Consequences of Premature Silicone Stent Loss Following Endonasal Dacryocystorhinostomy

Consequences of Premature Silicone Stent Loss Following Endonasal Dacryocystorhinostomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Consequences of Premature Silicone Stent Loss Following Endonasal Dacryocystorhinostomy Neofytos Mavris, Reem Agbareia, Zvi Gur This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9192494/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Premature silicone stent loss after primary endonasal dacryocystorhinostomy (enDCR) may affect lacrimal drainage surgery outcomes, but its impact on surgical success is uncertain. Objectives To determine whether premature silicone stent loss (<2 months) after primary enDCR affects surgical success. Design Single-centre retrospective cohort study. Methods Single-centre retrospective cohort conducted at Hadassah Medical Center, including adults with primary acquired nasolacrimal duct obstruction who underwent primary enDCR with bicanalicular intubation between August 2020 and December 2024. The primary outcome was surgical success -absence of symptomatic epiphora/infection and/or patent lacrimal irrigation - assessed ≥3 months postoperatively. Outcomes were compared between eyes with “premature” stent loss and those without (“late”). Results We included 107 eyes (mean age 60.3±17.8 years; 72.9% female). Median follow-up was 239 days (IQR 137–592). Premature stent loss occurred in 21 eyes (19.6%), with a median time to loss of 14 days (range 6–35). Overall surgical success was 86.9% (93/107). Success was comparable between premature and late groups: 85.7% (18/21) vs 87.2% (75/86), p=1.00. Complications were uncommon (2.8% overall) and similar between groups (4.8% vs 2.3%, p=0.48). Revision surgery was required in 12.1% overall (14.3% premature vs 11.6% late, p=0.72). Most premature losses occurred within 30 days, and early loss was not associated with surgical failure. Conclusions In primary enDCR with bicanalicular intubation, premature stent loss within two months was not associated with reduced surgical success or higher reoperation rates. Conservative management with close follow-up is reasonable after early loss, and shorter stent-retention protocols may be considered; prospective studies should define the optimal duration. dacryocystorhinostomy nasolacrimal duct obstruction silicone stent lacrimal intubation surgical outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 KEY MESSAGE Current evidence: Silicone stenting is widely employed in endonasal dacryocystorhinostomy (enDCR) to maintain ostium patency; however, the optimal duration of stent retention and the clinical implications of premature stent loss remain uncertain. Study findings: Premature silicone stent loss (<2 months) following primary enDCR is not associated with reduced surgical success, with comparable outcomes observed relative to standard-duration stenting. Premature stent loss is not associated with increased postoperative complications or higher rates of revision surgery, indicating that early loss does not adversely affect clinical outcomes. These findings support a conservative management approach following early stent loss and suggest that shorter stent-retention durations may be adequate in selected patients. INTRODUCTION Dacryocystorhinostomy (DCR) remains the definitive surgical intervention to restore tear drainage in primary acquired nasolacrimal duct obstruction (PANDO) by creating a new tear passageway ( 1 , 2 ). The evolution of DCR has seen a significant shift from external dacryocystorhinostomy (extDCR) to endonasal dacryocystorhinostomy (enDCR) approach, driven by advancements in endoscopic technologies ( 3 ). These technologies offer comparable efficacy to extDCR ( 4 , 5 ) while avoiding external scars, an important advantage for young patients ( 3 ). The role of silicone stents in enDCR is contentious. While studies such as those by Fayers et al. demonstrate a higher success rate with stenting ( 6 ), other studies have reported equal surgical outcomes with and without stenting ( 7 – 9 ). There remains limited evidence regarding the impact of stent duration on surgical outcomes in enDCR ( 10 ). Recommendations range from six weeks to six months, aiming at preventing fibrotic stenosis of the newly formed ostium ( 11 ). At the Hadassah Medical Center, the common practice for enDCR involves bicanalicular intubation (BCI) using silicone stents. The stent is removed at least two months after the surgery. Given the varied practices and the absence of a consensus on the optimal duration for stent placement, this study aims to fill this significant gap by evaluating whether shorter stent durations can achieve outcomes equivalent to longer durations, in patients following primary enDCR. METHODS This was a retrospective study of adult patients (≥ 18 years) who underwent primary enDCR with BCI (Lacrimal Intubation Set, mdi Europa GmbH, Langenhagen, Germany) from August 2020 to December 2024 at Hadassah Medical Center. All patients demonstrated a confirmed PANDO, with or without coexisting dacryocystitis, prior to surgery. Demographic data, surgical details, complications, clinical outcomes, and the need for revision surgery were recorded. Patients were excluded in case of secondary DCR procedures, had incomplete or missing medical records, or had coexisting conditions (e.g., lacrimal trauma, primary nasolacrimal neoplasm, abnormal lid position, sarcoidosis) likely to impact the lacrimal