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Success rate of external, endonasal, and transcanalicular laser DCR with or without silicone stent intubation for NLD obstruction: a network meta-analysis of randomized controlled trials

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Abstract

Purpose

To define and compare the effectiveness of external dacryocystorhinostomy (EX-DCR), endonasal (EN-DCR), and transcanalicular laser-assisted (TL-DCR) with or without silicone stent (S) intubation.

Methods

Studies were retrieved from PubMed, Scopus, and WoS. Frequentist and Bayesian network meta-analyses were performed and pooled estimations were expressed as risk ratio (RR). We included all original investigations of prospective, randomized controlled trials comparing success rate for any two of the following six surgical procedures: standard EX-DCR with or without S, cold EN-DCR with or without S, and TL-DCR with or without S. The primary outcome measure was the objective success rate.

Results

Thirty-two studies with 3277 cases were included in the final quantitative analysis. TL-DCR with S was inferior to EN-DCR with S (RR: 1.20; 95% CI: 1.05–1.37), EX-DCR with S (RR: 1.17 95% CI: 1.05–1.29), EN-DCR without S (RR: 1.18; 95% CI: 1.03–1.35), and EX-DCR without S (RR: 1.15; 95%CI: 1.05–1.26) in frequentist statistics. No other statistical difference was found between other surgeries. When we excluded studies with additional interventions (nasal and revision surgery) for sensitivity analysis, 23 studies with 2468 cases were included to analysis. The success rates of TL-DCR with S and EN-DCR without S became similar (RR: 1.14 95% CI: 0.99–1.30) but there was no change in other outcomes. Similar results were found in Bayesian statistics. The surface under the cumulative ranking curve was higher for EN-DCR with S (0.75), whereas it was higher for EX-DCR with S (0.56) after sensitivity analysis.

Conclusion

Between endoscopic and external and transcanalicular laser without S procedures, there is no statistical difference. The rank probability showed that EN-DCR with S was a more appropriate surgical option when patients with nasal disease were included, whereas EX-DCR with S was a more appropriate surgical option when patients with nasal disease were excluded from the analysis.

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Abbreviations

CINeMA:

Confidence in network meta-analysis

DCR:

Dacryocystorhinostomy

EN-DCR:

Endonasal DCR

EX-DCR:

External DCR

NLDO:

Nasolacrimal duct obstruction

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCTs:

Randomized controlled trials

RR:

Risk ratio

S:

Silicone stent

TL-DCR:

Transcanalicular laser-assisted DCR

References

  1. Evereklioglu C, Oner A, Somdaş MA et al (2007) Figure-of-eight vertical mattress suture technique for anterior flap suspension to overlying tissues in external dacryocystorhinostomy. Am J Ophthalmol 143(2):328–333. https://doi.org/10.1016/j.ajo.2006.09.057

    Article  PubMed  Google Scholar 

  2. Evereklioglu C (2020) Primary probing with and without Monoka Silastic Stent Intubation for Epiphora in Older Children and Adults. Curr Eye Res 45(1):87–90. https://doi.org/10.1080/02713683.2019.1643026

    Article  CAS  PubMed  Google Scholar 

  3. Cokkeser Y, Evereklioglu C, Er H (2000) Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg 123(4):488–491. https://doi.org/10.1067/mhn.2000.105470

    Article  CAS  PubMed  Google Scholar 

  4. Jawaheer L, MacEwen CJ, Anijeet D (2017) Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database Syst Rev 2(2):Cd007097. https://doi.org/10.1002/14651858.CD007097.pub3

    Article  PubMed  Google Scholar 

  5. Levin PS, StormoGipson DJ (1992) Endocanalicular laser-assisted dacryocystorhinostomy. An anatomic study. Arch Ophthalmol 110(10):1488–1490. https://doi.org/10.1001/archopht.1992.01080220150037

    Article  CAS  PubMed  Google Scholar 

  6. Drnovsek-Olup B, Beltram M (2010) Transcanalicular diode laser-assisted dacryocystorhinostomy. Indian J Ophthalmol 58(3):213–217. https://doi.org/10.4103/0301-4738.62646

