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Endoscopic dacryocystorhinostomy in warfarinized patients
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 327 – 329 www.elsevier.com/locate/amjoto
Endoscopic dacryocystorhinostomy in warfarinized patients Wendy Smith, FRCS (ORL-HNS), Christos Merkonidis, FRCS, Mark Draper, FRCS (ORL-HNS), Matthew Yung, PhD, FRCS4 Department of Otolaryngology, The Ipswich Hospital N.H.S. Trust, Heath Road, Ipswich, Suffolk, UK Received 5 December 2005
Abstract
Purpose: To report the results of endoscopic dacryocystorhinotomy (EDCR) in anticoagulated patients who did not interrupt their anticoagulant regimen for the procedure. Materials and methods: A case note review was made of all 9 patients taking warfarin who had EDCR at Ipswich Hospital from May 1998 to October 2003. Age, gender, indications for surgery, complications, and outcome were analyzed, and the results were compared to EDCRs in nonwarfarinized patients. Results: Of the 9 patients, 7 had complete relief of epiphora. Two patients had a persistent watering eye. One of them had blockage of upper, lower, and common canaliculi, and the other was found to have adhesions between the lateral nasal wall and middle turbinate. A total of 6 patients had no postoperative complications; 2 had minor periorbital bruising that did not delay discharge, and only 1 patient had ooze through a Kaltostat nasal pack and was kept in the hospital for 2 days. None required readmission. Conclusions: EDCR is a safe and efficacious treatment in patients with distal nasolacrimal obstruction in anticoagulated patients and does not require stopping the warfarin perioperatively. D 2006 Elsevier Inc. All rights reserved.
1. Introduction
2. Materials and methods
It has been shown that endoscopic dacryocystorhinostomy (EDCR) can give a success rate of 80% to 90%, which is comparable of that of external dacryocystorhinotomy (DCR) [1-5]. External DCR usually requires a general anesthetic and overnight stay in the hospital. It also carries a 3% postoperative hemorrhage rate [6]. In warfarinized patients, hospital stay can be prolonged for several days if the warfarin status is interrupted by the operation [5]. We report for the first time in the literature the results of nonlaser-assisted endoscopic DCR in patients who maintained their usual warfarin regimen throughout the perioperative period, hence maintaining their therapeutic International Normalized Ratio (INR).
A retrospective analysis of all the patient’s notes who had EDCR at Ipswich Hospital between May 1998 and October 2003 was performed. Patients who were taking warfarin at the time of their operation were identified from regional anticoagulant therapy lists and case notes. From these, the patients’ age, sex, indications for surgery, and surgical outcome were noted. The hemorrhage rate was compared to those patients having EDCR who were not on aspirin or warfarin. Since 1994, EDCR was performed by the senior author (MWY) on all patients with lacrimal obstruction, including proximal lacrimal blockage. All were performed routinely under local anesthetic. Patients on warfarin were allowed to continue with their usual warfarin regimen to maintain their therapeutic INR. Careful preoperative explanation of the proposed anesthetic and surgery was given to each patient. Intranasal anesthesia was commenced by the application of cocaine (25%) and adrenaline (0.1%) paste applied to the nasal cavity on Tumarkin wires an hour before surgery by trainee ear, nose, and throat (ENT) staff on the ward. On
4 Corresponding author. The Ipswich N.H.S. Trust, Heath Road, Ipswich, IP4 5PD Suffolk, UK. Tel. +44 1473 703527. E-mail address: [email protected] (M. Yung). 0196-0709/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.01.016
328
W. Smith et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 327–329
Table 1 Summary of results of patients on warfarin undergoing EDCR using conventional instruments Patient number
Age
Sex
Reason on warfarin
DCR
Concomitant surgery
Level of blockage
Nasal packing
Complications
Result after 6 mo
1