drainage system. Ethical approval was obtained from the local institutional review board (Protocol Number 0493-24-HMO). Surgical approach All procedures were conducted under general anesthesia. Nasal packing with adrenaline (1:10,000) was placed under the middle turbinate. The nasal cavity and operative area were sterilized using povidone-iodine. The nasal packing was removed, and the endoscope was inserted. Nasal decongestion was achieved with 2% lidocaine containing epinephrine at a 1:100,000 ratio. Osteotomy was completed using Kerrison bone punch and Takahashi forceps, thus exposing the lacrimal sac. Following hemostasis, a crescent blade was used to incise and open the lacrimal sac from its most superior to its most inferior aspect. A Bowman probe was employed to evaluate the patency of the lacrimal drainage system. A bicanalicular silicone stent was pushed into place via both the lower and upper puncta using a metallic guide. Both ends of the stent were removed through the nose and tied with 3 square knots. Foam gel soaked in 40 mg/mL triamcinolone acetonide (Kenalog®, Bristol-Myers Squibb, USA) was compressed into the osteotomy site. The stent was then secured to the medial aspect of the lateral nostril using a Prolane single suture 5 − 0 (Ethicon, Johnson & Johnson, Somerville, NJ, USA). No antimetabolites were applied during any part of the procedure. Outcomes The primary outcome was to evaluate the clinical impact of “premature” stent loss, defined as the loss or removal of the stent earlier than two months post-surgery, and compare it to those with no premature stent loss, “late”. Surgical success was defined as the absence of symptomatic tearing and/or infection or a patent lacrimal drainage system (confirmed via irrigation test) at least three months after surgery. Failure was characterized by continued epiphora, infection, or demonstrable obstruction upon lacrimal irrigation of both the upper and lower canaliculi. Patients who did not have at least three months of in-person follow-up after surgery were contacted to evaluate any symptoms of epiphora. In the case of symptomatic epiphora, patients were invited for a follow-up visit to undergo a lacrimal irrigation test. Secondary outcomes included incidence of premature stent loss, time to stent loss, complication, and revision surgery rates. Statistical Analysis Continuous data were summarized as mean ± SD or median (IQR). Group comparisons used the Welch t-test (age), Wilcoxon rank-sum test (follow-up), and Fisher’s exact test (categorical variables). Kaplan–Meier estimation assessed time to premature stent loss. A two-sided P < 0.05 was considered significant. Analyses were performed in R 4.4.2. RESULTS A total of 107 eyes from 107 patients (78 females, 72.9%) who underwent primary enDCR with bicanalicular silicone stenting met the inclusion criteria. The mean patient age was 60.3 ± 17.8 years (Table 1 ) . Table 1 Overall descriptive characteristics Variable Overall Number of eyes 107 Age – mean (SD) 60.3 (17.8) Female – n (%) 78 (72.9%) Follow-up – median (IQR), days 239 (137–592) Success – n (%) 93 (86.9%) Complication – n (%) 3 (2.8%) Revision surgery – n (%) 13 (12.1%) Primary Outcomes At a median follow-up of 239 days (IQR: 137–592), the overall surgical success rate was 86.9% (93/107 eyes). Premature stent loss occurred in 21 eyes (19.6%), with a median time to loss of 14 days (range: 6–35). Surgical success was comparable between the premature and late stent loss groups. Specifically, success was achieved in 18 of 21 eyes (85.7%) in the premature loss group and 75 of 86 eyes (87.2%) in the late group (P = 1.00; Table 2 ). Table 2 Early vs Late comparisons. Variable Early Late p -value Age – mean (SD) 65.7 (15.8) 59.0 (18.1) 0.099 Female – n (%) 14 (66.7%) 64 (74.4%) 0.584 Follow-up – median (IQR), days 305 (190–571) 230 (129–592) 0.399 Success – n (%) 18 (85.7%) 75 (87.2%) ~ 1 Complication – n (%) 1 (4.8%) 2 (2.3%) 0.484 Revision surgery – n (%) 3 (14.3%) 10 (11.6%) 0.716 Complications and Reoperations Postoperative complications were rare, occurring in 3 of 107 eyes (2.8%). Complication rates did not differ significantly between the premature (1/21 eyes; 4.8%) and late stent groups (2/86 eyes; 2.3%) (P = 0.48). Revision surgery was performed in 13 eyes (12.1%) overall. The rate of revision was slightly higher in the premature group (3/21 eyes; 14.3%) than in the late group (10/86 eyes; 11.6%), though this difference was not statistically significant (P = 0.72). The median follow-up duration was 305 days (IQR: 190–571) in the premature group and 230 days (IQR: 129–592) in the late group. Kaplan–Meier analysis indicated that most premature stent losses occurred within the first 30 days postoperatively ( Fig. 1 ). However, premature stent loss was not associated with an increased risk of surgical failure. Demographic Comparisons No significant demographic differences were identified between the premature and late groups. Patients with premature stent loss were slightly older (mean age: 65.7 vs. 59.0 years; P = 0.099) and had a lower proportion of females (66.7% vs. 74.4%; P = 0.584), but these differences did not reach statistical significance ( Table 2 ). DISCUSSION The findings from our study provide important insights into the clinical consequences of premature silicone stent loss following primary enDCR with bicanalicular intubation. Our results demonstrate that premature stent loss, occurring in 19.6% of patients with a median time of 14 days postoperatively, was