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Comparison of anesthetic and surgical outcomes of dacryocystorhinostomy using loco-regional versus general anesthesia
Abstract
Objective:
The aim of this study was to compare anesthetic and surgical outcomes of external dacryocystorhinostomy (DCR) under loco-regional anesthesia (LA) versus general anesthesia (GA).
Methods:
Retrospective chart review of all patients that underwent DCR by one surgeon (IH) over the course of a ten-year period (April 1994 to March 2003).
Results:
A total of 221 DCR were performed on 209 patients during the study period: 71 were done under LA (72.0 ± 13.3 years) and 150 under GA (64.2 ± 13.0 years; P<0.001). LA patients had a shorter length of surgery (56.2 ± 15.3 vs. 64.0 ± 18.1 minutes; P=0.001) and required less antiemetic drugs during the first four hours after surgery (P=0.03). Pain was well controlled and patients were comfortable per- and post-operatively. Excluding ecchymosis (38.0% LA vs. 21.6% GA; P=0.01), the rate of minor complications did not differ between the two groups: infection, inflammation or edema (14.1 vs. 18.2%; P=0.13), hematoma (1.4 vs. 2.7%; P=0.52) and epistaxis (22.5 vs. 14.2%; P=0.44). Rates of recurrent symptoms and/or re-intervention (11.3 vs. 13.1%; P=0.91) were comparable for LA and GA.
Conclusion:
This study suggests that external DCR performed under LA and monitored anesthesia care may be advantageous. The length of surgery is reduced, post-operative side effects are diminished, and excluding ecchymosis, the rate of minor complications is not increased. These benefits are desirable in a predominantly elderly population where avoidance of GA risks is at times necessary.
... Obviously, the specific risks of GA are avoided in LA. Previous studies demonstrated that there was a much lower incidence of PONV after DCR with LA than after DCR with GA [10,11] . The anesthetics used for GA also act as vasodilators and enhance bleeding, which brings greater risk of complications [2,4,8910. ...
... into pain with 2 alternative values – either the requirement of postoperative analgesic by the patient, or no requirement. In their series there was no significant difference between LA i GA groups with respect to need of analgesic post-operatively; 50.7% of patinents in the LA group required analgesic and 46% in the GA group. [11] Our mean operating time was 24 minutes for LA (24.24±4.66) and GA (24.32±4.67), rather similar to the 36 minutes found in the Caesar et al. series (longest duration – 65 minutes – was in a patient with persistent ooze from the bony rhinostomy) [2]. Maheshwari's mean operative time was 15.5 minutes [15]. On the other hand, the significan ...
... a patient with persistent ooze from the bony rhinostomy) [2]. Maheshwari's mean operative time was 15.5 minutes [15]. On the other hand, the significantly longer operating time in the Harissi- Dagher et al. series could have led to more tissue trauma and more frequent post-operative need for analgesics (LA 56.2±15.3 minutes and GA 64.0±18.1minutes) [11]. Most participants complained of pain in their nose or orbit after surgery. The localization of pain is the same for both types of anesthesia following surgery; however, higher levels of pain are experienced after GA (Table 2). PONV is present in 20% to 30% of patients operated on under GA [13]. In the region of the throat, nose and eye ...
There has been only 1 study on postoperative pain after external dacryocystorhinostomy (DCR) that compared pain between 2 groups of patients; 1 group received local anesthesia and the other received general anesthesia. To further characterize the relationship between these 2 types of anesthesia and postoperative pain, we designed a study in which a single patient received these 2 different anesthesia modalities for a short interval on 2 different sides.
There were 50 participants in this study. External DCR was performed on the same participant on both sides using local anesthesia on 1 side and general anesthesia on the other. Postoperative pain was measured using the visual analogue scale (VAS), and localization and timing of pain were reported by the participants. Postoperative nausea and vomiting (PONV) were documented if present.
