Recently many hands-on training workshops have been conducted to impart education to physicians regarding the use of laser for the treatment of haemorrhoids and other Ano-rectal disorders in Pakistan. Many websites are also promoting some doctors as laser specialists for the cure of this disease.
Brief review of the literature regarding the pathogenesis and treatment of haemorrhoids is presented here for safe and effective use of this technology, and better understanding of the disease and its management.
What are haemorrhoids?
In the galaxy of benign anal disorders, symptomatic piles occur in 4% of the population. The anus receives its blood and nerves supply from two sources. Normally blood vessels from the intestinal side form three sets of dilatations, two on the right side and one on the left side. These vascular pads engorge under certain conditions, such as long-standing constipation, prolonged straining at the time of passage of stool, sedentary lifestyle, and diet that is deficient in fibre content. With advancing age, the fibro muscular system of the intestine, which keeps the vascular cushion within its place loosens, due to which these cushions hinder the passage of stool in the anal canal. These dilated and loosened vessels, covered with thin membrane of mucous, readily discharge bright red arterial blood. If not checked, through lifestyle adjustment and well-known office procedures, the process of descent from intestine to the verge of the anal continues. Ultimately the vascular pads pop out of the anus requiring repositioning by the patient.
With occasional bleeding episodes, these dilated cushions are the first degree haemorrhoids, advancing to complete prolapse from the anus to become fourth degree haemorrhoids. Bleeding may now be accompanied by itching due to mucous discharge, pain due to thrombosis, and prolapse. First degree haemorrhoids can be seen on examination by the surgeon, while stage-2 and further haemorrhoids are felt by the sufferer. Due to social taboos and occasional painless bleeding people generally procrastinate seeking treatment. The primary haemorrhoids are different from secondary haemorrhoids, which may occur due to some underlying disease like cancer. It is, therefore, recommended that in advanced age symptomatic haemorrhoids must be further investigated and screened for some underlying disease.
Anatomy and physiology of the anal canal
Anus is the lowest part of the large intestine. The smooth muscles of the intestine (colon) and the skeleton muscles of the pelvis, under complex neurological mechanisms hold and allow to pass solid, liquid, and gaseous material at the will of the individual. Unlike being static in cadaver, the living anus is dynamic with anterior angulation. It is estimated to be 1.5 to 2.5cm in the front, 2 to 3cm on the side, and 3 to 4cm on the back. With the discharge of semi-solid material, its diameter may change between 1.2 to 4cm. communicating vascular cushions return blood to the corresponding veins without the Valvular mechanism in place, which is normally present in the veins in other parts of the human body. As described, corpora cavernosa recti make the muscular sphincters of the anus more competent to handle the ugly situation of involuntary discharge from the anus. These cushions are held firmly in the upper part of the anus with minimum allowance for descent by the muscle fibres of the intestine during defecation. This supporting mechanism may grow weak with advancing age, prolonged straining, incoordination in the muscular control mechanism, and raised intra-abdominal pressure.
Treatment of haemorrhoids
Vascular anal cushions are normal but the progress to symptomatic piles is an abnormality, the pathogenesis of which is not fully understood, though some risk factors have been mentioned. Symptomatic haemorrhoids were known to ancient physicians and they recorded the appearance and treatment of the condition. The treatment varied from tying, cutting, freezing, burning, or ligating. In fact, most of the present procedures for the treatment of haemorrhoids are innovations of the older versions with more efficacy to control the disease and least structural and functional loss if any. The first and second degree haemorrhoids, in most of the cases, respond to dietary changes and suitable life style adjustment. First, second, and early third degree can be settled with office procedures done in the outpatient clinics. Sclerotherapy, rubber band ligation, cauterization and infrared photocoagulation are the common office procedures suitable in 85% of the patients. The estimated recurrence rate of 20% to 25% in the five-year period has been recorded in these procedures.1 Doppler ultrasound has been used to identify the vessels supplying blood to the anal cushions and ligating the same. The results were initially promising with lesser pain and hospital stay, and early return to work. Depending upon the size and degree of the haemorrhoids and mid-term follow-up recurrence has ranges from 0% to 40%.
Modern surgery, saw a decent progress in cutting the haemorrhoids and leaving the raw area to heal secondarily or primarily by closing the wounds after cutting the haemorrhoids. The post-operative pain, hospital stay, and recurrence of the symptoms have remained comparable in both the procedures. Too much cutting of the tissue around the anus has met with complications like narrowing of the anus or loss of control over the discharge of flatus or faeces. Less cutting is met with recurrence of the symptomatic diseases. The most appropriate selection is in between, which is the gold standard. The surgical excision (cutting) has been replaced with surgical fixing as haemorrhoidopexy. Longo’s surgical circular stapler was the innovative method for this purpose, causing the removal of doughnut like circular piece of mucosa above the haemorrhoids. The procedure met initial success with spectacular results, but with disastrous complications. Even at the cost of complications, long-term follows-up remained the same. There was less initial pain and hospital stay was reduced but the rate and nature of the complications were severe. The stapled haemorrhoidopexy, because of unpredictable results, never got widespread popularity.2
Laser, which stands for light amplification through stimulated emission of radiation, has remained in medicinal use for quite a long time. Laser appeared in proctology, in 2000, and made its place with much hype for its efficacy. With improvement in fibre optic technology to control the accuracy of heat energy, surgeons have been using Diode laser with confidence in internal haemorrhoids. The laser has no role in ulcerated, prolapsed, and strangulated haemorrhoids. The laser, by emitting light at different frequencies, produce heat which works by photocoagulation of the vessels and photoablation of the tissue. Experts have different views regarding the efficacy of laser in coagulating the haemorrhoidal vessels at the site of entry in the anus (haemorrhoidal artery). Recent systematic review and meta-analysis has appeared in the Annals of Coloproctology comparing the results of laser haemorrhoidoplasty (LH) with conventional haemorrhoidectomy (CH).3 The authors have conducted meta-analysis in accordance with the Cochran guidelines, and have concluded that recurrence of medium-term symptoms at 12 months has remained similar in both CH and LH. LH offers favourable short-term outcomes with reduced pain, lesser hospital stay, and early return to work and daily activities.
References
1. Fischer’s Mastery of surgery, Editor Josef Fischer, section VII, the gastro-intestinal tract, seventh edition, pg 1922, Wolters Kluwer
2. MRB Keighley, Fischer Mastery of Surgery Editor Josef Fischer, section VII, the gastro-intestinal tract, seventh edition, pg 1927, Wolters Kluwer.
3. Ian Jun Yan wee et al Laser haemorrhoidoplasty versus conventional haemorrhoidectomy for grade II /grade III haemorrhoids: a systematic review an meta-analysis; Ann Coloprctol2023;391(1):3-10, www.coloproctol.org.
4. Kamal Gupta, Lasers in proctology; recurrence after laser haemorrhoidoplasty, pg 108; Springer Nature Singapore
* The author is former
Vice Chancellor SMBBMU
Larkana, Pakistan.
