title: The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.
abstract: OBJECTIVE
  To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees.
  
  
  METHODS
  Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips.
  
  
  RESULTS
  Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture.
  
  
  CONCLUSIONS
  Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.
authors.affiliation: a Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom .
authors.forename: Raman
authors.initials: R
authors.lastname: Malhotra
authors.affiliation: a Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom .|b Oxford Eye Hospital, John Radcliffe Hospital , Oxford , United Kingdom .
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Norris
authors.affiliation: a Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom .|c Department of Ophthalmology , Shrewsbury and Telford Hospital NHS Trust , Shrewsbury , United Kingdom , and.
authors.forename: Suresh
authors.initials: S
authors.lastname: Sagili
authors.affiliation: a Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom .
authors.forename: Zaid
authors.initials: Z
authors.lastname: Al-Abbadi
authors.affiliation: a Corneoplastic Unit, Queen Victoria Hospital , East Grinstead , United Kingdom .|d Department of Phthalmology , Rabin Medical Center , Petah-Tiqwa , Israel.
authors.forename: Inbal
authors.initials: I
authors.lastname: Avisar
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence / Q000592:standards*; D003608:Dacryocystorhinostomy / Q000592:standards*; D004503:Education, Medical, Graduate; D004724:Endoscopy / Q000592:standards*; D005257:Fellowships and Scholarships; D005260:Female; D006801:Humans; D007767:Lacrimal Duct Obstruction / Q000628:therapy*; D059032:Learning Curve; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009301:Nasolacrimal Duct / Q000601:surgery; D009885:Ophthalmology / Q000193:education*; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D013518:Surgery, Plastic / Q000193:education*; D013524:Surgical Flaps; D011795:Surveys and Questionnaires
keywords: Endoscopic DCR; lacrimal; training