Pain levels were significantly higher with general anesthesia 3 hours post-surgery, and 6 hours post-surgery the pain remains higher following general anesthesia but is borderline insignificant (p=0.051). However, 12 hours post-surgery, there is no significant difference in the pain level (p=0.240). There was no significant difference in the localization of pain with local and general anesthesia. Postoperative nausea is significantly more frequent after general anesthesia, and vomiting only occurs with general anesthesia. Local anesthesia was preferred by 94% of the participants (47 out of 50).
The vast majority of patients in our study who have undergone both GA and LA DCR would choose LA again, providing a compelling case for use of the LA technique.
... 7 In particular, pharmacological innovations have now rendered general anesthesia (GA) the approach of choice thanks to several advantages such as optimal surgical condition and alleviation of the patient's anxiety and pain, especially during periosteal elevation and osteotomies. 25,26 Nevertheless, in several cases, the presence of significant systemic comorbidities might jeopardize the possibility of GA, thus justifying the use of local anesthesia: in this case, several advantages can be noted such as reduction of surgical time, nausea, and vomiting as well as reduced intra-operative bleeding and hospitalization, with significant decreases in procedural costs with almost no influence on the final procedural outcome. 27,28 In this regard, a recent meta-analysis that compared END-DCR performed with general and local anesthesia demonstrated that even in cases where powered instruments were used the procedure in local anesthesia provided good functional success rates, that seems to be slightly different to GA (p = 0.048): however, due to the low number of available publications, no conclusive statements were made. ...
... 29 In addition, in uncollaborative patients operated with END-DCR in local anesthesia, there is the risk of difficult visualization of the surgical field through the endoscopic instrumentations, thus undermining the final outcome. 25,26,30 For all the above-mentioned reasons, given the wider surgical field through an external approach, which is helpful in uncollaborative subjects, greater historical experience, and no influence on the final success rate, EXT-DCR should be considered the surgical approach of choice in the treatment of DALO in local anesthesia, even if no definitive data has been provided. ...
Endoscopic (END-DCR) and external dacryocystorhinostomies (EXT-DCR) are nowadays considered the gold standard techniques for non-oncologic distal acquired lacrimal disorders (DALO). However, no unanimous consensus has been achieved on which of these surgeries is the most suitable to the individual patient. Herein, we review the available literature of the last 30 years with the aim of defining a simple and reproduceable treatment algorithm to treat DALO. A search of PubMed, EMBASE, Scopus and Cochrane databases was last performed in December 2021 to examine evidence regarding the role of END-DCR and EXT-DCR in primary and revision surgeries. If considered primary surgeries, END-DCR should be preferred in case of intranasal comorbidities, given the possibility to directly visualize and treat potential intranasal pathologies. Conversely, EXT-DCR should be chosen in case of need/preference for local anesthesia, given the major historical experience and wider surgical field that helps to resolve intra-operatory complications (e.g., bleeding) in an uncollaborative patient. In the absence of the abovementioned conditions, the decision of one or other approach should be discussed with the patient. In recurrent cases, END-DCR should be considered the treatment of choice given the major likelihood to visualize the causes of primary failure and directly resolve it. In conclusion, END-DCR should be considered the treatment of choice in revision cases or in primary ones associated with intranasal pathologies, whereas EXT-DCR should be chosen if local anesthesia is needed. In the absence of these scenarios, it is still open to debate which of these two approaches should be used.
... 5 At present, considering DCR surgeries, general anaesthesia is considered the gold standard approach, due to several advantages that provide excellent operative conditions, alleviation of the patient's anxiety and complete elimination of surgical pain, especially during periosteal elevation and osteotomies. 4,43 Besides, the discomfort of trickling blood into the throat during a LA can be uncomfortable to the awake patient and occasionally dangerous in patients with altered sensorium secondary to the sedation. However, even if the procedure in itself is considered as low risk, in some situations GA may be extremely hazardous, especially in the elderly who may present a variety of comorbidities. ...
