Article Type : Case Report
Authors : Irfan Sattar
Keywords : Hemorrhoidoplasty; Subepithelial plexus; Hemorrhoids
Introduction: Hemorrhoids disease is the
commonest disease of the rectum and anal canal. The worldwide prevalence ranges
from 2.9% to 27.9%, of which more than 4% are symptomatic. Bleeding from the
rectum which is painless and associated with episodes of defecation is the most
common complaint by patients with hemorrhoids. Multiple treatment options for
symptomatic hemorrhoids are available worldwide which includes conservative
medical management with dietary modifications and topical therapy using
emollients, non-surgical treatments and various surgical techniques. But most
of these surgical procedures are associated with significant postoperative pain
, delayed return to normal activities and readmissions , that’s why the
surgeons are shifting to minimally invasive laser therapy for symptomatic
hemorrhoids as laser hemorrhoidoplasty is associated with less postoperative
pain, shorter operative time and early return to work. The aim of this study
was to evaluate the clinical results of Laser Hemorrhoidoplasty for symptomatic
hemorrhoids.
Material and Methods: This is a
retrospective single center observational study of 70 patients who underwent
laser hemorrhoidoplasty for symptomatic hemorrhoids in a period of 20 months between
june 2021 to January 2023. All the laser hemorrhoidoplasty procedures were done
by me personally at Phoenix Hospital Abu Dhabi, United Arab Emirates. Patients
with symptomatic haemorrhoids of grade II - IV were included in the study. The
patients were followed up after 1 week, 3 week and 3 months for the evaluation
of clinical results.
Results: Most of the patients are in the
age group of 24 - 47 years. In the study male patients were found to be more
90% as compared to female 10%. The most common severity of disease presentation
was grade three (71.5%) followed by grade four (18 %) then grade two
(10.5%).The average operative time observed for the laser hemorrhoidoplasty was 34 minutes and
the mean hospital stay was 18 hours. Postoperatively on the 1st day 93 % of
patients developed mild pain after the procedure, only 7% of the patients have
moderate to severe pain. Postoperatively after one week around 60% of the
patients have mild pain and discomfort on defecation only, although 40% of the
patients have no pain at all. At three week time only 5% of the patients have
mild discomfort on defecation only, no patient have actual pain at this time.
Post laser hemorrhoidoplasty mild bleeding in the form of spotting after
defecation was seen in 60% of patients but only 12% continued spotting till one
week, 35% of the patients had no bleeding after the procedure at all. No
patient had bleeding complain at the three week time.
Conclusion: Our study demonstrated that
the minimally invasive Laser hemorrhoidoplasty (LHP) technique for the
management of hemorrhoids is associated with shorter operative time, less
postoperative pain and bleeding, has the advantage of short hospital stay and
faster recovery. However Larger randomized long term studies are required to
demonstrate the exact recurrence rates and patient satisfaction.
Hemorrhoids disease is the commonest disease of the
rectum and anal canal. The worldwide prevalence ranges from 2.9% to 27.9%, of
which more than 4% are symptomatic [1,2]. The prevalence of hemorrhoids
increases with age, with a peak incidence in persons aged 45-65 years with
subsequent decline after 65 years [3,4]. Men are more frequently affected than
women [5]. Hemorrhoids are basically anorectal submucosal vascular cushions
which turn out to be pathological giving rise to bleeding, pain and protrusion
outside the anal canal. Hemorrhoids can both be external and internal based
upon whether they are below or above the dentate line, while internal
hemorrhoids arise from the subepithelial plexus in the anal canal above the
dentate line, external hemorrhoids are vascular plexuses present outside and
covered with skin [6]. Internal hemorrhoids can be classified into four grades
according to the degree of prolapse although the symptoms may not be conducive
with the extent or severity of patients' sufferings [7]. Hemorrhoids may have
varied clinical presentations such as bleeding, pain, mucus discharge, itching
and something coming out of the rectum [8]. Bleeding from the rectum which is
painless and associated with episodes of defecation, is the most common
complaint by patients with hemorrhoids. The severity can lead to continuous
severe bleeding and anaemia, thrombosed hemorrhoids, prolapsed with edema, or
strangulation. The exact cause of hemorrhoids is unknown. Hemorrhoids are
considered to be due to the downward displacement of suspensory (Treitz) muscle
[9,10]. A lot of pressure is put on human rectal veins due to our upright
posture, which can potentially cause bulging. Other contributing factors
include aging, chronic constipation or diarrhea, Pregnancy, Heredity, Straining
during bowel movements.
