Laser hemorrhoidoplasty (LHP) using a 1470nm radial fiber laser - early efficacy assessment based on your own data



 Introduction.

 Hemorrhoidal disease is one of the most common colorectal diseases. There are many ways to treat it, but the most common surgical procedure is Milligan-Morgan hemorrhoidectomy.

Objective of the work. The aim of the study was to compare the effectiveness of the more frequently performed Milligan-Morgan surgery and laser hemorrhoidoplasty with the use of a 1470 nm radial laser. The following variables were considered: length of procedure, procedure-related hospitalization time, patient pain after the procedure, and time to return to normal daily activity.

Materials and methods.

 The study group consisted of 178 patients, of which 82 underwent laser haemorrhoidoplasty and 96 patients operated on with the Milligan-Morgan method. 45% of the group were women, 55% men. The mean age of the patients was 50 years, the youngest patient was 19, the oldest 65. The mean age of the patients was lower in the LHP surgery group (54.23 vs 45.15 years). Patients were followed up for an average of 14 months (range 3-35 months).

RESULTS: The mean LHP operation time was shorter than that of the Milligan-Morgan method (13.9 vs 22.3 min). It was not necessary to reoperate after LHP surgery, while after the classic hemorrhoidectomy it was necessary to reoperate three times. The average return to work time after LHP surgery was 14 days (the shortest 5 days), after classic hemorrhoidectomy it was 21 days (the shortest 15 days). After Milligan-Morgan surgery, 51% of patients required opioid analgesics and no such treatment was required after LHP surgery.

CONCLUSIONS: The LHP method is an effective method for treating grade II-IV hemorrhoidal disease and is associated with less pain than classic hemorrhoidectomy. The time of surgery and hospitalization after LHP is shorter than that after surgery with the Milligan-Morgan method. Recovery time for normal daily activities is also shorter.


 Hemorrhoidal disease is one of the most common colorectal conditions. Although many treatment methods have been developed, Milligan-Morgan hemorrhoidectomy remains the most widely practiced surgical technique.

Scope. The aim of this study was to compare the efficacy of Milligan-Morgan hemorrhoidectomy and laser hemorrhoidoplasty using a 1470 nm radial fiber laser. The following variables were analyzed: length of procedure, length of hospital stay related to the procedure, postoperative pain, and time to return to normal daily activities.

MATERIAL AND METHODS.

 The study group included 178 patients (women 45%, men 55%), including 82 patients undergoing laser hemorrhoidoplasty and 96 patients undergoing Milligan-Morgan hemorrhoidectomy. The mean age of the patients was 50 years, with the youngest patient 19 years old and the oldest patient 65 years old. The mean age of the patients was lower in the laser hemorrhoidoplasty group (54.23 vs 45.15 years). The mean follow-up was 14 months (3-35 years).

RESULTS.

The mean duration of laser hemorrhoidoplasty was shorter than that of Milligan-Morgan hemorrhoidectomy (13.9 vs 22.3 min). Revision surgery was not required after laser haemorrhoidoplasty, while in three cases a new surgery was required after classic haemorrhoidectomy. The average and shortest time to return to work was 14 and 5 days for laser hemorrhoidoplasty compared to 21 and 15 days for classic hemorrhoidectomy, respectively. Opioid analgesics were required in 51% of patients after Milligan-Morgan haemorrhoidectomy and none of the patients after laser haemorrhoidoplasty.

CONCLUSIONS.

 Laser hemorrhoidoplasty is an effective therapeutic approach in grade II-IV hemorrhoidal disease. It is associated with less pain than conventional hemorrhoidectomy. The length of the procedure itself and hospital stay is shorter after laser hemorrhoidoplasty than with Milligan-Morgan hemorrhoidectomy. The return to normal daily activities is also faster in the first case.

INTRODUCTION

Hemorrhoidal disease is the most common colorectal condition. The estimated prevalence is 2.9-27.9%, including more than 4% of symptomatic patients (1). The occurrence of symptoms does not always involve reporting the patient to a general practitioner or directly to a general surgeon. This is most likely due to the embarrassment caused by the location of the disease. Most often, patients with long-term symptoms try to self-medicate with over-the-counter medications.

Common symptoms of hemorrhoidal disease include bleeding during bowel movements, irritation around the anal area, and prolapsed hemorrhoids. While not always severe, these symptoms help reduce the quality of life.

Therapeutic approaches in hemorrhoidal disease can be classified as conservative and surgical. It is estimated that up to 85% of patients can be successfully treated with conservative methods (2). Other patients require interventional management (instrumental or surgical).

Instrumental methods include, among others (3):

- Barron's elastic ligature (1963) (4)

- sclerotherapy,

- infrared coagulation.

These are outpatient instrumental approaches, which can be performed without the need for a hospital stay. They are recommended for patients with grade I-III hemorrhoids; however, each of these techniques has its own indications and contraindications.

The 2018 American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines for Hemorrhoid Management, published in "Diseases of the Colon & Rectum," are current guidelines that standardize management in a patient with the disease. hemorrhoidal (3). They strongly emphasize the role of diet and lifestyle modification, as well as present data on pharmacotherapy. Modification of diet and lifestyle plays a crucial role in both conservative treatment and pre- and post-operative management.

Surgical approaches include conventional hemorrhoidectomy, which can be classified as open (Milligan-Morgan) and closed (Ferguson). Although no significant benefit of Milligan-Morgan hemorrhoidectomy has been shown in many studies and, conversely, the Ferguson method has been shown to produce better therapeutic results, open hemorrhoidectomy remains the most common conventional procedure (2). Laser hemorrhoidoplasty (LHP), which uses a 1470 nm radial fiber laser, also falls into the group of surgical techniques.