... It is noteworthy that LA is also associated with adverse events that warrant recognition such as globe perforation, retrobulbar haemorrhage, injury of the optic nerve, fire when diathermy is used close to oxygen delivered nasal prongs and watery gagging. 4,43,49 The latter adverse event is caused because, in LA, the patient is in the supine position with no airway protection, which may cause gagging and/or airway obstruction due to the irrigation performed during drilling and the de-fog of the endoscope that may reach the oropharynx. 46 Nevertheless, some authors prevent these complications using posterior nasal packing which, by the way, should be careful positioned since accidental ingestion of the nasal packing gauze during END-DCR has occurred. ...
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.
... However, most of the risk factors of PONV are beyond control, such as gender of female, prior history of PONV, nonsmoking status and duration of anesthesia 3 .Several clinical trials compared the incidence of PONV in patients undergoing general and local anesthesia surgery. All these trials showed that patients were more likely to experience PONV after general anesthesia surgery [4][5][6][7] . According to Sinclair's report 8 , patients with general anesthesia were 11 times more likely to develop PONV than those with local anesthesia. ...
... Thus, DCR may not be the most preferred surgery by this technique, although a couple of studies demonstrated that DCR can be performed with high acceptance rates under LA with intravenous sedation. [21,22] Ours is a nonprofit organization, where anesthesia charges for TIVA technique is 1000 INR, whereas the same amounts to 3000 INR for conventional GA. Cost analysis of ketamine with respect to GA was studied in London, where definite cost benefit was shown with i.v. ...
Background:
Ocular blindness and ocular morbidities are very much prevalent in pediatric age group in India. Mostly, these are all surgically amenable, provided they have access to safe anesthesia. Suboptimal facilities for conventional general anesthesia (GA) led to a different thought process. The combination of anesthetic and analgesic property of ketamine was utilized in a low-resource setting at a tertiary ophthalmic center for pediatric ophthalmic surgeries.
Aims:
The aim of this study was to decipher whether this technique is acceptable and feasible.
Settings and design:
It was a prospective consecutive series at a rural eye center done over a period of 5 years.
Materials and methods:
Inclusion criterion was children undergoing eye surgeries between the ages of 7 and 18 years, who could be adequately counseled about the concept of painless intravenous cannulation and subsequent painless block. Intravenous anesthesia comprised of ketamine, in conjunction with peribulbar block. Complications of the technique, time to discharge, mean pain score, and patient and surgeon satisfaction score were documented.
Statistical analysis used:
Data were analyzed on Microsoft Excel.
Results:
A total of 905 cases were conducted uneventfully without conversion to GA. No emergency resuscitation was required. The surgeon and the patient had a satisfying experience, with the technique being totally acceptable to them.
Conclusions:
Intravenous ketamine is an inexpensive and safe anesthetic technique when used in conjunction with regional block and is certainly a boon for minimal resource ophthalmic setup in rural India.
To evaluate the efficacy and safety of a sub-anaesthetic dose of propofol for reducing patient recall of peribulbar block in eye surgery.
A retrospective analysis of patients scheduled for elective cataract extraction or trabeculectomy using peribulbar anaesthesia with an intravenous bolus of propofol to provide sedation during the administration of the block. The dose of propofol was based on age and body weight. Patients' vital signs were monitored with continuous pulse oximetry and blood pressure measurements. Efficacy of sedation was assessed by recording patient's recall of the anaesthetic block after 8-10 min.
Data from 2043 patients were analysed. The dose of propofol used ranged from 15-75 mg. Propofol was effective in abolishing recall in 87.5% of the patients studied. Only four patients required airway support but no major systemic side effects were encountered.
A single sub-anaesthetic dose of propofol prior to administering peribulbar block is effective in reducing recall of the injection and safe without major systemic side effects.
Nowadays, microsurgical discectomy is being performed as an outpatient procedure. A retrospective chart review was done to document factors that delayed discharge or led to unanticipated admission.