Multiple treatment options for symptomatic hemorrhoids
are available worldwide which includes conservative medical management with
dietary modifications and topical therapy using emollients, non-surgical
treatments and various surgical techniques. The various non-surgical treatments
include rubber band ligation, injection sclerotherapy, cryotherapy, infrared
coagulation and diathermy coagulation, all of which may be performed as
outpatient procedures without anaesthesia. These nonsurgical methods are
considered to be the primary option for grades one to three (grade I-III)
hemorrhoids [11]. If conservative measures fail to control symptoms, should be
considered for surgical treatment. These procedures include ligation, fixation,
excision, or a combination of these approaches. Because most internal
hemorrhoid symptoms are due to tissue prolapse, ligation and fixation
procedures effectively scar the mucosa to the underlying sphincter so tissue
can no longer prolapse. The technique employed may be open (Milligan–Morgan) or
closed (Ferguson). Milligan-Morgan hemorrhoidectomy is still the gold standard
and frequently performed procedure for symptomatic hemorrhoids [12]. However, the technique is associated with
significant postoperative pain leading to delayed return to normal activities
and readmissions. Other techniques of hemorrhoid surgery involve using devices
such as stapler or Doppler guided transanal hemorrhoid ligation or procedures
such as laser therapy. The pain is the commonest postoperative problem
associated with the surgical techniques. The other early complications are bleeding,
urinary retention and subcutaneous abscess. The long-term complications include
anal fissure, anal stenosis, incontinence, fistula and recurrence of
hemorrhoids [13,14]. Because of the significant postoperative pain , delayed
return to normal activities and readmissions , the surgeons are shifting to
minimally invasive laser therapy for symptomatic hemorrhoids, as laser
hemorrhoidoplasty is associated with less postoperative pain , shorter
operative time and early return to work [15]. Laser hemorrhoidoplasty is a
relatively emerging new procedure in UAE for hemorrhoid treatment in which the
hemorrhoidal blood flow is coagulated by the laser. Due to an intense amount of
heat, the laser beam cauterizes and seals off the blood vessels, therefore the
hemorrhoids will simply shrink while reducing the risk of excessive bleeding
during and after the procedure. However, against all the benefits, specific
training and precaution measurements are required to use the laser therapy.
However surgeons must use the goggles to protect their eyes from invisible
radiations produced by laser [16,17].
This is a retrospective single center observational
study of 70 patients who underwent laser hemorrhoidoplasty for symptomatic
hemorrhoids in a period of 20 months between june 2021 to January 2023. All the
laser hemorrhoidoplasty procedures were done by me personally with the help of
a nursing assistant in Phoenix Hospital Abu Dhabi, United Arab Emirates.
