Transcutaneous (External) Dacryocystorhinostomy with Reconstruction of the Ductus nasolacrimalis

Abstract

Background Dacryocystorhinostomy (DCR) is regarded as the gold standard for the treatment of chronic dacryocystitis (CDC). Different modifications of the surgical procedure have been developed over the years.

Methods Patients with CDC due to postsaccal lacrimal stenosis and under treatment with DCR have been included in this retrospective study. Two groups of different surgical procedures were analysed: firstly DCR without reconstruction of the ductus nasolacrimalis (DNL, group 1) and secondly patients with reopening the DNL (group 2). Criteria for success were absence of permanent epiphora, absence of inflammation of the lacrimal sac (functional success), and no recurrent surgery with free patency of the lacrimal duct (anatomical success). This was obtained by questionnaire after a follow-up of at least 12 months. The impact of gender, ectasia of the lacrimal sac, dacryoliths, and prior lacrimal surgeries was analysed.

Results Overall, 248 surgeries were enrolled in this trial. Mean age in group 1 was 68 years (range: 22 to 92 years) and gender ratio was 3.2 to 1 (female : male). In that group, 68 operations could be followed up. In group 2, 62 operations on patients of a mean age of 63 years (range: 24 to 89 years) and a gender ratio of 2.9 to 1 (female : male) were observed. Complete success occurred in 75.0% in group 1 and 75.8% in group 2. Recurrent operations were necessary in one case of group 2 (1.6%) and 4 cases of group 1 (5.9%). Gender (group 1 p = 1; group 2 p = 0.115; between groups p = 0.511), ectasia of the lacrimal sac (group 1 p = 0.877; group 2 p = 0.674; between groups p = 0.878), dacryolith (group 1 p = 1; group 2 p = 0.465; between groups p = 1), and prior lacrimal surgery (group 1 p = 0.092; group 2 p = 0.051; between groups p = 0.520) did not influence the success rates in each group or between groups. Significantly more dacryoliths were found during operations of group 2 (p = 0.010).

Conclusion Reconstruction of the DNL during DCR is a possible and easy modification, with a slightly better success rate in curing CDC. Intraoperatively, dacryoliths might not be apparent remain in the deeper parts of the lacrimal ducts. Therefore, these segments should be inspected during surgery.

Fazitbox

Bereits bekannt:

• Die extDZR ist eine effektive Methode zur Behandlung der chronischen Dakryozystitis mit einer hohen Akzeptanz seitens der Patienten und Operateure. Postoperativ zeigt sich in über 90% eine anatomische Offenheit (Spülbarkeit) der TNW.

• Verschiedene Modifikationen der extDZR existieren. Dabei sollte die Anlage einer Schleimhautanastomose zwischen Tränensack und Nase angestrebt werden. Die direkte Vereinigung der Schleimhautblätter aus Tränensack und Nase mittels Naht ist von Vorteil.

• Unklar ist, ob eine Eröffnung des DNL im Rahmen einer extDZR unkompliziert möglich ist und einen zusätzlichen Nutzen hinsichtlich des OP-Erfolges bringt.

Neu beschrieben:

• Die Eröffnung des DNL kann im Rahmen einer extDZR sicher durchgeführt werden. Eine temporäre Schienung ist dabei in den DNL einzubringen. Die OP-Modifikation scheint einen tendenziell besseren Langzeiterfolg zu ermöglichen.

• Anatomischer und funktioneller Erfolg sollten jeweils gesondert bewertet werden, da ersterer lediglich die Voraussetzung einer vollkommenen Beschwerdefreiheit ist. Für die Patienten ist der funktionelle Erfolg der wichtigere Parameter. Beide Größen weichen bisweilen stark voneinander ab.

• Eine intraoperative Inspektion des Sakkusbodens und des DNL sollte stets durchgeführt werden, da hier vorliegende Pathologien persistieren bzw. unerkannt bleiben. Durch Inspektion dieser Region lassen sich Dakryolithen häufiger nachweisen.

Conclusion Box

Already known:

• extDCR is an effective method for treating chronic dacryocystitis with a high acceptance rate by patients and surgeons. Postoperatively, anatomical patency (irrigability) of the ELD is seen in over 90% of cases.

• Several modifications have been made to extDCR. The aim is to create mucosal anastomosis between the lacrimal sac and the nose. It is advantageous to suture the mucosal flaps formed from the lacrimal sac and nasal mucosae together directly.

• It is unclear whether opening of the NLD can be performed without complications in the context of extDCR, and whether it brings an additional benefit in terms of surgical success.

Newly described:

• The opening of the NLC can be performed safely in the context of an extDCR. The process involves inserting a temporary stent into the NLD. This surgical modification seems to facilitate a tendency towards better long-term success.

• Anatomical and functional success should be assessed separately, as the former is merely a prerequisite for complete freedom from symptoms. For patients, functional success is the most important parameter. These two factors sometimes differ greatly from each other.

• Intraoperative inspection of the NLD and floor of the lacrimal sac should always be performed, as any pathologies present in these areas will otherwise persist or remain unrecognized. Inspection of this region leads to more frequent detection of dacryoliths.

Key words

dacryocystorhinostomy - nasolacrimal ducts - lacrimal intubation - patient satisfaction - functional success - anatomical success

Publication History

Received: 04 July 2023

Accepted: 18 August 2023

Article published online:
15 November 2023

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