Laser Hemorrhoidoplasty Procedure vs Open Surgical Hemorrhoidectomy: a Trial Comparing 2 Treatments for Hemorrhoids of Third and Fourth Degree

Laser hemorrhoidoplasty vs. rubber band ligation: a randomized trial comparing 2 mini-invasive treatment for grade II hemorrhoids

PURPOSE

As a minimally invasive procedure, laser hemorrhoidoplasty (LHP) can not only relieve the symptoms of hemorrhoids, but also protect the anal cushion structure. This study aimed to investigate the clinical efficacy of LHP in the treatment of grade II hemorrhoids.

METHODS

A total of 70 patients with grade II hemorrhoids were randomly assigned to receive LHP or Rubber Band Ligation (RBL) (n = 35 per group) in 2019 from a single center. The postoperative pain, bleeding, feeling of anal distension(local falling, swelling, foreign body sensation, stool) and postoperative recurrence rate were compared between the two groups.

RESULTS

The postoperative pain, bleeding, and feeling of anal distension in the LHP group were improved significantly as compared with the RBL group within 2 weeks after surgery (P < 0.01). Both methods can relieve the symptoms of grade II hemorrhoids. There was no difference in the recurrence rate between the two groups at 1 year after surgery (P > 0.05). The patients in LHP group took less time to return to normal activities (P < 0.001).

CONCLUSIONS

As a minimally invasive treatment, LHP is easy and not traumatic and results in mild postoperative pain and few complications. It is an ideal choice for grade II hemorrhoids.

Diode laser hemorrhoidoplasty versus conventional Milligan-Morgan and Ferguson hemorrhoidectomy for symptomatic hemorrhoids: Meta-analysis

Conventional hemorrhoidectomy is the mainstay of treatment for symptomatic haemorrhoids, but reported postoperative complications remains the main concern. On the contrary, with its minimally invasive nature, laser hemorrhoidoplasty showed the potential to reduce postoperative complications and discomfort. Therefore, we performed a systemic review and meta-analysis to evaluate the postoperative outcome of laser hemorrhoidoplasty compared to conventional hemorrhoidectomies, including Milligan-Morgan and Ferguson techniques. Of all studies from PubMed, EMBASE, Cochrane database, and Google Scholar, we included 17 trials with 1196 patients, of whom 596 (49.8 %) underwent laser hemorrhoidoplasty and 600 (50.2 %) underwent conventional hemorrhoidectomy. The primary outcomes were operative blood loss and postoperative haemorrhage, and the secondary outcomes were the operative time, postoperative pain score, complications, and haemorrhoid recurrence. In this study, we found that laser hemorrhoidoplasty showed benefits in operative blood loss (weighted mean difference [WMD]: -16.43 ml, 95 % confidence interval [CI]: -23.82 to -9.04), postoperative hemorrhage/bleeding (odds ratio [OR]: 0.16, 95 % CI: 0.10 to 0.28), operative time (WMD: -12.42 min, 95 % CI: -14.56 to -10.28), postoperative pain score on day 1 (WMD: -2.50, 95 % CI: -3.13 to -1.88), and anal stenosis (OR: 0.14, 95 % CI: 0.03 to 0.65) in comparison with conventional hemorrhoidectomy. However, incidence of fecal/flatus incontinence, urinary retention and hemorrhoid recurrence were not significantly different between the 2 groups. Consistent results were found in 5 subgroup analyses, including studies with low risk of bias, studies using 1470 nm laser, and studies using 980 nm laser, studies conducted in Asia, and studies conducted in Europe and America.

Comparison of Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy Techniques in the Treatment of Grade 2 and 3 Hemorrhoidal Disease

INTRODUCTION

The estimated prevalence of hemorrhoidal disease (HD) worldwide ranges from 2.9% to 27.9%. Conservative, medical, non-operative, and surgical therapy approaches are applied in HD treatment. Milligan-Morgan (MM) hemorrhoidectomy which is the most well-known and frequently applied surgical treatment method, and Laser hemorrhoidoplasty (LH) are among the accepted treatment methods in Grade 2-3 HD treatment where medical treatment is insufficient.

PURPOSE

In this study, the early results of laser hemorrhoidoplasty and Milligan-Morgan hemorrhoidectomy techniques were compared.

MATERIAL AND METHODS

A randomized clinical trial. The study included ASA 1-3, total 85 patients aged 18-70 years old with symptomatic Grade 2 and Grade 3 hemorrhoidal disease whose symptoms persisted despite at least one month of medical treatment. Fifty-four patients were allocated to Group L, whereas 31 were allocated to Group M. Age, gender, weight, body mass index, preoperative symptoms, presence of additional disease, use of anticoagulant medication, and length of hospital stay of the patients included in the study were recorded. Rescue analgesic used was recorded. Postoperative VAS score and complications were recorded within 10 days. The total energy numbers applied to all packages were recorded.

