Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 2  |  Page : 560--565

Comparative study between intrahemorrhoidal diode laser treatment and Milligan–Morgan hemorrhoidectomy


Alla A Alsisy1, Yahia M Alkhateep1, Ibrahim EI Salem2,  
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Ministry of Health, Mansoura, Dakahlia Governorate, Egypt

Correspondence Address:
Ibrahim EI Salem
Temy El-Amded, Dakahlia Governorate
Egypt

Abstract

Objective The aim of this study was to compare between intrahemorrhoidal diode laser coagulation with Milligan–Morgan (MM) hemorrhoidectomy. Background Because of the increased number of patients suffering from hemorrhoids and increased complications of MM hemorrhoidectomy, using intrahemorrhoidal diode laser therapy in this study was proved to be beneficial in terms of being easily used, noninvasive, nontoxic, painless, and highly effective. Patients and methods This study included 60 patients with symptomatic hemorrhoids of grades II and III. Thirty patients were treated with intrahemorrhoidal diode laser coagulation and the remaining were treated with MM hemorrhoidectomy. We measured operative time, postoperative pain, complications, and resolution of symptoms. We followed up patients for 3 months for evaluating healing, resolution of symptoms, and complications. Results Postoperative pain scores at the first 24 h were significantly lower in the laser group compared with the MM group (P < 0.001). The operative time and intraoperative bleeding were much more in the MM group (P < 0.001). The consumption of analgesics was significantly reduced in the laser group (P = 0.018). Three patients in the laser group were presented with thrombosis of hemorrhoids 3–4 days after the laser procedure, which was resolved with medical treatment, but no patients in the MM group developed thrombosis of hemorrhoids (P = 0.076). Three months of follow-up showed comparable results in terms of resolution of symptoms and curability rate. Conclusion Intrahemorrhoidal therapy with a 980-nm diode laser is associated with reduction of postoperative pain, intraoperative bleeding, and administered with analgesics. Our results suggest that intrahemorrhoidal diode laser treatment if available is preferred to open hemorrhoidectomy.



How to cite this article:
Alsisy AA, Alkhateep YM, Salem IE. Comparative study between intrahemorrhoidal diode laser treatment and Milligan–Morgan hemorrhoidectomy.Menoufia Med J 2019;32:560-565


How to cite this URL:
Alsisy AA, Alkhateep YM, Salem IE. Comparative study between intrahemorrhoidal diode laser treatment and Milligan–Morgan hemorrhoidectomy. Menoufia Med J [serial online] 2019 [cited 2019 Dec 16 ];32:560-565
Available from: http://www.mmj.eg.net/text.asp?2019/32/2/560/260884


Full Text



 Introduction



Hemorrhoidal disease is ranked number one among colorectal diseases with predictable prevalence ranging from 2.9 to 27.9%, with more than 4% of those patients who are symptomatic[1].

Because of the increased incidence of hemorrhoids and despite treatment diversity, several complications such as bleeding, strangulation, thrombosis, fibrosis, ulceration, suppuration, and portal pyemia can occur[2].

There are many treatments of hemorrhoids varying from medications and band ligation to stapled hemorrhoidopexy, laser photocoagulation, sclerothereapy, Doppler-guided artery ligation, and finally surgery[3].

Milligan–Morgan (MM) procedure is the gold standard and the most frequently used surgical method. Postoperative pain is the most common trouble with this surgery. The other early complications are urinary retention, hemorrhage (secondary or reactionary), and abscess formation. The long-term complications include anal fissure, anal stenosis, stool incontinence, perianal fistula, and recurrence of the disease[4].

These drawbacks have led to the introduction of diode laser treatment in this study, giving rise to numerous advantages such as easy and efficient application, and noninvasive nontoxic painless nature, in addition to reduce the need of pharmaceutical drugs, drug interactions, and their side effects[5].

In this study, we aim to evaluate the efficacy of the intrahemorrhoidal diode laser compared with MM surgery in the management of hemorrhoids.

 Patients and Methods



A prospective study was carried out in the Department of Surgery of Menoufia University Hospital after obtaining approval of the Ethics Committee. Patients who fulfilled the inclusion and exclusion criteria and completed the follow-up for 3 months were included in the study. There were 60 consecutive patients during the period from April 2016 to September 2017.

Eligible patients were randomly assigned using sealed opaque envelopes in the operating room into one of the two groups: group A (intrahemorrhoidal diode laser treatment, n = 30), group B (MM hemorrhoidectomy, n = 30).

