*Sławomir Glinkowski1, 2, Daria Marcinkowska1, 2
Diode laser technology in the treatment of hemorrhoid disease. Laser HemorrhoidoPlasty (LHP) – description of the method
Zastosowanie lasera półprzewodnikowego w leczeniu choroby hemoroidalnej. Laserowa hemoroidoplastyka (LHP) – opis metody
1MEDICALL – Institute of Health in Piotrków Trybunalski
2Department of General and Oncologic Surgery, Health Centre in Tomaszów Mazowiecki
Choroba hemoroidalna jest jednym z najczęściej występujących schorzeń proktologicznych. W przedstawionych przez The American Society of Colon and Rectal Surgeons (ASCRS) w „Diseases of the Colon & Rectum” w 2018 roku metodach jej leczenia uwagę zwraca pominięcie wykorzystania technik laserowych. Pierwsze próby wykorzystania lasera w leczeniu choroby hemoroidalnej miały miejsce pod koniec lat 70., gdzie do wykonania hemoroidektomii zaczęto używać zamiast noża chirurgicznego lasera CO2. Obecnie jednym z nowszych urządzeń jest emitujący w sposób wachlarzowy falę o długości 1470 nm laser Leonardo, dzięki któremu opracowano technikę laserowej hemoroidoplastyki (LHP).
Zaletą zabiegu jest zmniejszenie masy guzka hemoroidalnego poprzez obliterację naczyń i następowe jego włóknienie. Przywraca to prawie anatomiczne warunki panujące w kanale odbytu bez konieczności wycinania powiększonych krwawnic. Powstanie włókien tkanki łącznej gwarantuje właściwe przyleganie śluzówki do tkanek leżących poniżej, co zapobiegać ma nawrotowi dolegliwości, szczególnie związanych z wypadaniem hemoroidów.
W artykule przedstawiono opis sposobu przeprowadzenia zabiegu zalecany przez producenta urządzenia z modyfikacjami powstałymi na bazie własnych doświadczeń.
Hemorrhoids is one of the most common proctological diseases of the anal canal. In the guidelines presented in 2018 in „Diseases of the Colon & Rectum”, the American Society of Colon and Rectal Surgeons (ASCRS) hasn’t specified laser techniques as a method of treatment. The first attempts of laser trail in hemorrhoidal treatment were made at the end of the 70s by using laser CO2 instead of scalpel. Nowadays one of the newest devices is Leonardo laser which emits fan-shaped movement of 1470 nm length. It enabled the development of laser hemorrhoidoplasty technique (LHP).
The advantage of this procedure is decrease of hemorrhoidal plexus by obliteration of hemorrhoidal vessels leading to their fibrosis. It reclaims almost anatomical architecture of anal canal without a necessity to excise the extended hemorrhoids. Development of the connective tissue fibers guarantees adequate adhesion of mucosa to the underlying tissue which prevents the recurrence of the disease, especially the ones connected with prolapsing of hemorrhoids.
The article contains a description of the method recommended by the manufacturer of Leonardo laser with the autors’ modifications developed on the basis of their own experience.
Hemorrhoids is one of the most common reasons for patients to report to the surgery. It is estimated that it is a cause of complaints from 2.9 to almost 30% of the society (1). About 1/3 of patients report to doctors for help, however, a large part tries to cure ailments with commonly advertised and over-the-counter medications. When the patient comes to the surgeon for help, it is extremely important to make a proper diagnosis; without one, it is impossible to implement an appropriate therapy. A correct diagnosis is usually based on the interview collected from the patient. In each case, a physical examination and anoscope or rectoscopy are also necessary to eliminate other possible diseases in the anal canal. Additionally, in numerous cases, colonoscopy should be made to eliminate the colon disease as the reason for complaint and anal bleeding (2).
The methods for treating hemorrhoids can be generally divided into conservative, instrumental and operational. Conservative treatment, which is applicable in the case of first-degree and sometimes second-degree hemorrhoids, according to Goligher classification, firstly includes pharmacotherapy with the use of phlebotropic drugs and topical preparations (3). A proper diet with large quantities of fiber and the right amount of water is of great importance. It affects a proper regularity of bowel movement and the quality of the feces. In the case of failure of conservative treatment, recurrence of ailments or second-degree or third-degree hemorrhoids, instrumental methods are commonly used. It is know that even fewer than 1 out of 10 patients with hemorrhoids will require instrumental treatment, and an even lower proportion should be classified for surgery (4). The most common applications among instrumental methods are: RBL (rubber band ligation), sclerotherapy, cryotherapy and IRC (infrared coagulation therapy). When surgical intervention is necessary, various procedures are possible, depending on the severity of the ailments and the surgeon’s experience. Milligan-Morgan method is still the most common surgical procedure for the excision of hemorrhoids (4, 5). In some appropriately equipped centers, a CO2 laser (6) is used instead of a surgical knife to excise the bleeds in classical hemorrhoidectomy. In recent years, an increasingly rare use of surgical methods, which are currently used mainly in the treatment of stage 4 hemorrhoids, has been noticed.
