ...
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External dacryocystorhinostomy (DCR) is a reliable but difficult surgical technique for the treatment of any obstruction of the lacrimal drainage system lying distal to the internal opening of the common canaliculus. In this prospective study, a simplified external DCR procedure and the results obtained on a series of 45 consecutive patients, in which traditional external DCR was indicated, are described. In this modified procedure only very large and mobile anterior flaps of the lacrimal sac and nasal mucosa are created. Thanks to the large size and the great motility the two flaps can be easily sutured. Two double armed 6/0 polyglycolic acid sutures are used to join the two flaps, to elevate them anteriorly in order to avoid adhesions with underlying tissues, and to approximate the deep planes of the wound. The mean operative time was measured. At the end of follow up period (mean 17 months, range 14-24 months) all patients had no sign or symptoms of tearing and normal Jones I dye test. The mean operative time was 28.6 minutes (range 23-44 minutes). We believe that our modified technique can be used to simplify and speed up traditional external DCR without decreasing its well known reliability.
A dacryocystorhinostomy may fail due to a problem along the canaliculus, at the ostomy site of nasolacrimal sac to nose, due to an intranasal problem or related to the stent. The "sump syndrome" occurs when a residual nasolacrimal sac forms, collects fluids, and leads to tearing. This entity, although uncommon, has a characteristic clinical history and radiologic appearance.
We compared outcomes after dacryocystorhinostomies (DCRs) performed by the traditional external approach (EX-DCR) or by a nonlaser, nonendoscopic endonasal approach (EN-DCR). Retrospective, nonrandomized, comparative interventional case series. A total of 354 consecutive cases of DCR were reviewed in 349 patients performed by one surgeon over a 4-year period with a minimum 1 year of follow-up using either EX-DCR or EN-DCR. Only patients with primary nasolacrimal duct obstruction and no eyelid, lacrimal sac, or canalicular pathology were included. A total of 153 EX-DCR and 201 EN-DCR patients were identified. EX-DCR was performed under sterile conditions, and EN-DCR was performed with a clean setup. Silicone stents were placed for 3 months. Patency of the lacrimal system as assessed by history and irrigation. Outcomes were graded as full success, partial success, or failure. Operative durations and postoperative complications were recorded from hospital charts. There was no significant difference in age or gender distribution between the two groups. The mean operative duration was 34.3 minutes for EX-DCR and 18.5 minutes for EN-DCR (P < 0.0001, t test). Full success was achieved in 90.2% of EX-DCRs and 89.1% of EN-DCRs. Partial success was recorded in 2.0% of EX-DCRs and 4.0% of EN-DCRs. The failure rate was 7.8% for EX-DCR and 7.0% for EN-DCR. There was no statistical significance between these outcomes with a two-sample test for equality of proportions with continuity correction (P = 0.914, power = 80% for alpha = 0.05 to detect a decreased success rate of 12%). Eleven of the failed cases in each group underwent revision EN-DCR surgery, with 90.9% success in each group. Epistaxis requiring perioperative nasal packing occurred in 7 (4.6%) EX-DCR patients and 11 (5.5%) EN-DCR patients. Wound complications in EX-DCR included bruising in four patients, localized infections in two patients, and punctal eversion in six patients. In EN-DCR, inadvertent incision of the periorbita occurred in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled during an EN-DCR. Five patients had an EX-DCR on one side and an EN-DCR on the other side. All five reported retrospectively that they preferred the endonasal approach. The EN-DCR approach is more rapid than the traditional external approach, has an equivalent surgical success rate, and was preferred by patients who had alternative techniques performed on opposite sides.
A prospective randomized study was carried out to compare the success rate of external dacryocystorhinostomy (DCR) with and without excision of the posterior sac mucosal flap. Forty patients (Group A) underwent DCR without excision of the posterior sac mucosal flap, and the results obtained were compared with those of another series of 40 patients (Group B) where DCR was performed with excision of the posterior sac flap. A large posterior flap was excised from the lacrimal sac and a large, mobile, anteriorly-hinged, nasal mucosal flap was fashioned. The latter was joined to the anterior sac flap using a 6/0 double-armed polyglycolic acid suture. Four patients in Group B had signs and symptoms of tearing (90% success rate) at the end of the follow-up period (mean 11.05 months, range 9-14 months). Group A had six patients with recurrent signs and symptoms (85% success rate) by the end of a mean follow-up period of 11.3 months (range 9-14 months). Excision of the posterior sac mucosa may improve the success rate of external DCR.
The study was conducted at the DHQ hospital Lakki Marwat from Jan, 1999 to Dec, 2002 to assess the intra and postoperative complications and success rate of external dacryocystorhinostomy (DCR) with suturing of the bridge between anterior flaps of nasal mucosa and lacrimal sac with the muscle layer. We operated upon 120 patients suffering from chronic dacryocystitis (CDC). Females were 81 (67.5%) and males were 39 (32.5%). Majority of the patients were between the age group 40 to 60 years. Indications for dacryocystorhinostomy (DCR) were epiphora, acute on chronic dacryocystitis and a mucocele. All the cases were operated under local anaesthesia with external approach and only anterior flap suturing and engaging it in the muscle layer. These patients were followed for a period of six months. The overall success rate was 98.33%. The successful outcome was defined as symptomatic relief from epiphora and dacryocystitis and a patent nasolacrimal duct upon syringing. Dacryocystorhinstomy is a safe procedure under local anaesthesia. It is associated with minimal complications, which can be easily managed. This technique has a very high success rate and a short learning curve.
To compare the results of external dacryocystorhinostomy (DCR), using two different patterns of flap anastomosis with creation of both sac and nasal mucosal anterior and posterior flaps: one that includes suturing of both flaps and the other that involves excision of the posterior flaps. This randomized, clinical trial included 63 consecutive patients undergoing DCR. Patients were alternately assigned to two groups on the basis of the pattern of flap anastomosis. An H-shaped incision was created in the lacrimal sac and the nasal mucosa in all patients. In group A, posterior and anterior flaps were separately approximated; in group B, only the anterior flaps were sutured after resection of both posterior flaps. Postoperative hemorrhage, epiphora, and patency of the tract were assessed on follow-up visits. Final scores and success rates of the two groups were compared by using the Mann-Whitney U and chi. The mean length of follow-up was 10.87 +/- 4.75 months for all patients. One patient in group B was lost to follow-up. The difference between the groups in postoperative bleeding, epiphora, and patency scores was found to be statistically insignificant (p = 0.451, p = 0.974, p = 0.583, respectively). The final success rates in groups A and B were 93.75% and 96.67%, respectively. There was no statistically significant difference in success rate between the groups (p = 0.593). Our study suggests that DCR with double-flap anastomosis has no advantage over DCR with only anterior flaps. Anastomosis by suturing only anterior flaps and excision of the posterior flaps is easier to perform and does not appear to adversely affect the outcome of DCR surgery.