not associated with reduced surgical success rates when compared to patients who retained their stents for the intended two-month period. This finding challenges the assumption that premature stent loss necessarily compromises surgical outcomes in enDCR. The overall success rate of 86.9% in our cohort is consistent with previously reported outcomes for enDCR, which typically range from 82–95% ( 12 , 13 ). Importantly, the comparable success rates between the premature (85.7%) and late (87.2%) stent loss groups (P = 1.00) suggest that the duration of stent retention may be less critical than previously believed. This finding aligns with the landmark study by Vicinanzo et al., who reported similar results in external DCR, where 18% of patients experienced premature stent loss with a 90.5% success rate compared to 95.8% in those without premature loss (P = 0.24) ( 14 ). The temporal pattern of stent loss observed in our study, with most occurring within the first 30 days postoperatively, is consistent with other reports in the literature ( 14 ). This premature loss pattern suggests that factors influencing stent retention are primarily related to the immediate postoperative period, including patient compliance, anatomical factors, and healing characteristics, rather than the inherent properties of the stent itself. Several mechanisms may explain why premature stent loss does not necessarily compromise surgical outcomes in enDCR. First, the primary function of bicanalicular stents is to maintain ostium patency during the critical healing period when fibrosis and granulation tissue formation are most likely to occur ( 15 ). However, recent evidence suggests that the most crucial period for maintaining ostium patency may be shorter than traditionally assumed. Studies examining premature stent removal have demonstrated that even planned removal at 2 weeks postoperatively can achieve success rates comparable to standard 6-week protocols ( 16 ). Second, the endoscopic approach itself may provide advantages that reduce dependence on prolonged stent retention. Unlike external DCR, the endonasal approach allows for better visualization and management of the nasal cavity, potentially reducing the formation of synechiae and granulation tissue that could lead to ostium closure ( 15 , 17 ). Additionally, the preservation of the medial canthal ligament and pump function in enDCR may contribute to better long-term outcomes regardless of stent duration ( 18 ). The success of DCR surgery depends on multiple factors beyond stent duration. These results suggest that the initial surgical technique, adequate osteotomy size, and proper mucosal handling may be more important determinants of success than stent retention time. Studies have shown that factors such as the size and location of the rhinostomy, the quality of mucosal flaps, and the prevention of excessive scarring play crucial roles in long-term success ( 19 ). The role of postoperative inflammation and healing response should not be underestimated. Research has demonstrated that excessive fibrosis and granulation tissue formation are primary causes of DCR failure ( 19 , 20 ). The use of adjuvant therapies such as mitomycin C has been shown to reduce fibrosis and improve success rates, particularly in revision cases ( 21 ). However, our study suggests that in primary enDCR, the natural healing process may be sufficient to maintain ostium patency even without prolonged stent support. The literature on premature stent loss in external DCR provides valuable context for our findings ( 14 ). Limbu et al.'s randomized controlled trial demonstrated no significant difference in outcomes between 2-week and 6-week stent removal protocols in external DCR ( 16 ). These findings, combined with our results, suggest that the phenomenon of successful outcomes despite premature stent loss is consistent across different DCR techniques. Our low complication rate (2.8%) and revision rate (12.1%) are consistent with reported outcomes for enDCR ( 15 , 17 ). The slightly higher revision rate in the premature stent loss group (14.3% vs. 11.6%) did not reach statistical significance, suggesting that premature stent loss does not substantially increase the risk of surgical failure requiring reintervention. This finding is particularly important for patient counseling, as it indicates that patients experiencing premature stent loss can be reassured that their risk of requiring revision surgery is not significantly elevated. Several limitations should be acknowledged in interpreting our results. First, our study is retrospective, which may introduce selection bias and limit the ability to control for confounding variables. Second, we did not perform a formal sample size calculation; instead, all eligible cases treated at our centre during the study period were included, which may limit the statistical power to detect small differences between groups. Third, the definition of "premature" stent loss as less than two months may not capture the optimal duration for stent retention. Future prospective studies examining different time intervals for stent removal could provide more definitive guidance on optimal stent duration. Based on our findings, we recommend that patients with premature stent loss can generally be managed conservatively, with reintervention guided by symptoms and endoscopic findings rather than the timing of loss. Furthermore, our results support the consideration of shorter stent retention protocols in