Phoenix hospital is a 50 bed private hospital and I am working here as a
specialist general surgeon with seventeen years’ experience of post fellowship
in general surgery. Patients with symptomatic hemorrhoids of grade II - IV were
included in the study. The diagnosis was established in OPD with a full history,
physical examination, per rectal examination and proctoscopy. Routine
preoperative investigations which were performed include complete blood count,
random blood sugar, serum creatinine, urine analysis and coagulation profile
with addition of chest X-ray and ECG for the patients above the age of 40
years. The two most common symptoms of patients’ presentation were bleeding and
intermittent prolapse with defecation. An Informed written consent was obtained
from the patients after detailed explanation about the laser technique and
potential risks of the procedure. All the patients were given pre-operative
prophylactic antibiotic with Single dose of cefuroxime (1.5 gm.) and
metronidazole (500 mg) intravenously 30 minutes before the surgery. The
operation was performed under spinal anaesthesia in lithotomy position. In the
operative technique used for procedure, lubricated split proctoscope was
introduced into the anus and the hemorrhoid positions identified at all three
columns. Prior to laser therapy 5 - 7 ml
of normal saline injected in the
sub-mucosal plane up to the dentate line
through a puncture at the mucocutaneous
junction to avoid injury to the surrounding structures. The laser fibre probe
was introduced into the middle portion of the hemorrhoidal plexus through the
same entry point at the mucocutaneous junction and advanced in the hemorrhoidal
plexus parallel to the anal canal up to above the dentate line. Then the laser
fibre withdrawn gradually by delivering the laser shots in a pulse fashion at a
power of 8W with the duration of 3 s each shot followed by a pause of 1 s
(Swing 12 Metrum cryoflex diode laser conical fibre 1470 nm was used), again
the laser fibre advanced in the hemorrhoidal plexus parallel to the anal canal
up to above the dentate line in the upper direction and lower direction
respectively and withdrawn gradually by delivering the laser shots in the
hemorrhoidal plexus. Total of 10 – 12 shots of laser was delivered to one
hemorrhoidal plexus. After the laser shots an ice finger was applied intra
anally for 3–4 minutes to minimize the harmful effect of heat. This procedure
was repeated for each hemorrhoid. The total energy given to all hemorrhoids
ranged from 600 to 1500 joules depending on the number and size of the
hemorrhoids. At the end of the procedure bleeding checked and lidocaine soaked
anal pack was placed in the anal canal which was removed after 12 hours with
sitz bath. The patient was discharged home within 12 - 24 hours with local
lubricant cream, analgesics and laxatives to keep the stool soft for next one
week. The patients were followed up after 1 week, 3 week and 3 months.
Postoperative pain was observed by using a 10-point visual analog scale (VAS)
on which 0 represents no pain and 10 represents the worst pain imaginable.
A total number of 70 patients were included in this
study that underwent laser hemorrhoidoplasty for symptomatic hemorrhoids in a
period of 20 months from June 2021 to January 2023. Most of the patients are in
the age group of 24 – 47 years, ranging from 21 to 64 years. In the study male
patients were found to be more (63) 90 % as compared to female (7) 10%. The
most common severity of disease presentation was grade three (71.5%) followed
by grade four (18 %) then grade two (10.5%). The average operative time
observed for the laser hemorrhoidoplasty was 34 minutes, ranging from 22 to 50
minutes and the mean hospital stay was 18 hours, ranging from 12 to 24 hours
(majority of the patients got discharged within 18 hours). All the patients
were followed up in outpatient department after 1 week, 3 week and 3 months.
Postoperative pain was observed by using a 10-point visual analog scale (VAS)
on which 0 represents no pain and 10 represents the worst pain imaginable.
Postoperatively on the 1st day 93% of patients developed mild pain after the
procedure, 7% of the patients have moderate to severe pain controlled by
injectable analgesia which replaced by oral analgesia at the time of discharge
from hospital. Postoperatively after one week around 60% of the patients have
mild pain and discomfort on defecation only, although 40% of the patients have
no pain at all. At three week time only 5% of the patients have mild discomfort
on defecation only, no patient have actual pain at this time.
Post laser hemorrhoidoplasty mild bleeding in the form
of spotting after defecation was seen in 60% of patients but only 12% continued
spotting till one week, 35 % of the patients had no bleeding after the
procedure at all, although two of the patients have moderate bleeding on the
first day which was managed conservatively by packing only, one patient
presented in emergency department after one week with severe bleeding and clots
which was also managed by packing conservatively. No patient had bleeding complain
at the three week time.
No patients developed any infection, anal fistula,
stenosis or fecal incontinence after laser procedure this study. Although 4
patients developed urinary retention after laser procedure which was relieved
by Foleys catheterization and 10 % of the patients have mild constipation up to
1 – 2 week time which was managed by oral laxatives.
At the 3 months visit time 60 % of the patient did not
follow up, but out of remaining 40% of the patients only one patient had
recurrence as second degree hemmorrhoids, no patient had history of bleeding,
pain, stenosis or incontinence at this time.
