Laser hemorrhoidoplasty versus open hemorrhoidectomy in Upper Egypt

INTRODUCTION

Hemorrhoids are a common anorectal problem. Patients suffered from hemorrhoidal disease may complain of a variety of symptoms, but there are two cardinal symptoms bleeding and prolapse. The principles of treatment for hemorrhoids are to alleviate symptoms, not necessarily to improve the appearance of the anal canal.¹ The estimated worldwide prevalence of Hemorrhoidal disease ranges from 2.9% to 27.9%, more than 4% of which are symptomatic.^{1, 2} Nearly, 1/3 (33.3%) of those patients search for medical consultation. Race distribution showing that a Gaussian distribution with a top prevalence among 40 and 65 years followed by the decrease of the prevalence after the age of 65.^3,4 Female patients are less frequently affected than male.⁵ The anorectal vascular cushions in conjunction with the sphincter

ani internus (IAS) are important in the preservation of continence through providing soft tissue support and maintaining tight closure of the anal canal. Taken into consideration Hemorrhoids are due to the downward displacement of suspensory (Treitz) muscle.⁶ Patients with hemorrhoidal disorder can also additionally complained of a variety of symptoms, but there are two cardinal symptoms bleeding and prolapse.⁷

Patients with asymptomatic hemorrhoids do not need management. Treatment varies from simple measures which include dietary modification, alternate defecatory habits to office maneuvers and operative hemorrhoidectomy.

In symptomatic patients with third and fourth-degree piles the ideal treatment is Hemorrhoidectomy. Despite hemorrhoidectomy is considered as a minor approach, it is also related to considerable postoperative drastic effects, which include severe pain, bleeding, long operative time and infected wound that led to prolongation of the period of recovery.⁸

Recent advances in devices which include laser hemorhoidoplasty have been considered an effective alternative, with reduction of pain, reduction of blood loss, accelerate healing of the wound and faster return to ordinary activities. The management modalities for symptomatic patients with hemorrhoids have varied over time. These alternatives modalities have included conservative medical control, non-surgical management and numerous surgical approaches. The various non-surgical procedures consist of rubber band ligation (RBL), injection sclerotherapy, cryotherapy, infrared coagulation. All of which can be achieved as outpatient approaches without anesthesia. These non-surgical procedures are considered to be the primary choice for grades I to III hemorrhoids.⁸ in the failure of conservative approaches to control symptoms, the strategy of treatments was changed to surgical treatments. The indicators to shift for surgery consist of the presence of a considerable external component, hypertrophied papillae, thrombosed piles or recurrence of previous presentations. The surgical procedure was open (Milligan–Morgan) and the instruments used are the scalpel, scissor, electrocautery. Milligan-Morgan hemorrhoidectomy is the gold standard and frequently performed approach in the United Kingdom.⁹ Post hemorrhoidectomy pain is the most common drastic complication associated with surgical procedures. The retention of urine (20.1%), bleeding (secondary or reactionary) (2.4%–6%) and subcutaneous abscess (0.5%) are other early complications. The delayed drastic compilations consist of anal fissure (1% -2.6%), anal stenosis (1%), incontinence (0.4%), fistula (0.5%) and recurrence of hemorrhoids.^10,11

PATIENTS AND METHODS

Preoperative assessment

An informed written consent was taken from all patients who accepted for participation in the study. A full history was taken, physical examination, per rectal examination and proctoscopy. Routine preoperative investigations which were performed include complete blood count, random blood sugar, liver function test, kidney function test, and coagulation profile. In this comparative and prospective study 40 patients were included, which were divided into 2groups, Group I: 20 patients were managed with laser hemorhoidoplasty and group II: 20 patients treated with open surgical hemorrhoidectomy. This study was performed at the department of general surgery, Al-Azher University Hospital, Assuit, Al-Rehab Hospital, Assuit between November 2019 and November 2020. After a detailed physical examination and proctoscopy, the laser technique was performed with (Biolitec AG, Germany) (Figure1).

Fig 1: Biolitec AG, Germany.