selected patients, particularly those at low risk for complications. This approach could reduce stent-related complications, improve patient comfort, and decrease healthcare resource utilization while maintaining comparable surgical success rates. In conclusion, our study demonstrates that premature silicone stent loss following primary enDCR does not significantly compromise surgical outcomes. These findings challenge traditional assumptions about the necessity of prolonged stent retention and suggest that the current practice of routine stent replacement following premature loss may not be warranted. Future prospective studies examining optimal stent duration and the role of patient-specific factors in determining stent requirements will further refine our understanding of this important clinical issue. Declarations Competing Interests : The authors declare no relevant financial or non-financial conflicts of interest. Ethics approval and consent to participate This study was approved by the Hadassah Medical Center Ethics Committee (Jerusalem, Israel) under approval number HMO-0408-21. The requirement for written informed consent was waived because the study used de-identified data from existing medical records. Consent for publication All authors have reviewed and approved the final version of the manuscript and consent to its publication. Conflict of interest statement The authors declare that they have no conflicts of interest to disclose. Funding No funding was received from any public, commercial, or not-for-profit organizations for this research. Author Contribution Neofytos Mavris: Study design and conceptualization, data collection, data analysis, and manuscript drafting.Reem Agbareia: Data collection, data analysis, and manuscript drafting.Zvi Gur: Supervision, conceptual guidance, and critical revision of the manuscript.All authors read and approved the final manuscript. Acknowledgements None. Data Availability The datasets generated and analysed during the current study are not publicly available and cannot be shared, in accordance with the restrictions imposed by the institutional Helsinki Committee. References A T. Nuovo metodo conservatore dicura radicale delle soppurazioni croniche del sacco lacrimale (dacriocistorinostomia). Clin Moderna [Internet]. 1904 [cited 2024 Nov 8];10:385–7. 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Indian Journal of Otolaryngology and Head & Neck Surgery [Internet]. 2021 Oct 1 [cited 2025 Jul 12];74(Suppl 2):1433. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9702396/ Penttilä E, Smirnov G, Seppä J, Kaarniranta K, Tuomilehto H Mitomycin C in revision endoscopic dacryocystorhinostomy: A prospective randomized study. Am J Rhinol Allergy [Internet]. 2011 Nov [cited 2025 Jul 12];25(6):425–8. Available from: https://pubmed.ncbi.nlm.nih.gov/22185749/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9192494","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614870804,"identity":"7298ba8a-bbf9-4c1a-9b9d-11218a78a384","order_by":0,"name":"Neofytos Mavris","email":"","orcid":"","institution":"Hadassah Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Neofytos","middleName":"","lastName":"Mavris","suffix":""},{"id":614870807,"identity":"a4cb3260-36d6-40b6-9b7a-cf9ce1a151e0","order_by":1,"name":"Reem 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11:44:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88716,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003efollow up duration by outcome.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9192494/v1/f5f5d5111ecbebecc307e0a9.png"},{"id":106095373,"identity":"9ce51b9a-f27d-438e-b95c-87607508d18c","added_by":"auto","created_at":"2026-04-03 11:47:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ecomplication rate\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9192494/v1/289567a44500386ccd1975af.png"},{"id":106095109,"identity":"c96ae943-9b88-4ac2-963e-2243e7f1900a","added_by":"auto","created_at":"2026-04-03 11:44:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":39417,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003erevision surgery rate.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9192494/v1/6064b5478ff00fa17aa4822f.png"},{"id":106091960,"identity":"d3da1ad8-737f-469a-99be-11132d6938ee","added_by":"auto","created_at":"2026-04-03 11:17:12","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":43008,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003etime to early stent loss.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9192494/v1/0a64cd23e59db4e589e51a48.png"},{"id":106096555,"identity":"a98cf478-1bdf-4ae1-9ed8-f2ac005699bb","added_by":"auto","created_at":"2026-04-03 11:55:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9192494/v1/ded76d2b-5765-4316-a309-561c2409599a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Consequences of Premature Silicone Stent Loss Following Endonasal Dacryocystorhinostomy","fulltext":[{"header":"KEY MESSAGE","content":"\u003cp\u003e\u003cstrong\u003eCurrent evidence:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Silicone stenting is widely employed in endonasal dacryocystorhinostomy (enDCR) to maintain ostium patency; however, the optimal duration of stent retention and the clinical implications of premature stent loss remain uncertain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy findings:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Premature silicone stent loss (\u0026lt;2 months) following primary enDCR is not associated with reduced surgical success, with comparable outcomes observed relative to standard-duration stenting.