69
M
Atrial fibrillation
Right
Septoplasty
None
None
2
81
F
Bilateral
Septoplasty
None
None
3
71
F
Left
Septoplasty
Kaltostat
4
71
M
Pulmonary embolism Atrial fibrillation Pulmonary embolism
Left
None
Kaltostat
Periorbital bruising None
5
80
F
Left
None
None
None
6
82
F
Right
None
Kaltostat
None
7
90
F
Right
None
Kaltostat
8
69
F
Right
None
Kaltostat
Periorbital bruising Ooze
9
71
F
Deep vein thrombosis Pulmonary embolism Atrial fibrillation Pulmonary embolism Pulmonary embolism
Lacrimal sac and duct Lacrimal sac and duct Lacrimal sac and duct Upper, lower, and common canaliculi Common canaliculus Lacrimal sac
Right revision
Trimming of middle turbinate
Kaltostat
None
Epiphora resolved Epiphora resolved Epiphora, adhesions Epiphora, proximal stenosis Epiphora resolved Epiphora resolved Epiphora resolved Epiphora resolved Epiphora resolved
arrival in the anesthetic room, 1 ml of 2% lignocaine and 1:80,000 adrenaline were injected into the lateral nasal wall anterior to the uncinate process by the ENT surgeon. The septum was also infiltrated with the same local anesthetic if septoplasty was also required. All patients had the lacrimal fossa block as detailed by Smith et al [7], whereby topical conjunctival anesthesia was obtained using 1% amethocaine eye drops and 2–3 ml of 2% lignocaine and 1:80,000 adrenaline injected between the caruncle and medial canthus to block the lacrimal fossa. A silicone stent was inserted routinely at the end of the operation. After the EDCR was performed, 3 patients had no packing at all, but the rest had a loose kaltostat pack inserted for 4 –12 hours. The patients were followed up at 3 months postoperatively when the silicone stent was removed and again at 6 months postoperatively for outcome assessment.
Common canaliculus Lacrimal sac and duct Lacrimal sac
surgery. Two patients had minor periorbital bruising that quickly resolved. Only 1 patient had ooze through a kaltostat dressing and was discharge within 48 hours of surgery. No patients required repacking of their nose or readmission. A total of 257 patients were identified as having EDCR who were not on warfarin or aspirin. Of these patients, 3 had significant epistaxis resulting in a prolonged hospital stay or readmission. Of the 9 patients, 7 had complete resolution of the epiphora even at 6 months. One failure was due to fibrous closure of the lacrimal window. The other patient with persistent epiphora after DCR was found to have blockage within both canaliculi in spite of a wide-open lacrimal window inside the nose. 4. Discussion
3. Results Of 318 EDCR procedures performed between May 1998 and October 2003, 9 patients (2 men and 7 women) were identified as taking warfarin at the time of their operation. The median age was 75.5 years (range, 69 –90 years). The details on each patient were listed in Table 1. The average INR was 2.5 with a range of 2.1 to 2.9. One patient suffered from bilateral epiphora, 4 had left-sided epiphora, and 4 had right-sided epiphora. In addition to the epiphora, 2 patients had a lacrimal mucocele, and 4 patients had symptoms of chronic dacryocystitis. Only 1 patient had had a previous dacryocystorhinostomy on the same side. A total of three patients had a concomitant septoplasty, and 1 patient had partial trimming of the middle turbinate to improve surgical access. All patients had surgery under local anesthetic. A total of three patients were discharged on the same day, and 5 patients were discharged as planned within 24 hours of
Epiphora mainly affects the elderly population, many of whom may carry other concomitant medical problems. Therefore, a balance between benefit and risk of the operation must be considered if DCR is contemplated. In patients requiring warfarin for atrial fibrillation, or after deep vein thrombosis and pulmonary embolism, the desired INR is 2.5 (range, 2.0 –3.0) [8]. The management of these patients receiving long-term anticoagulant therapy is clinically challenging because the anticoagulants place them at risk for serious bleeding complications but discontinuing the anticoagulant puts them at risk for thromboembolic complications. There is little consensus in the appropriate perioperative treatment of patients on long-term warfarin, some favor the conversion to a low molecular weight heparin or unfractionated heparin [9,10]. Others suggest that the risk of severe hemorrhage is not increased if warfarin is continued perioperatively [11,12]. Furthermore,