    Article  PubMed  PubMed Central  Google Scholar 

  7. Schlachter DM, Richani K, Black EH (2016) Diode laser-assisted endocanalicular dacryocystorhinostomy: a prospective study. Ophthalmic Plast Reconstr Surg 32(3):183–186. https://doi.org/10.1097/iop.0000000000000453

    Article  PubMed  Google Scholar 

  8. Piaton JM, Keller P, Limon S et al (2001) Holmium: YAG and neodymium: YAG laser assisted trans-canalicular dacryocystorhinostomy. Results of 317 first procedures. J Fr Ophtalmol 24(3):253–264

    CAS  PubMed  Google Scholar 

  9. Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 10(1):89. https://doi.org/10.1186/s13643-021-01626-4

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cumpston M, Li T, Page MJ et al (2019) Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev 10:Ed000142. https://doi.org/10.1002/14651858.ed000142

  11. Sterne JAC, Savović J, Page MJ et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898. https://doi.org/10.1136/bmj.l4898

    Article  PubMed  Google Scholar 

  12. Nikolakopoulou A, Higgins JPT, Papakonstantinou T et al (2020) CINeMA: an approach for assessing confidence in the results of a network meta-analysis. PLoS Med 17(4):e1003082. https://doi.org/10.1371/journal.pmed.1003082

    Article  PubMed  PubMed Central  Google Scholar 

  13. Owen RK, Bradbury N, Xin Y et al (2019) MetaInsight: an interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Res Synth Methods 10(4):569–581. https://doi.org/10.1002/jrsm.1373

    Article  PubMed  PubMed Central  Google Scholar 

  14. Elmorsy S, Fayek HM (2010) Rubber tube versus silicone tube at the osteotomy site in external dacryocystorhinostomy. Orbit 29(2):76–82. https://doi.org/10.3109/01676830903294891

    Article  PubMed  Google Scholar 

  15. Afzal MM, Mehmood A, Maqbool R et al (2014) 53-55 to compare the success rate of external dacryocystorhinostomy with and without silicon intubation in patients of nasolacrimal duct obstruction. Pak J Med Health Sci 8(1):53–55

    Google Scholar 

  16. Rather S, Singh T (2013) External dacryocystorhinostomy with & without silicon tube intubation in chronic dacryocystitis with nasolacrimal duct block. JK Sci 15(1):24

    Google Scholar 

  17. Zaman M, Babar TF, Abdullah A (2005) Prospective randomized comparison of dacryocystorhinostomy (DCR) with and without intubation. Pak J Med Res 44(2):75–78

    Google Scholar 

  18. Massoud OM, Elbakary MA, Shalaby OE et al (2020) Evaluation of the role of silicone intubation in non-complicated external dacryocystorhinostomy. Open Ophthalmol J 14(1)

  19. Sadaka AAA, Alamin AM, Gad NNM (2021) A comparative study of external dacryocystorhinostomy with stent versus no stent in acquired nasolacrimal duct obstruction. Egypt J Hosp Med 82(2):270–275. https://doi.org/10.21608/EJHM.2021.143888

    Article  Google Scholar 

  20. Saiju R, Morse LJ, Weinberg D et al (2009) Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation. Br J Ophthalmol 93(9):1220–1222. https://doi.org/10.1136/bjo.2008.147819

    Article  CAS  PubMed  Google Scholar 

  21. Chavan SS, Kale VD, Rao KN et al (2018) Comparison of application of mitomycin C Vs silicon stenting Vs conventional method in endonasal dacrocystorhinostomy: a randomized controlled trial of 150 patients. Iran J Otorhinolaryngol 30(96):11–18

    PubMed  PubMed Central  Google Scholar 

  22. Reddy YJ, Reddy YM, Kiran M et al (2015) A comparative study of outcomes of dacryocystorhinostomy with and without silicone stenting. IOSR J Dent Med Sci 14(7):82–85

    Google Scholar 

  23. Rao SVM, Rajshekar MM (2016) Dacryocystorhinostomy stent insertion in initial endoscopic dacryocystorhinostomy. Clin Rhinol An Int J 9(3):120–124. https://doi.org/10.5005/jp-journals-10013-1284