\u003c/p\u003e\n\u003cp\u003ePremature stent loss is not associated with increased postoperative complications or higher rates of revision surgery, indicating that early loss does not adversely affect clinical outcomes.\u003c/p\u003e\n\u003cp\u003eThese findings support a conservative management approach following early stent loss and suggest that shorter stent-retention durations may be adequate in selected patients.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eDacryocystorhinostomy (DCR) remains the definitive surgical intervention to restore tear drainage in primary acquired nasolacrimal duct obstruction (PANDO) by creating a new tear passageway (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The evolution of DCR has seen a significant shift from external dacryocystorhinostomy (extDCR) to endonasal dacryocystorhinostomy (enDCR) approach, driven by advancements in endoscopic technologies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These technologies offer comparable efficacy to extDCR (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) while avoiding external scars, an important advantage for young patients (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe role of silicone stents in enDCR is contentious. While studies such as those by Fayers et al. demonstrate a higher success rate with stenting (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), other studies have reported equal surgical outcomes with and without stenting (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). There remains limited evidence regarding the impact of stent duration on surgical outcomes in enDCR (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Recommendations range from six weeks to six months, aiming at preventing fibrotic stenosis of the newly formed ostium (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt the Hadassah Medical Center, the common practice for enDCR involves bicanalicular intubation (BCI) using silicone stents. The stent is removed at least two months after the surgery.\u003c/p\u003e \u003cp\u003eGiven the varied practices and the absence of a consensus on the optimal duration for stent placement, this study aims to fill this significant gap by evaluating whether shorter stent durations can achieve outcomes equivalent to longer durations, in patients following primary enDCR.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was a retrospective study of adult patients (\u0026ge;\u0026thinsp;18 years) who underwent primary enDCR with BCI (Lacrimal Intubation Set, mdi Europa GmbH, Langenhagen, Germany) from August 2020 to December 2024 at Hadassah Medical Center. All patients demonstrated a confirmed PANDO, with or without coexisting dacryocystitis, prior to surgery. Demographic data, surgical details, complications, clinical outcomes, and the need for revision surgery were recorded. Patients were excluded in case of secondary DCR procedures, had incomplete or missing medical records, or had coexisting conditions (e.g., lacrimal trauma, primary nasolacrimal neoplasm, abnormal lid position, sarcoidosis) likely to impact the lacrimal drainage system. Ethical approval was obtained from the local institutional review board (Protocol Number 0493-24-HMO).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical approach\u003c/h2\u003e \u003cp\u003eAll procedures were conducted under general anesthesia. Nasal packing with adrenaline (1:10,000) was placed under the middle turbinate. The nasal cavity and operative area were sterilized using povidone-iodine. The nasal packing was removed, and the endoscope was inserted. Nasal decongestion was achieved with 2% lidocaine containing epinephrine at a 1:100,000 ratio.\u003c/p\u003e \u003cp\u003eOsteotomy was completed using Kerrison bone punch and Takahashi forceps, thus exposing the lacrimal sac. Following hemostasis, a crescent blade was used to incise and open the lacrimal sac from its most superior to its most inferior aspect. A Bowman probe was employed to evaluate the patency of the lacrimal drainage system. A bicanalicular silicone stent was pushed into place via both the lower and upper puncta using a metallic guide. Both ends of the stent were removed through the nose and tied with 3 square knots. Foam gel soaked in 40 mg/mL triamcinolone acetonide (Kenalog\u0026reg;, Bristol-Myers Squibb, USA) was compressed into the osteotomy site. The stent was then secured to the medial aspect of the lateral nostril using a Prolane single suture 5\u0026thinsp;\u0026minus;\u0026thinsp;0 (Ethicon, Johnson \u0026amp; Johnson, Somerville, NJ, USA). No antimetabolites were applied during any part of the procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was to evaluate the clinical impact of \u0026ldquo;premature\u0026rdquo; stent loss, defined as the loss or removal of the stent earlier than two months post-surgery, and compare it to those with no premature stent loss, \u0026ldquo;late\u0026rdquo;. Surgical success was defined as the absence of symptomatic tearing and/or infection or a patent lacrimal drainage system (confirmed via irrigation test) at least three months after surgery. Failure was characterized by continued epiphora, infection, or demonstrable obstruction upon lacrimal irrigation of both the upper and lower canaliculi.