Operative technique

Group I: The position of the patient is the lithotomy, lubricated proctoscope was introduced into the anus (Fig. 2).  This approach has been started via a small incision at the mucocutaneous junction. the laser fiber was introduced into the hemorrhoidal plexus taking into consideration that the fiber should be parallel to the anal canal to avoid injury or burn of the mucosa or internal sphincter (Fig. 3). Using a 1470 nm diode laser, laser shots were delivered through the optic fiber in a pulsed fashion for the reduction of favorable degeneration of the periarterial healthy tissue. The limits of shrinkage can be controlled by the duration and power of the laser beam. Via the optic fiber, laser shots were generated at a power of 8 W with the duration of 7 s each shot followed by a pause of 1 s caused shrinkage of tissues approximately up to the depth 5 mm. at the end of each hemorrhoid, an ice finger was applied intra anally for 1–2 minutes to minimize the harmful effect of heat (Fig. 4). This procedure was repeated for each hemorrhoid.

Fig 2: Introduction disposable proctoscope.

Fig 3: Introduction of probe at mucocutaneous junction.

Fig 4: Introduction disposable proctoscope.

The discharged time of the Patients ranged from four to twelve hours, and the period of follow-up ranged from 2 to 6 months for evaluation of the progress of healing and complications. This approach was done as an outpatient maneuver. Preparation of bowel wasn’t needed.

Group II: 20 patients were treated with open surgical hemorrhoidectomy under spinal anesthesia. after gentle dilatation of anus, hemorrhoid is held by artery forceps one at pedicle and other at mucocutaneus junction, then V-shaped incision in the skin is made (Fig. 6) and deepened to pedicle down to underlying sphincter then pedicle is transfixed and ligated (Fig. 7) and the pile is excised 1\2 inch distal to ligature leaving the wound open. 2 to 3 hemorrhoids may be treated in the same manner. Patients were discharged within 4 to 12 hours and were followed for 2 to 6 months for healing progress and complications. Follow up of the patients for the level of postoperative pain and duration of the operation. Postoperative pain was recorded by using a 10-point visual analog scale (VAS) on which 0 represents no pain and 10 represents the worst pain imaginable. VAS protocol was followed up after 1 week, 2 weeks, 3 weeks, 1 month, 2 months and 6 months. The duration of intervention was recorded in minutes. The data were analyzed with statistical tests and presented with respective tables.

Fig 5: Post LHP abscess formation.

Fig 6: V shaped incision in skin at mucocutaneous junction.

Fig 7:Pedicle is transfixed and ligated.

RESULTS

The LHP was done on 20 consecutive patients which had symptomatic third-degree piles associated with mild prolapsed mucosa at proctoscopic examination and a history of infrequent attacks of prolapse which reduced manually, with mean age 47 ± 12.6 (range, 24–70) years. The number of male patients was 12 and 8 females. (Table1). The open surgical procedure was performed on 20 patients which had symptomatic grade III hemorrhoids and with or without complete prolapse. With mean age 49 ± 12.3 (range 28-72) years. The number of male patients was 11 and 9 females (Table 1).

Table 1: Characteristics of the patient group.

While the average time of hospitalization ranged from 4 to 12 hours in Group I, and ranged from 12 to 18 hours, with a mean of 13.8 (± 2.82) hours in Group II (Table 2). The mean operative time was 15.90 ± 3.5 min in the LHP group and 26.80 ± 5.8 min (p<0.01) (Table 3). As regard pain, early postoperative pain is lower in group I than group II. The same values also resulted for one month. These results are presented in Tables 4,5. No major drastic effects or complications were reported except 1 case recurrence and 1case stricture due to excess mucosal removal in Group II. Bleeding was observed in one case (the patient was taking aspirin) in Group I. And 2cases in Group II. One of the 2 patients was reported for surgical hemostasis which was necessary. Mild pain that necessitates medical treatment was recorded in 3 patients, one in LHP group and two in open surgery. No blood transfusions were needed in any of the cases. As regard to post-operative oedema there was one case reported in LHP group and three cases were reported in the open hemorrhoidectomy group. Also, there wasone case complained from post LHP abscess formation. (Fig. 5).

Table 2: Operative time and hospital stay.

Table 3: Operative and Early Postoperative complications in both groups.

Table 4 Pain presentation by VAS score in the LHP group

Table 5: Pain presentation by VAS score in the surgical group

 DISCUSSION