W. Smith et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 327 – 329
life-threatening thromboembolic complications have been reported as a result of stopping warfarin perioperatively [12]. Smithard et al [5] in 2003 reported their results of endoscopic laser-assisted DCR in 16 anticoagulated patients without disrupting their warfarin therapy. They had no cases of perioperative or postoperative epistaxis. They proposed that laser would be advantageous over conventional endonasal DCR with regard to the risk of bleeding, although they have not performed a comparative study on nonlaser-assisted DCR. Smithard et al [5] had to revise 6 of the 16 cases as a result of mucosa or scar tissue occluding the ostium. Laserassisted endonasal DCR has been found to be less successful in controlling epiphora when compared with external DCR or endonasal DCR using conventional instruments (83% for endosurgical and 71% for endolaser) [13]. We have shown that the more successful endonasal DCR using conventional instruments can be used in patients without interrupting the warfarin therapy. The ability to perform this under local anesthetic enables patients unsuitable for a general anesthetic to be considered for this operation. In the present series of endoscopic DCR on warfarinized patients, 80% were successful (including the patient having revision surgery) in relieving the symptom of epiphora. None had major bleeding as a result of continuing their warfarin perioperatively. 5. Conclusion Endoscopic DCR under local anesthetic has been shown in this study to be a safe and efficacious procedure in patients with epiphora and who are on anticoagulants. The ability to perform this surgery without the need to interrupt warfarin therapy is advantageous because it prevents placing these patients at risk from further thromboembolic disease
329
when their INR is reduced and is cost-effective by reducing hospital stays. In patients with suitable social backup, endoscopic DCR can be carried out as a planned day case procedure.
References [1] Wormold PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope 2002;112:69 - 72. [2] Yung MW, Hardman-Lea S. Analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction. Br J Ophthalmol 2002;86:792 - 4. [3] McLahlan DL, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of the re-operations. Ophthalmic Surg 1980;11: 427 - 30. [4] Burns JA, Cahill KV. Modified Kinosian dacryocystorhinostomy: a report of 122 cases. Ophthalmic Surg 1985;16:710 - 6. [5] Smithard A, Wynne D, Binham BJ, et al. Endonasal laser dacryocystorhinostomy: its role in anticoagulated patients. Laryngoscope 2003; 113:1034 - 6. [6] Tsirbas A, Mc Nab AA. Secondary haemorrhage after dacryocystorhinostomy. Clin Experiment Ophthalmol 2000;28:22 - 5. [7] Smith MG, Kong AS, Yung MW, et al. Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy. Clin Otolaryngol 2001;26:407 - 10. [8] Grahame-Smith DG, Aronson JK. Pharmacopeia in Oxford textbook of clinical pharmacology and drug therapy. 3rd ed. Oxford, UK: Oxford University Press; 2002. p. 605. [9] Jafri SM. Periprocedural thromboprphylaxis in patients receiving chronic anticoagulation therapy. Am Heart J 2004;147:3 - 15. [10] Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med 2003;70:973 - 84. [11] Cannon PD, Dharmar VT. Minor oral surgical procedures in patients on oral anticoagulants: a controlled study. Aust Dent J 2003;48:115 - 8. [12] Otley CC. Continuation of medically necessary aspirin and warfarin during cutaneous surgery. Mayo Clin Proc 2003;78:1392 - 6. [13] Moore WM, Bentley CR, Olver JM. Functional and anatomic results after two types of endoscopic endonasal dacryocystorhinostomy: surgical and holmium laser. Ophthalmology 2002;109:1575 - 82.