RESULTS

The incidence of minor perioperative hemorrhage was significantly lower in Group L compared to Group M (P = .035). The postoperative 3rd-hour VAS scores were statistically significantly lower in Group L compared to Group (P < .001). At the 3rd hour postoperatively, the need for rescue analgesia was statistically significantly higher in Group M compared to Group L. On the seventh postoperative day, Group M needed considerably more rescue analgesia compared to Group L (P < .001, P = 1.00, P = .035, respectively). The cut-off value of 571 J was calculated in Group L.

CONCLUSION

We believe that it is not an advantageous method compared to MM hemorrhoidectomy, both in terms of patient comfort and cost-effectiveness, since postoperative pain, which is shown as the most important advantage of LH over conventional hemorrhoidectomy methods in the literature, can be relieved with simple NSA-I rescue analgesia in patients undergoing MM. Trial Registration: 03.06.2021/21-63.

Laser hemorrhoidoplasty in the treatment of symptomatic hemorrhoids: a pilot Australian study

PURPOSE

Traditional therapeutic approaches to the surgical management of hemorrhoid disease such as hemorrhoidectomies are plagued with severe postoperative pain and protracted recovery. Our pilot study aims to the laser hemorrhoidoplasty (LH) patients with symptomatic hemorrhoid disease that have failed conservative management for the first time in an Australian population.

METHODS

Thirty patients were prospectively enrolled to undergo LH. Postoperative pain, time to return to function, and quality of life (QoL) were determined through the Hemorrhoid Disease Symptom Score and Short Health Scale adapted for hemorrhoidal disease and compared to a historical group of 43 patients who underwent a Milligan-Morgan hemorrhoidectomy by the same surgeon at 3, 6, and 12 months.

RESULTS

The LH group had significantly lower mean predicted pain scores on days 1 and 2 and lower defecation pain scores and lower opioid analgesia use on days 1, 2, 3, and 4. The median time to return to normal function was significantly lower in the LH group (2 days vs. 9 days, P<0.001). Similarly, the median days to return to the workplace was significantly lower in the LH group (6 days vs. 13 days, P=0.007). During long-term follow-up (12 months), hemorrhoid symptoms and all QoL measures were significantly improved, especially among those with grade II to III disease.

CONCLUSION

This pilot study demonstrates low pain scores with this revivified procedure in an Australian population, indicating possible expansion of the therapeutic options available for this common condition. Further head-to-head studies comparing LH to other hemorrhoid therapies are required to further determine the most efficacious therapeutic approach.

Laser technology in proctological diseases: is it really the wave of the future?

Different types of lasers have been applied for various proctological conditions. We discuss about published articles regarding the application of lasers, with concern about evidence-based use of these techniques and technologies. We performed a literature search about laser treatments for proctological conditions. 55 studies were included for the final revision. Meta-analysis of data was not performed because of heterogeneity of study designs and outcome measures. A scoping review was performed. Laser treatments for hemorrhoids require a shorter operative time and show less postoperative pain and bleeding compared to conventional hemorrhoidectomy, but are more expensive. Studies are heterogeneous in design, endpoints, postoperative assessment, length of follow-up and outcome measures. Only 3 RCTs are available and only three studies evaluate long-term outcomes. FiLaC (fistula laser closure) was initially described in 2011 for the treatment of anal fistula. In the published studies the reported healing rates vary between 20 and 82%, and the ideal indication is yet to be defined. Studies with long-term follow-up are lacking. SiLaT (sinus laser treatment) applied the technology used for FiLaC to the treatment of pilonidal sinus disease. This technique had less perioperative pain and shorter hospital stay, but a lower primary healing rate when compared to traditional techniques. Available data is very limited, and no randomized trials are published to date. Laser assisted techniques are a viable, minimally invasive, but expensive option for the treatment of several proctological conditions. Further researches are needed to assess if patients could benefit of their use, and for what indication.

Comparing outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in grade II-III hemorrhoidal disease: a retrospective analysis

BACKGROUND

Hemorrhoidal disease is a common ailment that presents a challenge in terms of standard treatment methods. Although surgical hemorrhoidectomy is often considered the gold standard, new surgical techniques have emerged, such as laser hemorrhoidoplasty and LigaSure hemorrhoidectomy, to address postoperative pain, bleeding, and extended return-to-work times. This study aims to compare the outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in patients with grade II-III hemorrhoidal disease.

METHODS

A retrospective analysis was conducted on a cohort of patients who underwent laser hemorrhoidoplasty or LigaSure hemorrhoidectomy. Data were collected on postoperative pain, complications, recurrence rates, and return-to-work times. The primary outcome was the difference in postoperative pain between the two groups, as assessed using the Visual Analog Scale (VAS).