Hemorrhoids disease is the commonest disease of the
rectum and anal canal. The worldwide prevalence ranges from 2.9% to 27.9%, of
which more than 4% are symptomatic [1,2]. Hemorrhoids may have varied clinical
presentations such as bleeding, pain, mucus discharge, itching and something
coming out of the rectum [8]. The severity can lead to continuous severe
bleeding and anemia, thrombosed hemorrhoids, prolapsed with edema, or
strangulation. There are many methods of HD treatment ranging from
conservative, band ligation, sclerotherapy, stapled hemorrhoidopexy, Doppler
guided transanal hemorrhoid artery ligation (THD), laser photocoagulation to
Milligan Morgan (MM). MM is still the
gold standard and most frequently used procedure with respect to long term
patient outcomes [18,19]. However, compared with the less invasive methods of
treatment, its use is associated with high post-operative pain scores and
slower return to work [19,20]. Laser hemorrhoidoplasty is a relatively emerging
new procedure with less postoperative pain, shorter operative time and early
return to work [15]. In this retrospective study also, we noticed remarkably
good results in terms of postoperative pain, operative time and early return to
work.
Postoperatively on the 1st day 93 % of patients
developed mild pain, 7 % of the patients have moderate to severe pain,
postoperatively after one week 60 % of the patients have mild pain and
discomfort on defecation, although 40 % of the patients have no pain at all
after one week. At three week time only 5 % of the patients have mild
discomfort on defecation only, which is almost consistent with Abdallah
Abdulkarim study from Aga khan hospital which showed 85.7% of the patients had
mild pain scores after LHP, 4.8% of patients had moderate pain score and 9.5%
had severe pain scores [15]. In another study by Masson, hemorrhoidectomy with
lasers is known to cause less postoperative pain compared to other surgical
methods such as open hemorrhoidectomy [21].
The average operative time observed for the laser
hemorrhoidoplasty in this study was 34 minutes, which is near to the results of
Abdallah Abdulkarim which showed mean operative times of 29.67 minutes [15]
which is also explained by Simillis et al. and Alsisy et al where the authors
noted decreased operative time when comparing laser hemorrhoidoplasty to open
hemorrhoidectomy [19].
Postoperatively duration of hospital was ranging from
12 to 24 hours (majority of the patients got discharged within 18 hours) which
is similar to the many other studies like by by Sankar MY , the lower length of
hospitalization in the laser group was significant [22].
In our study mild bleeding in the form of spotting
after defecation was seen in 60% of patients but only 16% continued spotting
till one week, 35 % of the patients had no bleeding after the procedure at all.
In laser hemorrhoidoplasty the post-operative bleeding is very less as seen in our
study and also mentioned by Jahanshahi et al. who reported that laser is a safe
technique for the treatment of hemorrhoids due to less postoperative
complications such as bleeding, pain, stenosis, and recurrence [23]. Shu YU Lim
also revealed in his study that postoperative bleeding rarely occurred in the
post-operative period of 6 weeks [24].
The other postoperative complications like delayed
bleeding, anal fistula, acute infection, anal fissure, anal stenosis or
incontinence were not observed in any of our patients within three months after
surgery. There was no recurrence of the disease during the three months and a
complete remission was observed in all cases and also no patient from our study
required redo operation. In this study, one patient developed thrombosis three
days after the laser surgery that was successfully treated with medications.
Two patients had early postoperative urine retention that was managed by
insertion of Foley's catheter. The patient with laser hemorrhoidoplasty
recovers easily and early as seen in our study, and also mentioned in the study
by Sankar, postoperative recovery period was significantly lower than other
surgical procedures such as open surgery [22]. LHP is a relatively new
technique for the hemorrhoidal treatment and the surgeons are still in the
learning curve. Despite that, the early outcomes of LHP are satisfactory in
terms of postoperative bleeding, pain and recurrence. Larger randomized long
term studies are required to demonstrate the exact recurrence rates and patient
satisfaction. Limitations in our study include the short period of follow up
and there was no direct comparison done to other techniques like gold standard
open Milligan Morgan surgery.
Our study demonstrated that the minimally invasive
Laser hemorrhoidoplasty (LHP) technique for the management of hemorrhoids is
associated with shorter operative time, less postoperative pain and bleeding,
has the advantage of short hospital stay and faster recovery. However Larger
randomized long term studies are required to demonstrate the exact recurrence
rates and patient satisfaction.