\u003c/p\u003e \u003cp\u003ePatients who did not have at least three months of in-person follow-up after surgery were contacted to evaluate any symptoms of epiphora. In the case of symptomatic epiphora, patients were invited for a follow-up visit to undergo a lacrimal irrigation test.\u003c/p\u003e \u003cp\u003eSecondary outcomes included incidence of premature stent loss, time to stent loss, complication, and revision surgery rates.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous data were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (IQR). Group comparisons used the Welch t-test (age), Wilcoxon rank-sum test (follow-up), and Fisher\u0026rsquo;s exact test (categorical variables). Kaplan\u0026ndash;Meier estimation assessed time to premature stent loss. A two-sided P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. Analyses were performed in R 4.4.2.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 107 eyes from 107 patients (78 females, 72.9%) who underwent primary enDCR with bicanalicular silicone stenting met the inclusion criteria. The mean patient age was 60.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall descriptive characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u0026ndash; mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.3 (17.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (72.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up \u0026ndash; median (IQR), days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e239 (137\u0026ndash;592)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccess \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (86.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision surgery \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePrimary Outcomes\u003c/h3\u003e\n\u003cp\u003eAt a median follow-up of 239 days (IQR: 137\u0026ndash;592), the overall surgical success rate was 86.9% (93/107 eyes). Premature stent loss occurred in 21 eyes (19.6%), with a median time to loss of 14 days (range: 6\u0026ndash;35).\u003c/p\u003e \u003cp\u003eSurgical success was comparable between the premature and late stent loss groups. Specifically, success was achieved in 18 of 21 eyes (85.7%) in the premature loss group and 75 of 86 eyes (87.2%) in the late group (P\u0026thinsp;=\u0026thinsp;1.00; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEarly vs Late comparisons.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u0026ndash; mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.7 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.0 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (74.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up \u0026ndash; median (IQR), days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e305 (190\u0026ndash;571)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e230 (129\u0026ndash;592)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccess \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (87.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e~\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision surgery \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComplications and Reoperations\u003c/h2\u003e \u003cp\u003ePostoperative complications were rare, occurring in 3 of 107 eyes (2.8%). Complication rates did not differ significantly between the premature (1/21 eyes; 4.8%) and late stent groups (2/86 eyes; 2.3%) (P\u0026thinsp;=\u0026thinsp;0.48).\u003c/p\u003e \u003cp\u003eRevision surgery was performed in 13 eyes (12.1%) overall. The rate of revision was slightly higher in the premature group (3/21 eyes; 14.3%) than in the late group (10/86 eyes; 11.6%), though this difference was not statistically significant (P\u0026thinsp;=\u0026thinsp;0.72). The median follow-up duration was 305 days (IQR: 190\u0026ndash;571) in the premature group and 230 days (IQR: 129\u0026ndash;592) in the late group.\u003c/p\u003e \u003cp\u003eKaplan\u0026ndash;Meier analysis indicated that most premature stent losses occurred within the first 30 days postoperatively \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e However, premature stent loss was not associated with an increased risk of surgical failure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDemographic Comparisons\u003c/h3\u003e\n\u003cp\u003eNo significant demographic differences were identified between the premature and late groups. Patients with premature stent loss were slightly older (mean age: 65.7 vs. 59.0 years; P\u0026thinsp;=\u0026thinsp;0.099) and had a lower proportion of females (66.7% vs. 74.4%; P\u0026thinsp;=\u0026thinsp;0.584), but these differences did not reach statistical significance \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings from our study provide important insights into the clinical consequences of premature silicone stent loss following primary enDCR with bicanalicular intubation. Our results demonstrate that premature stent loss, occurring in 19.6% of patients with a median time of 14 days postoperatively, was not associated with reduced surgical success rates when compared to patients who retained their stents for the intended two-month period. This finding challenges the assumption that premature stent loss necessarily compromises surgical outcomes in enDCR.