RESULTS

Patients in the laser hemorrhoidoplasty group experienced significantly lower postoperative pain compared to those in the LigaSure hemorrhoidectomy group. Bleeding amounts during the operation were also significantly lower in the laser group. However, the recurrence rate was higher in the laser group compared to the LigaSure group (9.4% versus 2.5%). Return to work and normal activities time after laser hemorrhoidoplasty was shorter than after LigaSure hemorrhoidectomy.

CONCLUSION

Laser hemorrhoidoplasty is a minimally invasive technique that can be safely applied in suitable grade II-III patients, offering lower postoperative pain rates, fewer complications, and shorter return to work and normal activity times compared to LigaSure hemorrhoidectomy. However, recurrence rates are still higher for laser hemorrhoidoplasty. Future studies should explore the potential of combining laser hemorrhoidoplasty with other surgical treatments.

Challenges and Prospects of Laser Haemorrhoidoplasty in a Low Resource Setting: The LUTH Experience

Background

Haemorrhoids are the most common condition of the anal canal causing significant disability. Traditional excisional haemorrhoidectomy and its various modifications, while effective, may be attended by severe postoperative pain and other complications. Laser haemorrhoidoplasty is reported to be effective with fewer complications and shorter hospital stay.

Objectives

The aim of this study was to report the outcome of intrahaemorrhoidal coagulation with 1470-nm diode laser at the Lagos University Teaching Hospital.

Patients and Methods

The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, grade of the haemorrhoids, duration of the procedures, and postoperative complications were evaluated.

Results

Eleven patients had laser haemorrhoidoplasty. There were seven males and four females. The age range was 23-71 years, with a median age of 47 years and an interquartile range (IQR) of 28-57 years. Duration of surgery ranged from 20 to 90 min, with a median of 33 min and IQR of 25-53 min. Postoperative pain was mild in eight patients and moderate in three. Ten patients were discharged as day cases and one 3 days later due to spinal anaesthesia-related headache and acute urinary retention. One patient later had an anal ulcer probably due to too much energy delivered during the procedure, this was managed conservatively. There was no postoperative wound infection, anal incontinence, anal stenosis, subcutaneous abscess, and fistula or recurrence.

Conclusion

The advantages of laser haemorrhoidoplasty make it a readily acceptable form of treatment for haemorrhoids in our setting.

Pain assessment following open hemorrhoidectomy under local anesthesia versus saddle block: a multicenter randomized controlled trial

BACKGROUND

There is disparity in evidence on pain assessment post open hemorrhoidectomy (OH) using local anesthesia and its use in developing countries compared to developed countries. Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3^rd or 4^th degree hemorrhoids.

METHODS

This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3^rd or 4^th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p < 0.05 as statically significant using visual analogue scale (VAS).

RESULTS

We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486-0.773: AUC = 0.63; p = 0.09) with a none significance by Kruskal-Wallis's test (p:0.925).

CONCLUSION

Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3^rd or 4^th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8^th October, 2021.

Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend

PURPOSE

Hemorrhoidal disease (HD) is a common condition, and several surgical techniques have been proposed to date without being able to achieve definitive consensus on their use and indications. Laser hemorrhoidoplasty (LHP) is a minimally invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser limiting the postoperative discomfort and pain. The aim of the current study was to evaluate the postoperative outcomes of HD patients undergoing LHP vs conventional Milligan-Morgan hemorrhoidectomy (MM).

METHOD

Postoperative pain, wound care management, symptoms' resolution, patients' quality of life, and length of return to daily activity of grade III symptomatic HD patients undergoing LHP vs MM were retrospectively evaluated. The patients were followed-up for recurrence of prolapsed hemorrhoid or symptoms.

RESULT

From January 2018 to December 2019, 93 patients received conventional Milligan Morgan as control group and 81 patients received laser hemorrhoidoplasty treatment using a 1470-nm diode laser. No significant intraoperative complications occurred in both groups. Laser hemorrhoidoplasty patients experienced lower postoperative pain score (p < 0.0001) and smoother wound management. After 25 ± 8 months follow-up, the recurrence of symptoms occurred in 8.1% after Milligan-Morgan and 21.6% after laser hemorrhoidoplasty (p < 0.05) with a similar Rorvik score (7.8 ± 2.6 in LHP group vs 7.6 ± 1.9 in MM group, p = 0.12).

CONCLUSION

LHP demonstrated high efficacy in selected HD patients guaranteeing lower postoperative pain, easier wound care, higher rate of symptoms resolution, and greater patient appreciation compared to MM, even though it had a higher recurrence rate. Larger comparative studies are needed to address this issue.