A written informed consent was obtained from all participants after an explanation of the associated risks, benefits, and description of the study protocol. The inclusion criteria included diagnosis of hemorrhoid grades II and III. The exclusion criteria included coexisting anorectal disease, local complications (such as perianal fistula, anal fissure, or abscess), previous history of anorectal surgery, regular use of immunosuppressants or analgesics, patients with neurologic deficit or chronic pain syndrome, and patients already taking narcotic analgesics in addition to unfit patients either for surgery or anesthesia due to bad general conditions, hematological disorders, liver cirrhosis, and uncontrolled diabetes.

Operative technique

The procedures were standardized as far as possible to allow comparability. The operations were performed under standardized spinal anesthesia with the patient in lithotomy position.

Group A: Laser group

In this study, we use ARC laser GmbH (Nuremberg, Germany) as a type of diode laser, which is composed of ARC laser generator device, ARC needle, and ARC bare fiber of 400 μm, as shown in [Figure 1].{Figure 1}

All cases underwent anorectal examination for any other anorectal disease such as cancer, fistula, prolapse, fissures, etc. Before laser shooting, we must wear antilaser glasses. A diode 30-W laser with 980-nm wavelength was used for this procedure. The light is coupled into a fiber with a distal fiber end prepared for radial emission and a cone shaped for easy interstitial application. After making a 1 mm opening at the external border of the hemorrhoid pocket, the fiber was introduced in the hemorrhoidal tissue parallel to the axis of the rectum up to the upper part of the enlarged hemorrhoid. Three pulses at a power of 15 W, each lasting for 1.2 s, with a 0.6 s pause between pulses, were delivered to the tissue. For hemorrhoidal tissues wider than 1 cm, the same three pulses of energy were applied after pulling back the fiber and repositioning it in a fan-shaped manner in the lateral portions of the tissue to coagulate all parts of the enlarged hemorrhoid. The laser beam induced a degeneration of mucosal and submucosal tissues, causing shrinkage of the underlying tissue and its arterial branch to a depth of ∼5 mm. The two procedures were limited only to hemorrhoidal cushions and were not applied all around the anal canal. To decrease postoperative edema, pressure with an ice pack was applied on the coagulated tissue for 30–45 s. Using a laser in a temporized pulsed-delivery manner results in reduced undesired degeneration of periarterial normal tissue. It was clearly seen that the hemorrhoids shrink in size. Finally, the fiber was withdrawn from it. This can be repeated for any hemorrhoid in another site.

Group B: Milligan–Morgan group

First, expose the field by Ferguson retractor (Amazon healthcare company, Seattle, Washington, USA) or a proctoscope, and then make an elliptical incision (v-shape incision) after fixation of the hemorrhoid by Allis forceps. Second, cutting the skin and the mucuous membrane at the mucocutaneous junction pushes the internal sphincter laterally, until reaching the pedicle of the hemorrhoid, which is then ligated or transfixed with silk ligature. At the end, excise the hemorrhoid distal to the ligature. Repeat the procedure for all hemorrhoids.

Outcome measures

Pain was assessed within the first postoperative 24 h using a visual analog scale (VAS) scoring system, with 0 corresponding to 'no pain' and 10 representing 'maximum pain'[6]. Intraoperative events and postoperative complications, including bleeding, urinary retention, wound infection, and administered morphine dose were evaluated. The operating time was assessed (min). Patients' symptoms and the recurrence of hemorrhoid columns were evaluated at each follow-up visit.

Discharge and follow-up

Patients were discharged the day after the surgery when well-tolerated oral feeding and pain level was less than 4 VAS with no postoperative complications. Patients were followed up for at least 3 months after the procedure.

Statistical analysis

Data were statistically described in terms of range, mean, SD, median, frequencies (number of cases), and percentages when appropriate. Comparison of quantitative variables between the study groups was done using the Student's t-test. A P value less than 0.05 was considered statistically significant.

 Results



A total of 60 patients were allocated to two groups with 30 cases, each undergoing either MM hemorrhoidectomy (group B) or intrahemorrhoidal coagulation with a 980-nm diode laser (group A). No harm or unintended effects were received by each patient. No changes were made in the method, design, and eligibility criteria of the study after ending the trial. The two groups were similar in terms of mean age and sex ratio, preoperative symptoms, hemorrhoid grades, and number of treated hemorrhoidal columns [Table 1].{Table 1}

Intraoperative bleeding volume and postoperative bleeding events were significantly higher in group B than those in group A (P < 0.05). The operative time was also significantly shorter in group A than in group B (30.63 ± 4.90 vs. 50.50 ± 10.12 min, P < 0.001).

Intraoperative blood loss was clearly higher in group B than in group A (36.50 ± 7.21 vs. 15.50 ± 4.80 ml, P < 0.001).