We present data based on a study and follow-up in 82 patients after laser hemorrhoidoplasty. The results obtained were compared with the results of the treatment of Milligan-Morgan hemorrhoidectomy, which is the most used surgical technique in our country for the treatment of hemorrhoidal disease. The latter approach was used in 96 patients.

SCOPE

The purpose of this study was to compare the efficacy of conventional hemorrhoidectomy and laser hemorrhoidoplasty for procedure duration, procedure-related hospital stay, postoperative pain, and time to return to normal daily activities.

MATERIAL AND METHODS

The study group included a total of 178 patients (80 women and 98 men) aged 19 to 65 (mean age 50), who underwent surgery due to grade I-IV hemorrhoidal disease. This group included 96 patients (54%) who underwent the Milligan-Morgan procedure due to haemorrhoidal disease, while other patients (46%, n = 82) were treated with a radial fiber laser.

Patients treated with the Milligan-Morgan (MM) method were admitted to a general surgery department of a district hospital (patients operated by a team of doctors operating in a specific department), while those treated with the laser method were admitted to a private facility (all patients were operated on by the study authors). This is because LHP is not reimbursed and can only be used in private medical centers. Patients undergoing the MM procedure were included in group 1 and those treated with LHP were included in group 2.

The average follow-up was at least 3 months (from December 2017 to July 2020). The mean follow-up was 14 months (3-35 months).

Enrollment in the study was done in parallel with qualifying for surgery. All patients completed a preoperative questionnaire prior to initiation of treatment (Appendix 1). Subsequently, a follow-up was carried out by the doctor, who entered the data in the patient's file on the basis of the information obtained from the patient.

Fig. 1. Grade IV haemorrhoidal disease qualified for Milligan-Morgan haemorrhoidectomy


RESULTS

Complete responses were obtained from 178 patients. A total of 80 women (45%) and 98 men (55%) participated in the study. Males represented the majority of patients in both groups, i.e. 50 (52%) men in group 1 and 48 (58.6%) men in group 2. There were 46 (48%) women in group 1 and 34 (41.4%) in the group 2 group.

The mean age of the patients was higher in group 1 (54.23 years) than in group 2 (45.15 years). The upper age limit was also lower in group 2 (58 years) than in group 1 (65 years)

Tab. 1. Comparison of group variables 1 (MM) and 2 (LHP)
 MMLHP
Number of patients9682
Females46 (48%)34 (41.4%)
Males50 (52%)48 (58.6%)
Mean age (years)54.2345.15
The youngest patient (years)3119
The oldest patient (years)6558
Median age (years)5442
It was also found from patients' medical records that comorbidities and chronic pharmacotherapy were less common in group 2. In both groups, these were mostly medications for cardiovascular diseases. Patients with comorbidities accounted for 69.8% (n = 67) in group 1 and 45.1% (n = 37) in group 2.
Five most common comorbidities reported by our patients are summarized in table 2.
Tab. 2. Five most common comorbidities in groups 1 (MM) and 2 (MM)
ComorbiditiesMMLHP
Hypertension5226
Ischaemic heart disease51
Diabetes mellitus219
Hypercholesterolaemia85
Depression116
Medical history of comorbidities was collected directly from patients and their medical records from previous hospital stays and follow-up visits.
Patients with grade IV haemorrhoidal disease accounted for the majority of group 1 (52.1%). Most patients in group 2 (64.6%) presented with grade III haemorrhoids. The smallest group of patients in groups 1 (10.4%) and 2 (3.7%) were those with grade II and grade IV haemorrhoids, respectively.
The mean duration of surgery was shorter in group 2 (13.9 min) compared to group 1 (22.3 min). The surgical treatment in group 1 was longer despite the fact that three haemorrhoidal columns were usually managed in both these groups (87.5% in group 1 vs. 91.5% in group 2) (Table 3).
Tab. 3. Comparison of the main features of operations performed in group 1 (MM) and group 2 (LHP)
  MMLHP
GradeGrade II10 (10.4%)26 (31.7%)
 Grade III36 (37.5%)53 (64.6%)
 
 Grade IV50 (52.1%)3 (3.7%)
Combined procedures 8 (8.3%)10 (12.2%)
Mean surgery time [minutes] 22.313.9
Number of columns managed11 (1.04%)2 (2.4%)
 24 (4.16%)5 (6.1%)
 384 (87.5%)75 (91.5%)
 47 (7.3%)0
Combined procedures were used in 84 patients in group 1 (97.7%) and 19 patients in group 2 (23.17%).
In group 1, these were:
- excision of a chronic anal fissure with superficial sphincterotomy of the internal sphincter fibers - 5 cases,
- excision of skin tags - 79 cases.
In group 2, these were:
- excision of a chronic anal fissure + botulinum toxin injection into the internal anal sphincter - 5 cases,
- recto anal repair (RAR) - 5 cases,
- excision of hypertrophied anodermal folds - 9 cases.
Excision of hypertrophied skin tags was also considered a combined procedure in group 1, although it is a common element of such interventions.
The need for a revision surgery after both procedures was another compared parameter. There was no need for reoperation in any of the patients in group 2. In group 1, reoperation was needed in 3 patients on the first day after surgery due to bleeding. The bleeding was caused by inaccurate ligation of the vascular pedicle.


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