    Article  Google Scholar 

  24. Shashidhar K, Nagalotimath U, Dixit D (2014) Endoscopic dacryocystorhinostomy with and without silicone stenting: a comparative study. Al Ameen J Med Sci 3:0

    Google Scholar 

  25. Fayers T, Dolman PJ (2016) Bicanalicular silicone stents in endonasal dacryocystorhinostomy: results of a randomized clinical trial. Ophthalmology 123(10):2255–2259. https://doi.org/10.1016/j.ophtha.2016.06.026

    Article  PubMed  Google Scholar 

  26. Al-Qahtani AS (2012) Primary endoscopic dacryocystorhinostomy with or without silicone tubing: a prospective randomized study. Am J Rhinol Allergy 26(4):332–334. https://doi.org/10.2500/ajra.2012.26.3789

    Article  PubMed  Google Scholar 

  27. Raghav MG, Naga R, Raghavan D (2018) A comparative study of the results of endoscopic dacryocystorhinostomy with and without stent placement. J Marine Med Soc 20(2):135

    Article  Google Scholar 

  28. Nitin T, Uddin S, Paul G (2022) Endonasal endoscopic dacryocystorhinostomy with and without stents-a comparative study. Indian J Otolaryngol Head Neck Surg 74(Suppl 2):1433–1441. https://doi.org/10.1007/s12070-021-02561-5

    Article  PubMed  Google Scholar 

  29. Harugop AS, Mudhol RS, Rekha BK et al (2008) Endonasal dacryocystorhinostomy: a prospective study. Indian J Otolaryngol Head Neck Surg 60(4):335–340. https://doi.org/10.1007/s12070-008-0112-z

    Article  CAS  PubMed  Google Scholar 

  30. Khatri MS, Kharaya A (2022) Clinical trial to compare success rate of endonasal dacryocystorhinostomy and external dacryocystorhinostomy for treatment of primary acquired nasolacrimal duct obstruction. Indian J Otolaryngol Head Neck Surg 74(Suppl 2):1266–1273. https://doi.org/10.1007/s12070-020-02352-4

    Article  CAS  PubMed  Google Scholar 

  31. Chong KK, Lai FH, Ho M et al (2013) Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction. Ophthalmology 120(10):2139–2145. https://doi.org/10.1016/j.ophtha.2013.02.036

    Article  PubMed  Google Scholar 

  32. Yu B, Xia Y, Sun JY et al (2021) Surgical outcomes in acute dacryocystitis patients undergoing endonasal endoscopic dacryocystorhinostomy with or without silicone tube intubation. Int J Ophthalmol 14(6):844–848. https://doi.org/10.18240/ijo.2021.06.08

    Article  PubMed  PubMed Central  Google Scholar 

  33. Çetin YS, Akın R, Düzenli U et al (2022) Effect of silver nitrate application on the success of endoscopic dacryocystorhinostomy. Am J Rhinol Allergy 36(2):216–221. https://doi.org/10.1177/19458924211042786

    Article  PubMed  Google Scholar 

  34. Smitha S, Jagannath B (2016) Endoscopic dacryocystorhinostomy with and without silicone stent: a comparative study. J Med Sci Clin Res 4(9):12861–12864

    Google Scholar 

  35. Unlu HH, Gunhan K, Baser EF et al (2009) Long-term results in endoscopic dacryocystorhinostomy: is intubation really required? Otolaryngol Head Neck Surg 140(4):589–595. https://doi.org/10.1016/j.otohns.2008.12.056

    Article  PubMed  Google Scholar 

  36. Cavaliere M, De Luca P, Scarpa A et al (2022) Longitudinal randomized study to evaluate the long-term outcome of endoscopic primary dacryocystorhinostomy with or without silicone tube. Eur Arch Otorhinolaryngol 279(2):1105–1109. https://doi.org/10.1007/s00405-021-07104-w