Postoperative pain was obviously lower in group A in the first 24 h after the procedure (P < 0.001, [Table 2]). Postoperative pain ranged from 1 to 8 with a mean value of 2 according to VAS in group A. Postoperative pain ranged from 3 to 10 with a mean value of 6 according to VAS in the MM group. In group A, mild pain (1–3) was represented in 21 (70% of patients) patients, moderate pain (4–6) was in six patients representing 20% of patients, and severe pain (7–10) was represented in three (10% of patients) patients. In the MM group (group B), mild pain (1–3) was in four (about 13.3% of patients) patients, moderate pain (4–6) was in 18 patients representing 60% of patients, and severe pain (7–10) was in eight patients representing 26.7% of patients [Table 3].{Table 2}{Table 3}

The dose of postoperative administered morphine and the number of patients who used analgesics after discharge were significantly lower in group A than in group B (P = 0.01) [Table 2].

The period of postoperative hospital stay was lower in group A than in group B (1.10 ± 0.31 vs. 1.20 ± 0.41 days, P = 0.286) [Table 2].

The period of the patients needed to return to their work was significantly lower in group A than in group B (7.53 ± 1.80 vs. 22.87 ± 3.91 days, P < 0.001) [Table 2].

There was no statistically significant difference between both groups according to postoperative bleeding on the day of the surgery (P = 1.00). Incidence of urine retention was significantly higher in group B than in group A (P = 0.038) [Table 4].{Table 4}

There was no statistical difference between both groups according to late postoperative complications with regards to anal discharge and acute thrombosis during the follow-up period (P = 0.076 and 0.076, respectively); in addition, anal stenosis was significantly higher in group B than in group A (P = 0.038) [Table 5]. However, three patients in group B experienced postoperative discharge, and three patients in group A were presented with thrombosis of the external hemorrhoid 3–4 days after the surgery, which was resolved with medications.{Table 5}

The outcome of patients after 3 months of follow-up is demonstrated in [Table 6]. No statistically significant differences were observed between both groups regarding complete resolution within the follow-up. Also, the two groups did not differ in terms of symptoms such as bleeding, pain, or itching, as well as the need to be operated again for symptomatic hemorrhoids or medical treatment for residual symptoms 3 months after the procedures (P > 0.05) [Table 6].{Table 6}

 Discussion



In this study, the mean operation time in the diode laser was shorter than MM hemorrhoidectomy. Intraoperative blood loss decreased in the laser group. On the day of the surgery, the patients, who underwent hemorrhoid surgery using the diode laser, had less postoperative pain and needed fewer dosages of pethidine injections and thereafter postoperative oral analgesics requirement. In this study, there was no statistically significant difference between both groups with regards to the length of postoperative hospital stay.

In this study, three patients had thrombosis 3–4 days after the laser surgery that they were medically treated by hot fomentations and Daflon as a medical agent, whereas in the MM group, 12 patients had postoperative complications: four patients had early postoperative urine retention who were managed by insertion of Foley's catheter and another patient had an early postoperative bleeding from the surgical wound and stayed in the hospital. Anal packing and hemostatic drugs stopped the bleeding. In addition, three patients experienced excessive discharge from the surgical wound, which was managed by antibiotics, followed by complete recovery during the follow-up period. Furthermore, another four patients had anal stenosis and were readmitted to the hospital and treated by lateral sphincterotomy under anesthesia, followed by complete recovery during the follow-up period.

There was no statistically significant difference in early postoperative bleeding, between both groups. Urine retention and anal stenosis were significantly higher in the MM group than in the laser group. In this study, patients underwent diode laser therapy and returned faster to normal activity than patients who underwent MM hemorrhoidectomy. In our study, during 3 months of follow-up, no recurrence was seen.

Different studies reported that laser therapy was more effective than open surgery in terms of reduced postoperative pain, operation time, blood loss, and time to return to normal activity.

The study by Sadra and Keshavarz[7] was founded on the superiority of using intrahemorrhoidal coagulation with a 980-nm diode laser in comparison with MM hemorrhoid surgery in patients with symptomatic hemorrhoid nonresponding to medical treatment. This promising efficacy was practical in terms of pain level, severity of intraoperative and postoperative hemorrhage, length of postoperative hospital stay, and dosage of obsessive morphine for pain relief. However, no difference was observed regarding the frequency of urinary retention, postoperative wound infection, regression of hemorrhoids, and improvement of the clinical signs of the hemorrhoid till 6 months after the procedure[7].

The study by Naderan et al.[8] verified that intrahemorrhoidal treatment with a 980-nm diode laser has some advantages over MM hemorrhoidectomy in treating patients for symptomatic hemorrhoids. This laser-ablation procedure has shorter operative time, less postoperative pain, and better regression of hemorrhoidal pockets. Two patients in the laser group were presented with thrombosis of the external hemorrhoid within 7–10 days after the technique, which was resolved medically. This can be a particular complication of intrahemorrhoidal treatment, as the external part may lose its venous drainage leading to thrombosis[8].