LHP – Laser HemorrhoidoPlasty
In 2018, The American Society of Colon and Rectal Surgeons (ASCRS) published guidelines for dealing with hemorrhoids in „Diseases of the Colon & Rectum” (2). These guidelines are presented as an update to the 2011 guidelines. All changes were made based on the currently conducted clinical trials and reports from the scientific literature. The scheme of conduct is directed primarily to general surgeons and proctologist surgeons who deal with anal diseases on a daily basis. Therefore, a large part of the study is devoted to the surgery procedures. Despite a very thorough presentation of the topic, covering both the diagnostic process and treatment methods, the authors of the guidelines did not mention any methods of treating hemorrhoids with the use of a laser – HeLP (Hemorrhoidal Laser Procedure) (7-9) and LHP (Laser HemorrhoidoPlasty) which is more often successfully used.
LHP has been known since 2006 and, in accordance with the manufacturer’s instructions, was designed for the treatment of second-, third- and some cases of fourth-degree hemorrhoids. According to the manufacturer, the greatest advantages of the LHP procedure are painlessness of the procedure and a maximal protection of sphincter and mucous membrane. The procedure does not involve the risk of stenosis of the anal canal, which may occur during classical hemorrhoidectomy. The LHP procedure aims to reduce the volume of the hemorrhoid, close the arteries that vascularize the hemorrhoidal column, and restore the anatomical structure of the anal canal. The risk of complications is minimized as there is no need to cut enlarged hemorrhoidal columns, and thus supply wounds formed after their excision. It shortens the time of stay in the hospital, and the surgery can be carried out as a one-day-surgery. Minimal incisions at the anus reduce the pain, which results in the minimization of painkillers consumption and the reduction of the time of a sick leave.
Description of the method
The LHP procedure performed with the use of a conical optical fiber, starts with the incision of the skin in the immediate vicinity of the enlarged hemorrhoidal column at the length of approx. 4 mm, and then widening the opening with the Pean’s tool or scissors. The incision in the skin can be made with electrocoagulation or the tip of the laser optical fiber, depending on the operator’s preference. Thus, an external opening is obtained to create a tunnel through which the fiber can be inserted. No wounds arise within the anal canal, the only hole is in the skin near the anus. At the end of the optical fiber, there is a pointer that can emit green or red light and allows tracing the end of the fiber in the hemorrhoidal tissue. For total safety, both the operating team and the patient should be equipped with special eye protection goggles. The fiber ought to be placed at the maximum depth to start the delivery of the energy pulses as close as possible to the hemorrhoid pedicle.
Our experience shows that in order to clearly visualize the entire hemorrhoidal column to which a bundle of energy will be applied, it is preferable to operate a reusable operating speculum applied in other typical proctology operations. In our opinion, disposable surgical speculators attached to the kit are less comfortable and do not allow full insight into the anal canal.
In order to tunnel hemorrhoidal lumps and visualize its pedicle, it is convenient to fasten the Pean tool or Kocher’s forceps to the anodermal fold and pull the whole hemorrhoidal column. This ensures traction when inserting the fiber optic probe and a good insight into the place where the energy from the laser fiber is to be applied. It also reduces the probability of puncturing the hemorrhoid with the tip of the laser, which is sharp (the probe is carried out all the time under eye control).
By means of the laser light of 1470 nm length and the conical shape of the probe, energy impulses are delivered to the hemorrhoidal column with fan-shaped pulses (divergently). After each pulse, the end of the optical fiber is withdrawn. Hemorrhoidal tissue treated with laser loses water, and the entire hemorrhoidal lump is cut off from the blood supply. The consequence of this process is the shrinking and fibrosis of the hemorrhoid mass. The formation of connective tissue fibers ensures proper adherence of the mucosa to the underlying tissues, which prevents the recurrence of ailments, particularly those associated with hemorrhoids prolapse.
It is recommended by the manufacturer to use a maximum of 300 J energy for each of the hemorrhoidal columns. In our study group, this value was exceeded in several cases, however, the maximum reached was 450 J. The procedure can be repeated for each affected hemorrhoid by making a separate skin incision to insert the fiber into a suitable plexus. This allows the plasticization of all hemorrhoidal columns during one operation. The procedure ends with hemostasis obtained by electrocoagulation or – in selected cases – by the oversewing ligation the bleeding vessels in the place where the fiber was inserted. Immediately after the treatment, the hemorrhoidal column exposed to laser light becomes hard and sometimes swollen. According to the manufacturer’s suggestions, increasing the cohesiveness of the hemorrhoid after the procedure is a kind of „guarantee” of its success; it was associated with a better final result in the studied group. In order to reduce the swelling that occurs after the procedure, it is possible to place a piece of ice (usually in the finger of a disposable rubber glove) for about 2-3 minutes, which was done in each case. Also, in each case, a seton infused with a disinfection liquid (usually of three medium-sized surgical swabs) was introduced into the anal canal.
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