The use of laser in rectal surgery

Local excision of rectal tumours

Local excision of colorectal tumour may be palliative or curative. Recent advances in minimal access techniques have allowed curative excision to be offered to a wider range of patients. Absolute indications for potentially curative local excision include mobile tumours, T1 tumours (assessed by ultrasonography), well or moderately differentiated histology (determined by biopsy) and tumour size less than 3 cm. Relative indications include T2 and T3 tumours (by ultrasonography), poorly differentiated histology (by biopsy) and tumour size greater than 3 cm depending on patient fitness. The rationale for these recommendations is described in detail.

Lasers in anorectal surgery

Laser technology has been applied widely in the treatment of hemorrhoids, condylomas, and anorectal neoplasms. It is claimed by its proponents to result in less pain, improved healing, and more rapid recovery as compared with conventional surgery. Laser therapy, however, is expensive and potentially dangerous, and advantages generally have not been substantiated by controlled clinical trials. The possible benefits and potential risks of laser treatment of anorectal disorders are examined.

Use of Nd-Yag laser ablation in colorectal obstruction and palliation in high-risk patients

Conventional treatment for colonic obstruction due to cancer or benign anastomotic strictures in high-risk patients or unresectable cases in some form of colostomy. This procedure has the negative aspects of requiring a general anesthetic and leaves the infirm patient with a stoma that they cannot easily attend to. Ablation of tumor by Nd-Yag laser has been available for several years, with passage of the laser fiber through a colonoscope. To evaluate the role of laser photocoagulation in the palliation of colorectal tumors or benign strictures, the authors summarized their initial experience, trying to define the indications, various methods of treatment, and complication rate in these patients. This technique is difficult to perform and has the added risk of intestinal perforation but does obviate anesthetic and surgical risks. Seven patients with recurrent metastatic colorectal obstruction, three patients with benign colonic strictures, and two patients with large villous tumors were treated with Nd-Yag laser passed via the colonoscope. The mean age was 71 years (range, 52 to 86 years). Five patients received sedatives only, six patients received epidural anesthetic, and one had a general anesthetic. The average total energy used was 3702 joules on noncontact fibers, and the average number of pulses was 126. Distance of the lesion from the anal margin ranged from 0.5 to 30 cm. Ten of twelve tumors were within 15 cm of the dentate line. In the most distal lesions, manual debulking with biopsy forceps facilitated the laser treatment. Symptomatic relief was achieved in all patients. One patient required a colostomy one month after treatment because of incontinence. Another patient needed a resection of a benign stricture after three laser treatments. Other than one case of microperforation, treated conservatively with antibiotics, no other complications occurred and there was no mortality. The authors believed that the Nd-Yag laser plays a specific role in the treatment of high-risk patients.

Laser therapy of cancer of the gastrointestinal and biliary tracts

Endoscopic laser therapy for the palliation of malignant tumors of the gastrointestinal (GI) tract has rapidly gained widespread acceptance by the medical community. This form of therapy can offer significant tumor palliation in a relatively noninvasive manner to patients who have few other therapeutic options. Since its initial use for the treatment of esophageal cancer it has been extended to the treatment of a number of other GI, tract malignancies and has in fact been utilized for the palliation of intra- as well as extrahepatic bile duct tumors. A number of advances have occurred, including improvements in lasers and laser delivery systems, refinement of treatment techniques, development of new wavelengths, and refinement of drugs that allow more specific therapy of cancer. With continued laboratory and clinical investigations, laser therapy should realize its full potential, ultimately becoming a curative treatment modality that will offer patients benefits that are equal to or greater than more invasive and disfiguring surgery without its attendant morbidity and mortality.

Nd-YAG laser photoablation of sessile villous and tubular adenomas of the colorectum

Neodymium (Nd)-YAG laser photoablation treatment was used to treat 46 patients with broad-based villous and tubular adenomas of the colon or rectum. These adenomas were distributed throughout the large bowel, with the majority (72%) located above the peritoneal reflection. Patients received an average of 2.1 treatments per adenoma, with 22 patients (48%) requiring only one treatment. Overall treatment success was achieved in 89% of cases (mean follow-up of 12 months), with four patients undergoing continued therapy. Of the patients who received a full course of treatment, only two (4%) were not taken to complete photoablation. Complications were minimal, and 92% of all laser treatments were done on an outpatient basis. Four patients had documented polyp recurrence that was controlled with additional laser treatment. Two patients with malignant polyps who were not surgical candidates were also treated with the laser, with no tumor recurrence seen at 11 and 14 months. Nd-YAG laser photoablation of large colonic polyps offers a safe, efficient, and cost-effective alternative to standard surgical resection.