Laser hemorrhoidoplasty for II-IV grade hemorrhoids: should we treat them the same?

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids.

The effects of laser procedure in symptomatic patients with haemorrhoids: A systematic review

Purpose

Haemorrhoids are normal structures in the human body, only seen as pathological when symptomatic. Nowadays, new techniques have surfaced using a diode laser which, after locating the target arteries, blocks the blood flow while hitting and shrinking the local mucosa/submucosa at a depth of 4 mm. Our work aimed to give a broad view over this new technique and its consequences in the post-operative follow-up with a systematic review.

Methods

EMBASE and MEDLINE databases were consulted, retrieving clinical trials, which mentioned the use of 980 nm diode laser on the treatment of haemorrhoids.

Results

Ten clinical trials analyzing the post-operative effects of laser haemorrhoidectomy were selected, including 2 randomized controlled clinical trials and 1 controlled clinical trial. The overall quality of the trials was low, indicating a high risk of bias.

Conclusion

The laser haemorrhoidectomy procedure revealed a high therapeutic potential, considering the reduced number of postoperative complaints (bleeding/pain), the high symptom resolution and the reduced recurrence, albeit the high heterogeneity between the studies in terms of reported results. Future investigations with higher quality and controlled double-blinded studies obtaining better-categorized results should be conducted in order to better evaluate this procedure and compare it to the current paradigm.

Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis

Laser hemorrhoidoplasty (LHP) is known as a new minimally invasive and painless procedure for symptomatic hemorrhoids. However, Milligan-Morgan (MM) may offer the best result of long-term cure rates. In this study, we aim to compare the efficacy between LHP and MM for hemorrhoidal disease treatment. Using specific keywords, we comprehensively go through the potential articles on PubMed, Europe PMC, and Google Scholar sources until April 19, 2022. All published studies on LHP and MM hemorrhoidectomy were collected. Statistical analysis was done by using Review Manager 5.4 software. Twelve studies with a total of 1756 patients with hemorrhoid grades II-IV were included for the analysis. Our pooled analysis revealed that LHP was associated with shorter operative time (p < 0.00001), shorter length of hospital stay (p = 0.0005), lower risk of urinary retention (p = 0.005) and anal stenosis (p = 0.0004), and lower VAS 24-h post-operative (p < 0.00001) when compared with MM. However, LHP and MM did not differ in terms of recurrence rate (p = 0.70). LHP was superior to MM procedure in terms of shortening the recovery time and minimizing post-operative complications for patients with hemorrhoidal disease.

Comparison of post-operative bleeding incidence in laser hemorrhoidoplasty with and without hemorrhoidal artery ligation: a double-blinded randomized controlled trial

Introduction

The effectiveness of hemorrhoidal artery ligation supplementation in reducing the incidence of post laser hemorrhoidoplasty bleeding has not been investigated.

Methods

This was a double-blind, randomized controlled trial comparing post-operative bleeding incidence in patients undergoing laser hemorrhoidoplasty (LHP) only versus LHP with hemorrhoidal artery ligation (HAL). Outcome measures included post-operative bleeding and its severity (i.e. verbal rating scale and Clavien-Dindo classification), presence of perianal swelling and pain score (visual analog score) at 1-day, 1-week and 6-weeks post-operatively. Statistical tests were performed and a value of P < 0.05 was considered significant.

Results

Seventy-six patients were randomized. There was no difference in median operating time. The bleeding incidence was highest at 1-week post-operatively (17.1%), and decreased to 1.3% at 6-weeks. There was no significant difference in bleeding incidence between both groups at any of the measured timepoints (P > 0.05). Severity of bleeding and incidence of post-operative perianal swelling were similar in both groups (P > 0.05). There was no difference in median pain scores.

Conclusion

Supplementation of HAL to LHP does not reduce the post-operative bleeding incidence. LHP is sufficient as a stand-alone procedure for treating haemorrhoids.

Trial registration: National Registration Number is NMRR-15-1112-24065 (IIR). The trial start date was 1st January 2015 with the ClinicalTrials.gov identifier and registration number as NCT04667169.

Systematic review and meta-analysis of postoperative pain and symptoms control following laser haemorrhoidoplasty versus Milligan-Morgan haemorrhoidectomy for symptomatic haemorrhoids: a new standard

PURPOSE

Haemorrhoidal disease (HD) plagues one in every ten people, with a plethora of surgical treatment modalities, of which laser haemorrhoidoplasty (LHP) is a relatively novel option. This systematic review and meta-analysis objectively evaluated the efficacy, safety, and tolerability of LHP compared against conventional (Milligan-Morgan) open haemorrhoidectomy (CoH).