After Institutional Review Board approval, the hospital medical records of 106 patients who underwent microsurgical discectomy on an ambulatory basis were reviewed. All patients were operated upon by a single surgeon at the Toronto Western Hospital. Perioperative data were collected on specifically designed data sheets. All anesthetic and surgical factors that affected discharge were noted.
Of the 106 patients reviewed, only six required unanticipated admission. Two patients were admitted due to nausea and vomiting, one due to severe pain, one due to urinary retention and two were surgical causes (dural tear). Eight patients had delayed discharge. Anesthesia causes were severe nausea, severe pain, low oxygen saturation, sore throat and dry eyes. Two patients had surgical causes. The incidence of postoperative nausea was 61% and postoperative vomiting was 9.4%. Eighty patients (75.4%) complained of pain in the postanesthesia care unit. Of these, 33.9% had visual analogue pain scale scores more than 6.
Ambulatory lumbar microdiscectomy can be carried out as an ambulatory procedure with an acceptably low unanticipated admission rate (5.7%). The percentage of patients with severe nausea (16%) and pain (33.9%) is high. Adequate perioperative pain management and effective control of nausea and vomiting may further improve the patients' experience after anesthesia for ambulatory microdiscectomy.
Performance of lacrimal surgery under neuroleptic (local) anesthesia has greatly facilitated the procedure and decreased the associated morbidity. We reviewed the outcome of lacrimal surgery in older patients to determine whether such surgery can be performed safely in the outpatient setting in this group.
METHODS:
Review of the office and hospital charts and the surgical and anesthetic records of 120 patients (84 women and 36 men) aged 70 to 90 years who underwent lacrimal drainage procedures (dacryocystorhinostomy [DCR], canaliculodacryocystorhinostomy, DCR with insertion of a Jones tube, or a revision endonasal procedure with probing and tube insertion) at a university-affiliated hospital in Toronto in 1996. The interval between surgery and data collection ranged from 10 to 22 months.
RESULTS:
Of the 120 patients 65 were aged 70 to 75 years, 38 were 76 to 80 years, 11 were 81 to 85 years, and 6 were 86 to 90 years. Ninety-six patients had a unilateral procedure, and 24 (22 of whom were aged 70 to 80) had a bilateral procedure. Concomitant conditions, such as hypertension and cardiac disorders, were found in 104 patients (87%). Of the 120 patients 98 (82%) (including all those aged 81 to 90) had local anesthesia, and 22 (18%) had general anesthesia. In one case anesthesia had to be changed from local to general during the procedure because of noncompliance. A total of 112 patients (93%) whose surgery was planned as a day procedure were able to leave the hospital the same day. Three additional patients were admitted to hospital for an overnight stay because of increased bleeding at the time of surgery (one patient) or a history of cardiac problems (two patients). Five patients who had planned overnight stays because of cardiac problems did well during surgery and were discharged the same day, without consequence. None of the patients had to be readmitted at a later date for bleeding or health problems. In 109 patients (91%) the presenting symptom(s) was completely relieved. Overall, 116 patients (97%) had a totally open system with no reflux on syringing.
INTERPRETATION:
The surgical goals and techniques of lacrimal surgery in older patients were not compromised by performing the surgery in the outpatient setting and under neuroleptic anesthesia in most cases.