Endoscopic dacryocystorhinostomy in warfarinized patients Wendy Smith, FRCS (ORL-HNS), Christos Merkonidis, FRCS, Mark Draper, FRCS (ORL-HNS), Matthew Yung, PhD, FRCS4 Department of Otolaryngology, The Ipswich Hospital N.H.S. Trust, Heath Road, Ipswich, Suffolk, UK Received 5 December 2005
Abstract
Purpose: To report the results of endoscopic dacryocystorhinotomy (EDCR) in anticoagulated patients who did not interrupt their anticoagulant regimen for the procedure. Materials and methods: A case note review was made of all 9 patients taking warfarin who had EDCR at Ipswich Hospital from May 1998 to October 2003. Age, gender, indications for surgery, complications, and outcome were analyzed, and the results were compared to EDCRs in nonwarfarinized patients. Results: Of the 9 patients, 7 had complete relief of epiphora. Two patients had a persistent watering eye. One of them had blockage of upper, lower, and common canaliculi, and the other was found to have adhesions between the lateral nasal wall and middle turbinate. A total of 6 patients had no postoperative complications; 2 had minor periorbital bruising that did not delay discharge, and only 1 patient had ooze through a Kaltostat nasal pack and was kept in the hospital for 2 days. None required readmission. Conclusions: EDCR is a safe and efficacious treatment in patients with distal nasolacrimal obstruction in anticoagulated patients and does not require stopping the warfarin perioperatively. D 2006 Elsevier Inc. All rights reserved.
1. Introduction
2. Materials and methods
It has been shown that endoscopic dacryocystorhinostomy (EDCR) can give a success rate of 80% to 90%, which is comparable of that of external dacryocystorhinotomy (DCR) [1-5]. External DCR usually requires a general anesthetic and overnight stay in the hospital. It also carries a 3% postoperative hemorrhage rate [6]. In warfarinized patients, hospital stay can be prolonged for several days if the warfarin status is interrupted by the operation [5]. We report for the first time in the literature the results of nonlaser-assisted endoscopic DCR in patients who maintained their usual warfarin regimen throughout the perioperative period, hence maintaining their therapeutic International Normalized Ratio (INR).
A retrospective analysis of all the patient’s notes who had EDCR at Ipswich Hospital between May 1998 and October 2003 was performed. Patients who were taking warfarin at the time of their operation were identified from regional anticoagulant therapy lists and case notes. From these, the patients’ age, sex, indications for surgery, and surgical outcome were noted. The hemorrhage rate was compared to those patients having EDCR who were not on aspirin or warfarin. Since 1994, EDCR was performed by the senior author (MWY) on all patients with lacrimal obstruction, including proximal lacrimal blockage. All were performed routinely under local anesthetic. Patients on warfarin were allowed to continue with their usual warfarin regimen to maintain their therapeutic INR. Careful preoperative explanation of the proposed anesthetic and surgery was given to each patient. Intranasal anesthesia was commenced by the application of cocaine (25%) and adrenaline (0.1%) paste applied to the nasal cavity on Tumarkin wires an hour before surgery by trainee ear, nose, and throat (ENT) staff on the ward. On
4 Corresponding author. The Ipswich N.H.S. Trust, Heath Road, Ipswich, IP4 5PD Suffolk, UK. Tel. +44 1473 703527. E-mail address: [email protected] (M. Yung). 0196-0709/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.01.016
328
W. Smith et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 327–329
Table 1 Summary of results of patients on warfarin undergoing EDCR using conventional instruments Patient number
Age
Sex
Reason on warfarin
DCR
Concomitant surgery
Level of blockage
Nasal packing
Complications
Result after 6 mo
1
69
M
Atrial fibrillation
Right
Septoplasty
None
None
2
81
F
Bilateral
Septoplasty
None
None
3
71
F
Left
Septoplasty
Kaltostat
4
71
M