Maloku et al.[1] reported that laser hemorrhoid treatment was more efficient than MM hemorrhoidectomy in reducing postoperative pain and mean time of operation.

Jahanshahi et al.[9] reported that laser is a safe technique for the treatment of hemorrhoids due to less postoperative complications such as bleeding, pain, stenosis, and recurrence.

Karahaliloglu[10] used a 980-nm diode laser in the treatment of patients with grade I and II hemorrhoids, and reported that this procedure is painless, resulting in faster recovery of all patients.

Plapler et al.[11] concluded that CO2 laser hemorrhoid surgery has advantages, principally in terms of postoperative pain in comparison with the MM procedure.

In a cross-sectional study, de Nardi et al.[12] reported that there was complete resolution of hemorrhage in 96.7% of their patients, diminishing of pain in all patients, and no significant complication during 2 years of follow-up[12].

Crea et al.[13] concluded that using a 980-nm diode laser for treatment of grade II and III symptomatic hemorrhoids was considered to be safe, efficient, and painless. No significant complications such as anal stenosis and recurrence occurred at 2 years of follow-up[13].

In contrast, Senagore et al.[14] compared the outcome of treatment between the Nd: YAG laser and open surgical excision in patients with advanced hemorrhoids. Their study showed no significant difference between the two groups for hemorrhage, mean time of operation, postoperative pain scores, postoperative administration of analgesics, wound healing, and time to return to normal activity[14].

 Conclusion



Although the use of the diode laser has some drawbacks as the increased cost over the MM surgery, it carries several advantages such as reduced postoperative pain, reduced doses of analgesics needed postoperatively, and good hemostasis as well as reduced postoperative pain that significantly reduced the time needed to return to work. Our study suggests that intrahemorrhoidal diode laser treatment, if available, is the favorite surgical method.

Recommendations

Further studies using a large number of patients and for a long period of follow-up may be needed to measure other complications and the recurrence rate. In our study, the main limitation was follow-up duration that was about 3 months.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Maloku H, Gashi Z, Lazovic R, Islami H, Juniku-Shkololli A. Laser hemorrhoidoplasty procedure versus open surgical hemorrhoidectomy. Acta Inform Med 2014; 22:365–367.
2Katdare MV, Ricciardi R. Anal stenosis. Surg Clin North Am 2010; 90:137–145.
3Pandini LC, Nahas SC, Nahas CS, Marques CS, Sobrado CW, Kiss DR. Surgical treatment of hemorrhoidal disease with carbon dioxide laser and Milligan–Morgan cold scalpel technique. Colorectal Dis 2006; 8:592–595.
4Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am 2002; 82:1153–1167.
5Barcly L. Best option for evaluating and treating hemorrhoids. BMJ 2008; 336:380–383.
6Delbos A. Management of post-operative pain on surgical wards. Ann Fr Anesth Reanim 1998; 17:649–662.
7Sadra M, Keshavarz M. Comparison of intrahemorrhoidal coagulation with 980 nanometer diode laser and Milligan–Morgan hemorrhoidectomy. J Clin Res Gov 2015; 4:1–4.
8Naderan M, Shoar S, Nazari M, Elsayed A, Mahmoodzadeh H, Khorgami Z. A randomized controlled trial comparing laser intra-hemorrhoidal coagulation and Milligan–Morgan hemorrhoidectomy. J Invest Surg 2016; 30:325–331.
9Jahanshahi A, Mashhadizadeh E, Sarmast MH. Diode laser for treatment of symptomatic hemorrhoid: a short-term clinical result of a mini-invasive treatment, and one-year follow-up. Pol Przegl Chir 2012; 84:329–332.
10Karahaliloglu AF. Laser hemorrhoidoplasty (LHP): a new surgical procedure for the treatment of advanced hemorrhoidal illness. Coloproctology 2010; 32:116–123.
11Plapler H, Hage R, Duarte J, Lopes N, Masson I, Cazarini C, et al. A new method for hemorrhoidal surgery: intra hemorrhoidal diode laser, does it work? Photo Med Laser Surg 2009; 27:819–823.
12De Nardi P, Tamburini AM, Gazzetta PG. Hemorrhoid laser procedure for second-and third-degree hemorrhoids: results from a multicenter prospective study. Tech Coloproctol 2016; 20:455–459.
13Crea N, Pata G, Lippa M. Hemorrhoidal laser procedure: short-and long-term results froma prospective study Am J Surg 2014; 208:21–25.
14Senagore A, Mazier WP, Luchtefeld MA. Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser. Dis Colon Rectum 1993; 36:1042–1049.