\u003c/p\u003e \u003cp\u003eThe overall success rate of 86.9% in our cohort is consistent with previously reported outcomes for enDCR, which typically range from 82\u0026ndash;95% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Importantly, the comparable success rates between the premature (85.7%) and late (87.2%) stent loss groups (P\u0026thinsp;=\u0026thinsp;1.00) suggest that the duration of stent retention may be less critical than previously believed. This finding aligns with the landmark study by Vicinanzo et al., who reported similar results in external DCR, where 18% of patients experienced premature stent loss with a 90.5% success rate compared to 95.8% in those without premature loss (P\u0026thinsp;=\u0026thinsp;0.24) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe temporal pattern of stent loss observed in our study, with most occurring within the first 30 days postoperatively, is consistent with other reports in the literature (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This premature loss pattern suggests that factors influencing stent retention are primarily related to the immediate postoperative period, including patient compliance, anatomical factors, and healing characteristics, rather than the inherent properties of the stent itself.\u003c/p\u003e \u003cp\u003eSeveral mechanisms may explain why premature stent loss does not necessarily compromise surgical outcomes in enDCR. First, the primary function of bicanalicular stents is to maintain ostium patency during the critical healing period when fibrosis and granulation tissue formation are most likely to occur (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, recent evidence suggests that the most crucial period for maintaining ostium patency may be shorter than traditionally assumed. Studies examining premature stent removal have demonstrated that even planned removal at 2 weeks postoperatively can achieve success rates comparable to standard 6-week protocols (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSecond, the endoscopic approach itself may provide advantages that reduce dependence on prolonged stent retention. Unlike external DCR, the endonasal approach allows for better visualization and management of the nasal cavity, potentially reducing the formation of synechiae and granulation tissue that could lead to ostium closure (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Additionally, the preservation of the medial canthal ligament and pump function in enDCR may contribute to better long-term outcomes regardless of stent duration (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe success of DCR surgery depends on multiple factors beyond stent duration. These results suggest that the initial surgical technique, adequate osteotomy size, and proper mucosal handling may be more important determinants of success than stent retention time. Studies have shown that factors such as the size and location of the rhinostomy, the quality of mucosal flaps, and the prevention of excessive scarring play crucial roles in long-term success (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe role of postoperative inflammation and healing response should not be underestimated. Research has demonstrated that excessive fibrosis and granulation tissue formation are primary causes of DCR failure (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The use of adjuvant therapies such as mitomycin C has been shown to reduce fibrosis and improve success rates, particularly in revision cases (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, our study suggests that in primary enDCR, the natural healing process may be sufficient to maintain ostium patency even without prolonged stent support.\u003c/p\u003e \u003cp\u003eThe literature on premature stent loss in external DCR provides valuable context for our findings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Limbu et al.'s randomized controlled trial demonstrated no significant difference in outcomes between 2-week and 6-week stent removal protocols in external DCR (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These findings, combined with our results, suggest that the phenomenon of successful outcomes despite premature stent loss is consistent across different DCR techniques.\u003c/p\u003e \u003cp\u003eOur low complication rate (2.8%) and revision rate (12.1%) are consistent with reported outcomes for enDCR (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The slightly higher revision rate in the premature stent loss group (14.3% vs. 11.6%) did not reach statistical significance, suggesting that premature stent loss does not substantially increase the risk of surgical failure requiring reintervention. This finding is particularly important for patient counseling, as it indicates that patients experiencing premature stent loss can be reassured that their risk of requiring revision surgery is not significantly elevated.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged in interpreting our results. First, our study is retrospective, which may introduce selection bias and limit the ability to control for confounding variables. Second, we did not perform a formal sample size calculation; instead, all eligible cases treated at our centre during the study period were included, which may limit the statistical power to detect small differences between groups. Third, the definition of \"premature\" stent loss as less than two months may not capture the optimal duration for stent retention. Future prospective studies examining different time intervals for stent removal could provide more definitive guidance on optimal stent duration.