Topicality
An unsuccessful outcome of dacryocystorhinostomy (DCRS) is usually conditioned by cicatrisation of the newly formed lacrimal outflow tract. A variety of causes, such as an underestimate of examination data, wrong choice of surgical approach, surgical interference technique defects, nonobservance of recommended treatment by patients and their wrong aftercare, promotes it. However, the prime causes of ill lucks, in the estimation of most dacryo-surgeons, are the operation technology imperfection and adverse action of the concomitant rhino-pathology. An active practical application of new DCRS methods, including the transcanalicular approach and use of laser-endoscopic technology for the formation of inosculation, is going on. Compared to the external DCRS it provided certain advantages: traumatism and complications number reduction, operation technique simplification, cutaneous scar absence. However, according to our data, purulent dacryocystitis relapses often requiring reintervention occur in long terms after the transcanalicular laser endoscopic dacryocystorhinostomy (TLED) in 20% of the cases.
The investigation purpose - is to evaluate the efficiency of TLED reoperations at chronic purulent dacryocystitis, to carry out the disease relapses analysis and study the influence of the concomitant rhino-pathology on their development.
Materials and methods
The purulent dacryocystitis returns analysis was carried out in 60 patients (62 eyes), who were primarily subjected to TLED. The patients´ age varied from 15 to 80 years old. There were 43 females (71,7%), 17 males (28,3%). 48 patients (50 eyes) were reoperated. 34 patients (36 eyes) of them were operated without using drainage (on the basic method) and 14 patients (14 eyes) - with temporary (for 3 months) bi-canalicular silicon intubation. The follow-up of 40 patients (42 eyes) made 18,8+1,9 months at the average.
The operations were carried out using diode laser ОМЕ-1150, «Endo Optiks» (USA), and endoscopic apparatus, «Storz» (Germany). For the lacrimal passages intubation a lacrimal set of Ritleng (F.C.I., France) and silicon stent with the outer diameter of 0,64 mm were applied.
Results
The relapses analysis showed that they appeared no sooner than the 1st month and no later than three years after the original surgery. The highest percentage of the relapses fell within the 2nd and 3rd months - 29% (18 cases). In the following 3 months their number made 13 (21%), and in half a year more - 20 (32,3%). Thus, during the first year 82,3% of unsuccessful TLED outcomes were registered. Most patients (80% or 48 from 60 persons) clearly associated the development of the disease relapses with the previous acute respiratory infection attended with the running nose.
The concomitant rhino-pathology at the examination was detected in 31 patients (51,7%) with the disease relapses. To compare let us point out that in the patients with positive results of the primary operation (236 patients) the concomitant rhino-pathology was found out in 59 persons only (25% of the cases), i.e. 2,1 as seldom. The most often diagnosed rhino-pathology in the relapse patients was chronic rhinitis (which generally had of hypertrophic character) - in 35,5%, sinuitis (mainly supramaxillary one) - 25,8% and nasal septum deviation, which in all the cases was combined with vasomotor changes of nasal mucosa, - 25,8%.
Postoperative complications (the analysis of 50 operations) were observed significantly more often after the silicon intubation (28,6%, 4 cases - silicon allergy, intubation granuloma, drainage drop-out, splitting of lacrimal points and canaliculi by the silicon stent), than at the carrying out of repeated operations without using transient drainage (11,1%, 4 caases of nose bleed, which in one of them required tamponade).
In the long terms (from 6 months to 3,5 years) the reoperation results were followed in 40 patients (42 eyes). The positive effect of reoperations was registered in 76,2% (32 eyes), among them recovery - in 66,7% (28 eyes), improvement - in 9,5% (4 eyes). The purulent dacryocystitis relapses were registered in 23,8% (10 eyes). The reoperations carried out using bi-canalicular silicon intubation turned out to be more effective - 78,6% of recovery, than repeated operations without using transient drainage - 60,7% of recovery.
Conclusions
1. The highest number of purulent dacryocystitis relapses was registered during the year after the TLED operation (82,3%), but especially often - during the first three months (29%). 2. A significant influence on the development of relapses was rendered by the concomitant rhino-pathology. 3. A more steady and long effect of reoperations was registered in the patients, who the TLED was carried out using transient silicon drain of the formed inosculation. However, the use of bi-canalicular silicon intubation has led to the increase in number and seriousness of post operational complications.
The work is submitted to the Scientific International Conference «Current problems of education, October, 15-22, 2008, Greece (Athens-Delphi-Meteor-Mycenae-Nafplio-Epidavr), came to the editorial office on 25.08.2008.