METHOD

A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Google Scholar was conducted. Randomised controlled trials (RCTs) and comparative cohort studies (CCSs) which compared LHP against CoH were included, with postoperative pain as the primary outcome. Secondary outcomes included intraoperative characteristics, short- and moderate-term outcome, and complications.

RESULTS

A total of 12 studies (6 RCTs and 6 CCSs), with a total of 1824 patients, were analysed. LHP resulted in reduced postoperative pain for the first day (mean difference of 2.07 visual analogue scale units), week, and month. The mean dosage and duration of postoperative analgesia use was similarly lower, with a mean difference of 4.88 mg (morphine) and 2.25 days, respectively. Crucially, recurrence was equivocal (HR: 0.72, CI: 0.21-2.40) at a mean follow-up duration of 8.58 ± 9.55 months. LHP resulted in lower blood loss and was 12.74 min shorter on average. LHP's postoperative recovery time was 9.03 days less with equivalent or decreased risk of most short- and moderate-term complications except anal thrombosis.

CONCLUSION

Our study suggests that LHP is more tolerable than CoH, providing patients with superior postoperative quality of life at equivalent moderate-term efficacy. These findings contribute to improved understanding of LHP and its potential at enhancing the quality of HD care.

The Laser Therapy for Hemorrhoidal Disease: A Prospective Study

Aim: This prospective study aimed to determine the outcomes and postoperative complications of hemorrhoid disease (HD) treated by hemorrhoidal laser procedure (HeLP).

Background: We, herein report the results of 18 months of methodical use of mini-invasive laser procedures in 100 patients with grades 2 and 3 hemorrhoids and minimum to a mild degree of rectal prolapse. The surgical technique is called HeLP.

Methods: Data were collected on the duration of the procedure, intraoperative complications, postoperative pain, the declivity of hemorrhoids, persistency or complete resolution, and recurrence of hemorrhoids were collected prospectively.

Results: No evidence of intraoperative complications occurred. The median follow-up was nine months. Postoperative pain was not significant or null in most patients. There was no rectal tenesmus or alteration of defecation habits. Plateau of hemorrhoid symptoms and downgrading of hemorrhoid size reached approximately three to seven months post-procedure. The frequency of pain, bleeding, pruritus ani, and acute hemorrhoidal syndrome decreased by 75-80%. There was a significant reduction in hemorrhoids with the rate of recurrence being 7% over 12 months of follow-up.

Conclusion: Our study evaluated and demonstrated that HeLP is an effective, safe, and non-painful procedure for the management of patients with the symptomatic second or third degree of hemorrhoid with mild to the minimum degree of rectal mucosal prolapse. It is a suitable ambulatory treatment.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Laser utility in the treatment of hemorrhoidal pathology: a review of literature

Hemorrhoidal disease is a common reason for consultation in proctology. It can be treated in several ways (medical, endoscopic, and surgical). Laser treatment has been described since 1960 and has developed in recent years. The purpose of this literature review was to study the results of laser treatment of hemorrhoids and to compare them with those of surgical methods. We performed a systematic search of the literature by querying the Medline, Google Scholar, and Cochrane Library databases. Retrospective studies and case reports were excluded. We selected 11 studies both techniques HeLP (hemorrhoid laser procedure) and LHP (laser hemorrhoidoplasty procedure). The total number of patients was 1179 including 1059 patients treated with laser and 120 treated surgically within the context of comparative studies. The age of the patients varies between 18 and 74 years old. HeLP laser treatment was significantly superior to surgical treatment in terms of postoperative pain (p < 0.001), hemorrhoidal disease downgrading (p < 0.001), and postoperative satisfaction (p < 0.001). Similarly, LHP laser treatment was significantly superior to surgical treatment in terms of operative duration (p < 0.00001), intraoperative bleeding (p < 0.00001), postoperative pain at H12 and H24 (p < 0.00001 and p = 0.0003), and postoperative bleeding rate (p < 0.001). The laser represents a revolution in the field of proctology mainly in the treatment of hemorrhoidal pathology. It is a safe, effective, and less painful mini-invasive technique. More rigorous studies will be needed to better evaluate this technique.