\u003c/p\u003e \u003cp\u003eBased on our findings, we recommend that patients with premature stent loss can generally be managed conservatively, with reintervention guided by symptoms and endoscopic findings rather than the timing of loss. Furthermore, our results support the consideration of shorter stent retention protocols in selected patients, particularly those at low risk for complications. This approach could reduce stent-related complications, improve patient comfort, and decrease healthcare resource utilization while maintaining comparable surgical success rates.\u003c/p\u003e \u003cp\u003eIn conclusion, our study demonstrates that premature silicone stent loss following primary enDCR does not significantly compromise surgical outcomes. These findings challenge traditional assumptions about the necessity of prolonged stent retention and suggest that the current practice of routine stent replacement following premature loss may not be warranted. Future prospective studies examining optimal stent duration and the role of patient-specific factors in determining stent requirements will further refine our understanding of this important clinical issue.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003e \u003cb\u003eCompeting Interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare no relevant financial or non-financial conflicts of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study was approved by the Hadassah Medical Center Ethics Committee (Jerusalem, Israel) under approval number HMO-0408-21. The requirement for written informed consent was waived because the study used de-identified data from existing medical records.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eAll authors have reviewed and approved the final version of the manuscript and consent to its publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of interest statement\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received from any public, commercial, or not-for-profit organizations for this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNeofytos Mavris: Study design and conceptualization, data collection, data analysis, and manuscript drafting.Reem Agbareia: Data collection, data analysis, and manuscript drafting.Zvi Gur: Supervision, conceptual guidance, and critical revision of the manuscript.All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available and cannot be shared, in accordance with the restrictions imposed by the institutional Helsinki Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eA T. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/22185749/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/22185749/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"dacryocystorhinostomy, nasolacrimal duct obstruction, silicone stent, lacrimal intubation, surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9192494/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9192494/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePremature silicone stent loss after primary endonasal dacryocystorhinostomy (enDCR) may affect lacrimal drainage surgery outcomes, but its impact on surgical success is uncertain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine whether premature silicone stent loss (\u0026lt;2 months) after primary enDCR affects surgical success.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle-centre retrospective cohort study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle-centre retrospective cohort conducted at Hadassah Medical Center, including adults with primary acquired nasolacrimal duct obstruction who underwent primary enDCR with bicanalicular intubation between August 2020 and December 2024. The primary outcome was surgical success -absence of symptomatic epiphora/infection and/or patent lacrimal irrigation - assessed ≥3 months postoperatively. Outcomes were compared between eyes with “premature” stent loss and those without (“late”).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe included 107 eyes (mean age 60.3±17.8 years; 72.9% female). Median follow-up was 239 days (IQR 137–592). Premature stent loss occurred in 21 eyes (19.6%), with a median time to loss of 14 days (range 6–35). Overall surgical success was 86.9% (93/107). Success was comparable between premature and late groups: 85.7% (18/21) vs 87.2% (75/86), p=1.00. Complications were uncommon (2.8% overall) and similar between groups (4.8% vs 2.3%, p=0.48). Revision surgery was required in 12.1% overall (14.3% premature vs 11.6% late, p=0.72). Most premature losses occurred within 30 days, and early loss was not associated with surgical failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn primary enDCR with bicanalicular intubation, premature stent loss within two months was not associated with reduced surgical success or higher reoperation rates. Conservative management with close follow-up is reasonable after early loss, and shorter stent-retention protocols may be considered; prospective studies should define the optimal duration.\u003c/p\u003e","manuscriptTitle":"Consequences of Premature Silicone Stent Loss Following Endonasal Dacryocystorhinostomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 11:17:08","doi":"10.21203/rs.3.rs-9192494/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53c2a5d8-1236-4d59-8b3c-97ecd2c0b3a2","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-03T11:17:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 11:17:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9192494","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9192494","identity":"rs-9192494","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}