Pulmonary embolism Atrial fibrillation Pulmonary embolism
Left
None
Kaltostat
Periorbital bruising None
5
80
F
Left
None
None
None
6
82
F
Right
None
Kaltostat
None
7
90
F
Right
None
Kaltostat
8
69
F
Right
None
Kaltostat
Periorbital bruising Ooze
9
71
F
Deep vein thrombosis Pulmonary embolism Atrial fibrillation Pulmonary embolism Pulmonary embolism
Lacrimal sac and duct Lacrimal sac and duct Lacrimal sac and duct Upper, lower, and common canaliculi Common canaliculus Lacrimal sac
Right revision
Trimming of middle turbinate
Kaltostat
None
Epiphora resolved Epiphora resolved Epiphora, adhesions Epiphora, proximal stenosis Epiphora resolved Epiphora resolved Epiphora resolved Epiphora resolved Epiphora resolved
arrival in the anesthetic room, 1 ml of 2% lignocaine and 1:80,000 adrenaline were injected into the lateral nasal wall anterior to the uncinate process by the ENT surgeon. The septum was also infiltrated with the same local anesthetic if septoplasty was also required. All patients had the lacrimal fossa block as detailed by Smith et al [7], whereby topical conjunctival anesthesia was obtained using 1% amethocaine eye drops and 2–3 ml of 2% lignocaine and 1:80,000 adrenaline injected between the caruncle and medial canthus to block the lacrimal fossa. A silicone stent was inserted routinely at the end of the operation. After the EDCR was performed, 3 patients had no packing at all, but the rest had a loose kaltostat pack inserted for 4 –12 hours. The patients were followed up at 3 months postoperatively when the silicone stent was removed and again at 6 months postoperatively for outcome assessment.
Common canaliculus Lacrimal sac and duct Lacrimal sac
surgery. Two patients had minor periorbital bruising that quickly resolved. Only 1 patient had ooze through a kaltostat dressing and was discharge within 48 hours of surgery. No patients required repacking of their nose or readmission. A total of 257 patients were identified as having EDCR who were not on warfarin or aspirin. Of these patients, 3 had significant epistaxis resulting in a prolonged hospital stay or readmission. Of the 9 patients, 7 had complete resolution of the epiphora even at 6 months. One failure was due to fibrous closure of the lacrimal window. The other patient with persistent epiphora after DCR was found to have blockage within both canaliculi in spite of a wide-open lacrimal window inside the nose. 4. Discussion
3. Results Of 318 EDCR procedures performed between May 1998 and October 2003, 9 patients (2 men and 7 women) were identified as taking warfarin at the time of their operation. The median age was 75.5 years (range, 69 –90 years). The details on each patient were listed in Table 1. The average INR was 2.5 with a range of 2.1 to 2.9. One patient suffered from bilateral epiphora, 4 had left-sided epiphora, and 4 had right-sided epiphora. In addition to the epiphora, 2 patients had a lacrimal mucocele, and 4 patients had symptoms of chronic dacryocystitis. Only 1 patient had had a previous dacryocystorhinostomy on the same side. A total of three patients had a concomitant septoplasty, and 1 patient had partial trimming of the middle turbinate to improve surgical access. All patients had surgery under local anesthetic. A total of three patients were discharged on the same day, and 5 patients were discharged as planned within 24 hours of
Epiphora mainly affects the elderly population, many of whom may carry other concomitant medical problems. Therefore, a balance between benefit and risk of the operation must be considered if DCR is contemplated. In patients requiring warfarin for atrial fibrillation, or after deep vein thrombosis and pulmonary embolism, the desired INR is 2.5 (range, 2.0 –3.0) [8]. The management of these patients receiving long-term anticoagulant therapy is clinically challenging because the anticoagulants place them at risk for serious bleeding complications but discontinuing the anticoagulant puts them at risk for thromboembolic complications. There is little consensus in the appropriate perioperative treatment of patients on long-term warfarin, some favor the conversion to a low molecular weight heparin or unfractionated heparin [9,10]. Others suggest that the risk of severe hemorrhage is not increased if warfarin is continued perioperatively [11,12]. Furthermore,