Laser treatment of pilonidal disease: a systematic review

Pilonidal disease (PD) is a common condition, and there is still an ongoing debate on ideal management that should be minimally invasive, safe, and efficient. The use of radially emitting laser in the treatment of chronic PD is a novel minimally invasive technique, and initial studies with a small number of patients showed promising results. This study aimed to assess the efficacy and safety of chronic PD treatment with a laser using a systematic review of the published literature. A systematic review was conducted after PubMed, Scopus, Embase, Web of Science, and the Cochrane database search for studies reporting laser treatment of chronic PD. Also, our unpublished prospective single-center study was included in this review. Ten of 87 studies were eligible for the review, including 971 patients. The median age of the patients was 26 (range 13-68), and the median operative time was 26 (range 6-65) min. With a median follow-up of 12 (range 7-25) months, 917 (94.4%) patients achieved primary healing with a weighted mean recurrence rate of 3.8%. The weighted mean complication rate was 10% (95% CI 5.7-14.3%, I2 = 82.28, p < 0.001), and all were minor. The published literature demonstrates that laser treatment is a promising procedure in the management of chronic PD. Furthermore, the review showed that standardized operative techniques and perioperative steps were used. The results were limited to the mild chronic PD. Classification of PD severity and standardized outcome reporting is required to define indications and contraindications for laser PD treatment. Randomized controlled trials are needed to determine the long-term effectiveness and superiority of laser treatment over other methods.

Efficacy and safety of acupoint catgut embedding in treating postoperative pain of mixed hemorrhoids: A randomized controlled trial protocol

BACKGROUND

Pain is a common complication after mixed hemorrhoids, which seriously affects the recovery of patients and prolongs the length of hospital stay. Acupoint catgut embedding has advantages in improving a variety of acute and chronic pain diseases, but there is still a lack of rigorous randomized controlled studies to verify its efficacy and safety in the treatment of postoperative pain of mixed hemorrhoids. Therefore, the purpose of this randomized controlled trial is to evaluate the clinical efficacy of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids.

METHODS

This is a prospective randomized controlled trial to study the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids. Approved by the clinical research ethics committee of our hospital, the patients were randomly divided into observation group and control group according to 1:1. The observation group received acupoint catgut embedding before the operation, while the control group received no special treatment. The efficacy and safety indexes were concerned after the operation, and the observation indexes included: resting state and visual analogue scale (VAS) score during defecation, postoperative hospitalization time, total amount of analgesic use, adverse reactions, etc. Finally, we carried on the data statistical analysis through the SPSS version 19.0.

DISCUSSION

This study will evaluate the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids, and the results of this study will provide a new idea for the selection of postoperative analgesia for mixed hemorrhoids resection.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/T2ZGY.

A comparative evaluation of laser hemorrhoidoplasty versus open surgical hemorrhoidectomy treatment of grade III and IV hemorrhoids. A prospective observational study

The aim of the present study was to evaluate and compare the efficacy and outcomes of laser hemorrhoidoplasty with that of open surgical hemorrhoidectomy. This prospective observational study consists of 50 subjects in each group. The open surgery group underwent a standardized Milligan-Morgan technique, and the laser group underwent laser hemorrhoidoplasty with a diode laser of 1470 nm (LASOTRONIX), 8.5 watts with a continuous pulse. Postoperative pain was considered as the primary outcome and was evaluated in both groups using the visual analog scale. There was a statistically significant difference between the two groups in VAS score at different follow-up period, with a mean score of 2.3±1.05 and 5.1±1.11 (24 hours) for the laser hemorrhoidoplasty group and open surgery group, respectively (p value < 0.008). There was an improvement in VAS score in the laser hemorrhoidoplasty group compared to the conventional open surgical group in 1, 7, 14, 21, and 30 days follow up.

Study Protocol for the Use of Conventional Open Haemorrhoidectomy versus Laser Haemorrhoidoplasty in the Treatment of Symptomatic Haemorrhoids: A Randomized Controlled Trial

BACKGROUND

Haemorrhoids result in a variety of symptoms that cause significant patient anxiety. Treatment has long been associated with post-operative complications, which cause significant symptoms and may result in readmissions. The open conventional haemorrhoidectomy (COH) is still regarded as the gold standard treatment for non-circumferential grade II-IV haemorrhoids. Laser haemorrhoidoplasty (LAH) has recently been studied and the initial results appear promising. This study aims to compare these 2 techniques in the treatment of symptomatic haemorrhoids. We hypothesize that LAH has significantly less pain and bleeding and better quality of life (QoL) scores 1, 3 and 12 months post-operatively.

METHODS

A prospective, randomized, double-blind, single-centre clinical trial will be conducted. All patients aged between 21 and 90 years who present with symptomatic grade II-IV haemorrhoids will be recruited. Exclusion criteria include those who have had previous operations for haemorrhoids and those with an increased risk of bleeding. Data collected will include patient demographics, pre- and intra-operative characteristics of the haemorrhoids, operative details and post-operative pain Visual Analogue Scale (VAS) score, complications, readmissions, and haemorrhoid-specific QoL surveys. Primary outcome will be median post-operative pain VAS score on post-operative days (POD) 1-10. Secondary outcomes include operative duration, bleeding on the first 10 days post-operatively, readmissions, procedure-related complications (fistulation, incontinence, stenosis), QoL scores, and recurrence of symptoms up to 12 months.

