title: Optimizing the outcome of transnasal endoscopic sphenopalatine artery ligation in managing refractory posterior epistaxis: A case-control analysis.
abstract: OBJECTIVE
  To optimize the outcome of transnasal endoscopic sphenopalatine artery ligation (TESPAL) by determining the key surgical steps and applying them accordingly.
  
  
  METHODS
  This is a case-control study carried out in a tertiary care teaching institution on subjects who underwent TESPAL during the period of October 2010 to September 2015. Their surgical and clinical records were reviewed, and success (no re-bleed) and failure (return with re-bleed) were considered the main outcome measures of TESPAL. Accordingly, depending on whether the subjects returned with re-bleed or not, they were classified as "failure" and "success" groups. After appropriate matching in terms of age, gender and a given set of exclusion criteria that could influence per-operative decision-making or contribute to post-operative epistaxis, the groups were considered as cases (subjects undergoing TESPAL and returned with re-bleed; part of the "failure" group following matching) and controls (subjects undergoing TESPAL and did not return with re-bleed; part of the "success" group following matching). Per-operative/surgical factors executed or followed in varied combinations in each group that influenced the outcome of TESPAL were then identified from the surgical notes and were subsequently analyzed statistically.
  
  
  RESULTS
  In 89% of cases, the sphenopalatine artery (SPA) pedicle was either clipped or cauterized, whereas in 90% of the controls, it was both clipped and cauterized. The posterior nasal artery (PNA), when found, was cauterized in 25% of the cases, compared to 85% in the controls. Also, the septal artery region was cauterized in only 33% of cases. Both cauterization/clipping of the SPA along with cauterization of PNA was done in 69% of the controls, whereas in 59% the septal artery region was also cauterized. However, there were no cases when all these steps were combined. The results were statistically significant.
  
  
  CONCLUSIONS
  When only the per-operative/surgical factors were considered, the outcome of TESPAL was most favorable when the procedure could be done combining both clipping and cauterization of the SPA, along with cauterization of the PNA and the septal artery region.
authors.affiliation: Department of Otorhinolaryngology and Head-Neck Surgery, Medical College and Hospital, Kolkata, West Bengal, India. Electronic address: duttamainak@yahoo.com.
authors.forename: Mainak
authors.initials: M
authors.lastname: Dutta
authors.affiliation: Department of Community Medicine, Bankura Sammilani Medical College and Hospital, West Bengal, India.
authors.forename: Dibakar
authors.initials: D
authors.lastname: Haldar
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D002425:Cautery; D004844:Epistaxis / Q000601:surgery*; D005260:Female; D006801:Humans; D008026:Ligation; D008297:Male; D008438:Maxillary Artery / Q000601:surgery*; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D009666:Nose / Q000098:blood supply; D012008:Recurrence; D012189:Retrospective Studies; D013525:Surgical Instruments; D055815:Young Adult
keywords: Post-nasal artery; Posterior epistaxis; Refractory; Septal branch of sphenopalatine artery; Transnasal endoscopic sphenopalatine artery ligation