This atlas is a comprehensive description of the techniques of ocular surgery which are in use today. Fourteen chapters are devoted to general surgical considerations, anesthesia, and surgery of the eye and its adnexa. The illustrations are numerous, detailed, and well executed. The artist, Robert Bray Wingate, is to be commended for his clear, precise drawings, for, as is customary with atlases, the value of this book rests as much upon its descriptive illustrations as upon its text. In fact, the text is reduced to a minimum and is used only to supplement the pictorial representation of various surgical procedures.Many, if not all, of the operations for such pathologic processes as entropion and ptosis are described. The discussion of cataract extraction includes such controversial operative techniques as the use of α-chymotrypsin and anterior chamber implants. However, the use of intrascleral implants in retinal detachment surgery is not mentioned.There
Primary acquired nasolacrimal duct obstruction (PANDO) of adults is a clinical syndrome of unknown cause, and the histopathology of the nasolacrimal duct has not been substantially studied. A technique of excisional biopsy of the soft tissue contents within the nasolacrimal canal during external dacryocystorhinostomy (DCR) is presented. No complications were associated with the biopsy technique in 14 cases. Two cases of lacrimal obstruction secondary to sarcoidosis and leukemia were discovered in biopsies of patients with the clinical syndrome of PANDO, demonstrating the value of routine biopsy during DCR. Biopsies revealed a spectrum of changes that correlated with duration of symptoms. Early cases revealed active chronic inflammation along the entire length of the narrowed nasolacrimal duct. Intermediate cases revealed focal resolution of the inflammatory process with fibrosis, while late cases showed fibrous obliteration of the entire duct. Although the first event in primary acquired nasolacrimal duct obstruction remains uncertain, clinicopathologic correlation suggests that compression of the duct by inflammatory infiltrates and edema precedes clinical chronic dacryocystitis.
To compare adverse medical events by different anesthesia strategies for cataract surgery.
Prospective cohort study.
Patients 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997.
Local anesthesia applied topically or by injection, with or without oral and intravenous sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl).
Intraoperative and postoperative adverse medical events.
Twenty-six percent of surgeries were performed with topical anesthesia and the remainder with injection anesthesia. There was no increase in deaths and hospitalizations associated with any specific anesthesia strategy. No statistically significant difference was observed in the prevalence of intraoperative events between topical and injection anesthesia without intravenous sedatives (0.13% and 0.78%, respectively). The use of intravenous sedatives was associated with a significant increase in adverse events for topical (1.20%) and injection anesthesia (1.18%), relative to topical anesthesia without intravenous sedation. The use of short-acting hypnotic agents with injection anesthesia was also associated with a significant increase in adverse events when used alone (1.40%) or in combination with opiates (1.75%), sedatives (2.65%), and with the combination of opiates and sedatives (4.04%). These differences remained after adjusting for age, gender, duration of surgery, and American Society of Anesthesiologists risk class.
Adjuvant intravenous anesthetic agents used to decrease pain and alleviate anxiety are associated with increases in medical events. However, cataract surgery is a safe procedure with a low absolute risk of medical complications with either topical or injection anesthesia. Clinicians should weigh the risks and benefits of their use for individual patients.
To establish the effectiveness, complications and patient acceptance of local anaesthesia (LA) with intra-venous sedation, for external dacryocystorhinostomy (DCR).
Data were prospectively collected over a 4-year period (1997-2000) on all patients undergoing external DCR under LA with intravenous sedation by one surgeon and one anaesthetist, using a standardized technique.
Of 183 DCR procedures, 145 (76.5%) were performed using LA in 123 patients aged 24-84 years (median 64 years). Eleven simultaneous bilateral DCR procedures were performed under LA. Another 11 patients had a contralateral DCR at a later date. In only three DCR (2.1%) was supplementation of LA required during the procedure because of pain. The only complication of the technique was one retrobulbar haemorrhage from the medial peribulbar injection. In this patient, the procedure was completed satisfactorily without further sequelae. All patients found the technique acceptable and all 11 patients who returned for surgery on the opposite side at a later date elected to have surgery under LA again.
External DCR can be satisfactorily and safely performed under LA with a high level of patient acceptance.
Manual of Oculoplastic Surgery New York: Churchill Livingstone Inc
- Mr Levine
Levine, MR. Manual of Oculoplastic Surgery New York: Churchill
Livingstone Inc; 1988. p. 1-16.p. 245-255.
Study of Medical Testing for Cataract Surgery Study Team Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery
- J Katz
- Ma Feldman
- Eb Bass
Katz J, Feldman MA, Bass EB, et al. Study of Medical Testing for
Cataract Surgery Study Team. Adverse intraoperative medical
events and their association with anesthesia management strategies
in cataract surgery. Ophthalmology 2001;108:1721-6.