DISCUSSION

Results from this trial may demonstrate the superiority of LAH over COH in terms of post-operative pain and recovery. This would likely increase the adoption of LAH for the treatment of symptomatic haemorrhoids.

TRIAL REGISTRATION

This trial was registered on 1/4/2020 at ClinicalTrials.gov. URL: https://www.clinicaltrials.gov/ct2/show/NCT04329364?term=NCT04329364&amp;draw=2&amp;rank=1.

Analysis of the main surgical techniques for hemorrhoids

Introduction Surgical treatment of hemorrhoidal disease is used in about 5–10% of cases where conservative treatments have not been effective.

Objective To learn the surgical techniques used in the treatment of hemorrhoidal disease grades III and IV in the light of literature.

Methods This is an exploratory study, with an integrative review of literature published from 2009 to 2015 from databases LILACS, SciELO, MEDLINE, PUBMED and the Portal of CAPES, using the following descriptors: “hemorrhoidectomy” and “hemorrhoids”, in the period from March to May 2015.

Results Nineteen articles were selected. In the four more described techniques, the surgical time ranged from 19.58 to 52 min, with relapses from 5%, from 17.5 to 35 min and recurrences of 7.5% to 8.2%, 23–35 min was 20% and 22.5% relapse, 12.5 and 13.2 min, 3.5% of relapses.

Conclusion Conventional techniques are still the most commonly performed with a good acceptance on the long-term resolution and low recurrence rate.

Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review

BACKGROUND

Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment.

METHODS

We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed.

RESULTS

Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis.

CONCLUSION

Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

European Society of ColoProctology: guideline for haemorrhoidal disease

AIM

The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD.

METHODS

The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE.

RESULTS

There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated.

CONCLUSION

This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II-III degrees hemorrhoids. Consecutive patients with II-III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.

Short- and long-term outcomes of laser haemorrhoidoplasty for grade II-III haemorrhoidal disease

AIM

Laser haemorrhoidoplasty is associated with minimal postoperative pain and good symptom improvement in the short-term. However, less is known about its long-term efficacy. This study aims to determine the short- and long-term outcomes of laser haemorrhoidoplasty.

METHOD

Between October 2010 and May 2012, 50 consecutive patients with grade II-III haemorrhoids were treated with laser haemorrhoidoplasty. Short-term follow-up was assessed on days 1, 30 and 60 and long-term follow-up was at 5 years (haemorrhoidal stage reduction, pain, patient satisfaction, symptom improvement, incapacity for work, continence, complications, recurrence).

RESULTS

Short-term follow-up was achieved for all patients and long-term follow-up for 44/50 patients (88%). At short-term follow-up, haemorrhoidal stage reduction was documented in 49 (98%) patients. Complete or good symptom improvement was reported by 36/50 (72%) and 10/50 patients (20%) at 60 days. Postoperative complications occurred in 9/50 patients (18%) with three Clavien-Dindo grade IIIb complications (two fistulas, one incontinence), one grade IIIa (perianal thrombosis) and five grade I (one perianal thrombosis, two perianal eczema, one local bleeding, one anal fissure). Postoperative pain was low (visual analogue scale 0-1) at day 1 in 37/50 (74%), at day 30 in 47/50 (94%) and at day 60 in 50/50 patients (100%). After a mean follow-up of 5.4 years (SD 5.4 months) the recurrence rate was 34% (15/44 patients) with a median time to recurrence of 21 months (range 0.2-6 years).

CONCLUSION

Although laser haemorrhoidoplasty achieves a high short-term success rate with respect to stage reduction and symptom improvement, it is associated with a high rate of minor postoperative complications and long-term recurrence. Therefore, laser haemorrhoidoplasty should be used with caution.

ELITE: a diode laser minimal invasive technique for hemorrhoids during the surgical treatment for anal fissure

A 44-year-old male patient diagnosed with Anal Fissure and Stage II Hemorrhoids in 2013. He has been suffering ever since, avoiding surgery, using local analgesic and anti-hemorrhoidal crèmes. Physical examination in February 2017, showed a chronic character of his problem and hemorrhoids to have progressed to Stage III. The common shared decision between patient and surgeon was to proceed with a combination of a LIS for the Anal Fissure and an ELITE minimal invasive procedure for hemorrhoids. The operating time of the dual procedure was short and the patient witnessed a remarkable, painless post-op rehab period. The results of the ELITE technique using a diode laser for treating hemorrhoidal nodules are very promising. In the hands of an experienced surgeon the technique is applicable to be used in combination with other procedures in order to treat several problems in the anal region at the same time.

Transanal hemorrhoidal dearterialization versus stapled hemorrhoidectomy in the treatment of hemorrhoids: A PRISMA-compliant updated meta-analysis of randomized control trials

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the outcomes of transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidectomy (SH) in the treatment of hemorrhoids by a meta-analysis.