    Article  PubMed  Google Scholar 

  37. Monga J, Sharma Y, Mishra G et al (2019) Resolving perplexity: comparison of endoscopic dacryocystorhinostomy with and without stent. Indian J Otolaryngol Head Neck Surg 71(Suppl 3):1843–1848. https://doi.org/10.1007/s12070-017-1241-z

    Article  PubMed  Google Scholar 

  38. Smirnov G, Tuomilehto H, Teräsvirta M et al (2008) Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: a prospective randomized study. Am J Rhinol 22(2):214–217. https://doi.org/10.2500/ajr.2008.22.3132

    Article  PubMed  Google Scholar 

  39. Nailwal S, Ram A, Mehrotra N et al (2015) Comparison of external and endonasal dacryocystorhinostomy in acquired nasolacrimal duct obstruction. J Evol Med Dent Sci 4(14):2283–2294

    Article  Google Scholar 

  40. Moras K, Bhat M, Shreyas C et al (2011) External dacryocystorhinostomy versus endoscopic dacryocystorhinostomy: a comparison. J Clin Diagn Res 5(2):182–186

    Google Scholar 

  41. Bhandary SA, Reddy E, Shetty SB et al (2015) Prospective randomised comparative study of external dacryocystorhinostomy and endoscopic dacryocystorhinostomy. J Evol Med Dent Sci 4(58):10187–10206

    Article  Google Scholar 

  42. Wu W, Yan W, MacCallum JK et al (2009) Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology 116(1):116–122. https://doi.org/10.1016/j.ophtha.2008.09.041

    Article  PubMed  Google Scholar 

  43. Hartikainen J, Antila J, Varpula M et al (1998) Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 108(12):1861–1866. https://doi.org/10.1097/00005537-199812000-00018

    Article  CAS  PubMed  Google Scholar 

  44. Goel R, Nagpal S, Kumar S et al (2017) Transcanalicular laser-assisted dacryocystorhinostomy with endonasal augmentation in primary nasolacrimal duct obstruction: our experience. Ophthalmic Plast Reconstr Surg 33(6):408–412. https://doi.org/10.1097/iop.0000000000000802

    Article  PubMed  Google Scholar 

  45. Mourya D, Rijal RK (2017) Transcanalicular laser-assisted dacryocystorhinostomy with diode laser. Orbit 36(6):370–374. https://doi.org/10.1080/01676830.2017.1337189

    Article  PubMed  Google Scholar 

  46. Marcet MM, Kuk AK, Phelps PO (2014) Evidence-based review of surgical practices in endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction and other new indications. Curr Opin Ophthalmol 25(5):443–448. https://doi.org/10.1097/icu.0000000000000084

    Article  PubMed  Google Scholar 

  47. Woog JJ, Kennedy RH, Custer PL et al (2001) Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 108(12):2369–2377. https://doi.org/10.1016/s0161-6420(01)00945-9

    Article  CAS  PubMed  Google Scholar 

  48. Narioka J, Ohashi Y (2008) Transcanalicular-endonasal semiconductor diode laser-assisted revision surgery for failed external dacryocystorhinostomy. Am J Ophthalmol 146(1):60–68. https://doi.org/10.1016/j.ajo.2008.02.028

    Article  PubMed  Google Scholar 

  49. Orsolini MJ, Schellini SA, Souza Meneguim RLF et al (2020) Success of endoscopic dacryocystorhinostomy with or without stents: systematic review and meta-analysis. Orbit 39(4):258–265. https://doi.org/10.1080/01676830.2019.1677726

    Article  PubMed  Google Scholar 

  50. Ing EB, Bedi H, Hussain A et al (2018) Meta-analysis of randomized controlled trials in dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 53(5):466–470. https://doi.org/10.1016/j.jcjo.2017.12.006

    Article  PubMed  Google Scholar 

  51. Xie C, Zhang L, Liu Y et al (2017) Comparing the success rate of dacryocystorhinostomy with and without silicone intubation: a trial sequential analysis of randomized control Trials. Sci Rep 7(1):1936. https://doi.org/10.1038/s41598-017-02070-y