W. Smith et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 327 – 329
life-threatening thromboembolic complications have been reported as a result of stopping warfarin perioperatively [12]. Smithard et al [5] in 2003 reported their results of endoscopic laser-assisted DCR in 16 anticoagulated patients without disrupting their warfarin therapy. They had no cases of perioperative or postoperative epistaxis. They proposed that laser would be advantageous over conventional endonasal DCR with regard to the risk of bleeding, although they have not performed a comparative study on nonlaser-assisted DCR. Smithard et al [5] had to revise 6 of the 16 cases as a result of mucosa or scar tissue occluding the ostium. Laserassisted endonasal DCR has been found to be less successful in controlling epiphora when compared with external DCR or endonasal DCR using conventional instruments (83% for endosurgical and 71% for endolaser) [13]. We have shown that the more successful endonasal DCR using conventional instruments can be used in patients without interrupting the warfarin therapy. The ability to perform this under local anesthetic enables patients unsuitable for a general anesthetic to be considered for this operation. In the present series of endoscopic DCR on warfarinized patients, 80% were successful (including the patient having revision surgery) in relieving the symptom of epiphora. None had major bleeding as a result of continuing their warfarin perioperatively. 5. Conclusion Endoscopic DCR under local anesthetic has been shown in this study to be a safe and efficacious procedure in patients with epiphora and who are on anticoagulants. The ability to perform this surgery without the need to interrupt warfarin therapy is advantageous because it prevents placing these patients at risk from further thromboembolic disease
329
when their INR is reduced and is cost-effective by reducing hospital stays. In patients with suitable social backup, endoscopic DCR can be carried out as a planned day case procedure.
References [1] Wormold PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope 2002;112:69 - 72. [2] Yung MW, Hardman-Lea S. Analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction. Br J Ophthalmol 2002;86:792 - 4. [3] McLahlan DL, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of the re-operations. Ophthalmic Surg 1980;11: 427 - 30. [4] Burns JA, Cahill KV. Modified Kinosian dacryocystorhinostomy: a report of 122 cases. Ophthalmic Surg 1985;16:710 - 6. [5] Smithard A, Wynne D, Binham BJ, et al. Endonasal laser dacryocystorhinostomy: its role in anticoagulated patients. Laryngoscope 2003; 113:1034 - 6. [6] Tsirbas A, Mc Nab AA. Secondary haemorrhage after dacryocystorhinostomy. Clin Experiment Ophthalmol 2000;28:22 - 5. [7] Smith MG, Kong AS, Yung MW, et al. Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy. Clin Otolaryngol 2001;26:407 - 10. [8] Grahame-Smith DG, Aronson JK. Pharmacopeia in Oxford textbook of clinical pharmacology and drug therapy. 3rd ed. Oxford, UK: Oxford University Press; 2002. p. 605. [9] Jafri SM. Periprocedural thromboprphylaxis in patients receiving chronic anticoagulation therapy. Am Heart J 2004;147:3 - 15. [10] Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med 2003;70:973 - 84. [11] Cannon PD, Dharmar VT. Minor oral surgical procedures in patients on oral anticoagulants: a controlled study. Aust Dent J 2003;48:115 - 8. [12] Otley CC. Continuation of medically necessary aspirin and warfarin during cutaneous surgery. Mayo Clin Proc 2003;78:1392 - 6. [13] Moore WM, Bentley CR, Olver JM. Functional and anatomic results after two types of endoscopic endonasal dacryocystorhinostomy: surgical and holmium laser. Ophthalmology 2002;109:1575 - 82.