METHODS

Randomized control trials (RCTs) comparing SH with THD were searched for in databases, including MEDLINE, PubMed, Web of science, Embase, and the Cochrane Library database. Data were independently extracted from each study, and a meta-analysis was performed using RevMan5.2 software.

RESULTS

Eight RCTs, including 977 patients, were included in this meta-analysis. No statistically significant differences were noted between THD and SH in terms of total complications (OR, 0.93; 95% CI, 0.69, 1.25), but a significant differences were noted in terms of bleeding (OR, 1.85; 95% CI, 1.10, 3.10). The total recurrence rate was higher in THD than in SH on short-term follow-up; however, the recurrence rate was equal in both the THD and SH groups on long-term follow-up. The present study showed that no significant difference between SH and THD in terms of postoperative pain (OR, 0.43; 95% CI, -0.43, 1.29), operative time (OR, -3.12; 95% CI, -7.01, 0.77), hospital time (OR, -0.00; 95% CI, -0.21, 0.20), time before returning to work (OR,-0.50; 95%CI, -4.42,3.43), and reoperation rate (OR, 1.81; 95% CI, 0.93, 3.54).

CONCLUSION

Our meta-analysis indicated that THD and SH are equally effective techniques for the treatment of hemorrhoids. However, future studies addressing cost-effectiveness, satisfaction rate, and recurrence rate over a long follow-up period are needed to validate these results.

Nd:YAG laser therapy for rectal and vaginal venous malformations

BACKGROUND

Limited therapeutic options exist for rectal and vaginal venous malformations (VM). We describe our center's experience using Nd:YAG laser for targeted ablation of abnormal veins to treat mucosally involved pelvic VM.

METHODS

Records of patients undergoing non-contact Nd:YAG laser therapy of pelvic VM at a tertiary children's hospital were reviewed. Symptoms, operative findings and details, complications, and outcomes were evaluated.

RESULTS

Nine patients (age 0-24) underwent Nd:YAG laser therapy of rectal and/or vaginal VM. Rectal bleeding was present in all patients and vaginal bleeding in all females (n = 5). 5/7 patients had extensive pelvic involvement on MRI. Typical settings were 30 (rectum) and 20-25 W (vagina), with 0.5-1.0 s pulse duration. Patients underwent the same-day discharge. Treatment intervals ranged from 14 to 180 (average = 56) weeks, with 6.1-year mean follow-up. Five patients experienced symptom relief with a single treatment. Serial treatments managed recurrent bleeding successfully in all patients, with complete resolution of vaginal lesions in 40% of cases. No complications occurred.

CONCLUSIONS

Nd:YAG laser treatment of rectal and vaginal VM results in substantial improvement and symptom control, with low complication risk. Given the high morbidity of surgical resection, Nd:YAG laser treatment of pelvic VM should be considered as first line therapy.

A Randomized Controlled Trial Comparing Laser Intra-Hemorrhoidal Coagulation and Milligan-Morgan Hemorrhoidectomy

PURPOSE

To compare laser intra-hemorrhoidal coagulation with Milligan-Morgan (MM) hemorrhoidectomy.

METHOD

Patients with symptomatic grade II or III internal hemorrhoids according to the Goligher's classification (refractory to medical treatment) were enrolled in this double-blinded randomized controlled trial study. In the laser group, hemorrhoidal columns were coagulated using a 980-nanometer (nm) radial laser emitting fiber (three, 15-W pulses of 1.2 s each, with 0.6-s intervals). Operative time, postoperative pain and complications, and recovery or resolution of symptoms were measured. Patients were followed up for at least one year for evaluating healing, resolution of symptoms, and late complications.

RESULTS

Postoperative pain scores (at 12, 18, and 24 hr after surgery) were significantly lower in the laser group compared with the MM group (p <.01). The operative time and intra-operative blood loss were more in the MM group (p <.001). The administration of analgesics was significantly reduced in the laser group (p <.05). Two patients in the laser group were presented with thrombosis of external hemorrhoid 7-10 days after the procedure, which was resolved with medical treatment, but no patients in the MM group developed hemorrhoidal thrombosis (p >.05). One-year follow-up showed comparable results in terms of the resolution of symptoms and sustainable cure.

CONCLUSIONS

Intra-hemorrhoidal coagulation with 980-nm diode laser reduces postoperative pain, intra-operative bleeding, and administered analgesics with a comparable resolution rate of hemorrhoid symptoms. However, for the patients who experience complications, such as hemorrhoidal thrombosis, the overall pain may be equivalent to or even worse than conventional hemorrhoidectomy.

A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids. Methods. This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n = 50) or DGHAL (n = 50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs. Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%, p = 0.030). Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.