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Kim DH, Kim SI, Jin HJ et al (2018) The clinical efficacy of silicone stents for endoscopic dacryocystorhinostomy: a meta-analysis. Clin Exp Otorhinolaryngol 11(3):151–157. https://doi.org/10.21053/ceo.2017.01781

    Article  PubMed  PubMed Central  Google Scholar 

  53. Kang MG, Shim WS, Shin DK et al (2018) A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol 11(2):81–88. https://doi.org/10.21053/ceo.2018.00031

    Article  PubMed  PubMed Central  Google Scholar 

  54. Sarode D, Bari DA, Cain AC et al (2017) The benefit of silicone stents in primary endonasal dacryocystorhinostomy: a systematic review and meta-analysis. Clin Otolaryngol 42(2):307–314. https://doi.org/10.1111/coa.12751

    Article  CAS  PubMed  Google Scholar 

  55. Unlu HH, Toprak B, Aslan A et al (2002) Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation. Ann Otol Rhinol Laryngol 111(8):704–709. https://doi.org/10.1177/000348940211100809

    Article  PubMed  Google Scholar 

  56. Saeed BM (2012) Endoscopic DCR without stents: clinical guidelines and procedure. Eur Arch Otorhinolaryngol 269(2):545–549. https://doi.org/10.1007/s00405-011-1727-3

    Article  PubMed  Google Scholar 

  57. Shapira Y, Macri C, Usmani E et al (2022) Outcomes of intubation and endoscopic DCR in functional nasolacrimal duct obstruction. Rhinology 60(4):308–312. https://doi.org/10.4193/Rhin22.047

    Article  CAS  PubMed  Google Scholar 

  58. Evereklioglu C, Horozoglu F, Polat OA et al (2023) Modified external revision-DCR in previous failed endonasal, transcanalicular or external-DCR: technical strategy and teaching pearls for success. Rom J Ophthalmol 67(1):14. https://doi.org/10.22336/rjo.2023.4

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Acknowledgements

Ayse Busra GS thanks to the “Republic of Türkiye Higher Education Council” for “100-2000 program” scholarship for PhD.

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Authors and Affiliations

  1. Department of Ophthalmology, Division of Oculoplastic, Orbital, and Lacrimal Surgery, Erciyes University Medical Faculty, Kayseri, Türkiye

    Cem Evereklioglu, Hidayet Sener, Osman Ahmet Polat, Hatice Kubra Sonmez & Fatih Horozoglu

  2. Department of Medical Informatics and Biostatistics, Erciyes University Medical Faculty, Kayseri, Türkiye

    Ayse Busra Gunay Sener

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  1. Cem Evereklioglu
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Contributions

All authors contributed to the study conception and design. Conceptualization: [Cem Evereklioglu]; methodology: [Hidayet Sener, Fatih Horozoglu]; formal analysis and investigation: [Hidayet Sener, Osman A. Polat, Ayse Busra Gunay Sener]; writing—original draft preparation [Cem Evereklioglu, Hidayet Sener, Hatice Kubra Sonmez]; writing—review and editing: [Fatih Horozoglu, Osman A. Polat, Ayse Busra Gunay Sener]. All authors read and approved the final manuscript.

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Correspondence to Cem Evereklioglu or Hidayet Sener.

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Supplemental Figure 6: Forest plot of Bayesian network meta-analysis. Reference surgery is EX-DCR without S. a Comparison of all included studies (N = 32). b When the study with additional intervention was excluded (N = 23). (TIFF 14.5 mb)

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Supplemental Figure 7: Litmus Rank-O-Gram: Higher SUCRA (Surface under the cumulative ranking curve) values and cumulative ranking curves near the top left indicate better performance. a Comparison of all included studies (N = 32). b When the study with additional intervention was excluded (N = 23). (TIFF 25312 kb)

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Evereklioglu, C., Sener, H., Polat, O.A. et al. Success rate of external, endonasal, and transcanalicular laser DCR with or without silicone stent intubation for NLD obstruction: a network meta-analysis of randomized controlled trials. Graefes Arch Clin Exp Ophthalmol 261, 3369–3384 (2023). https://doi.org/10.1007/s00417-023-06089-y

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