Doppler-guided hemorrhoidal dearterialization with laser (HeLP): a prospective analysis of data from a multicenter trial

Laser technology in proctological diseases: is it really the wave of the future?

Different types of lasers have been applied for various proctological conditions. We discuss about published articles regarding the application of lasers, with concern about evidence-based use of these techniques and technologies. We performed a literature search about laser treatments for proctological conditions. 55 studies were included for the final revision. Meta-analysis of data was not performed because of heterogeneity of study designs and outcome measures. A scoping review was performed. Laser treatments for hemorrhoids require a shorter operative time and show less postoperative pain and bleeding compared to conventional hemorrhoidectomy, but are more expensive. Studies are heterogeneous in design, endpoints, postoperative assessment, length of follow-up and outcome measures. Only 3 RCTs are available and only three studies evaluate long-term outcomes. FiLaC (fistula laser closure) was initially described in 2011 for the treatment of anal fistula. In the published studies the reported healing rates vary between 20 and 82%, and the ideal indication is yet to be defined. Studies with long-term follow-up are lacking. SiLaT (sinus laser treatment) applied the technology used for FiLaC to the treatment of pilonidal sinus disease. This technique had less perioperative pain and shorter hospital stay, but a lower primary healing rate when compared to traditional techniques. Available data is very limited, and no randomized trials are published to date. Laser assisted techniques are a viable, minimally invasive, but expensive option for the treatment of several proctological conditions. Further researches are needed to assess if patients could benefit of their use, and for what indication.

Hemorrhoid laser dearterialization: systematic review and meta-analysis

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

The effects of laser procedure in symptomatic patients with haemorrhoids: A systematic review

Purpose

Haemorrhoids are normal structures in the human body, only seen as pathological when symptomatic. Nowadays, new techniques have surfaced using a diode laser which, after locating the target arteries, blocks the blood flow while hitting and shrinking the local mucosa/submucosa at a depth of 4 mm. Our work aimed to give a broad view over this new technique and its consequences in the post-operative follow-up with a systematic review.

Methods

EMBASE and MEDLINE databases were consulted, retrieving clinical trials, which mentioned the use of 980 nm diode laser on the treatment of haemorrhoids.

Results

Ten clinical trials analyzing the post-operative effects of laser haemorrhoidectomy were selected, including 2 randomized controlled clinical trials and 1 controlled clinical trial. The overall quality of the trials was low, indicating a high risk of bias.

Conclusion

The laser haemorrhoidectomy procedure revealed a high therapeutic potential, considering the reduced number of postoperative complaints (bleeding/pain), the high symptom resolution and the reduced recurrence, albeit the high heterogeneity between the studies in terms of reported results. Future investigations with higher quality and controlled double-blinded studies obtaining better-categorized results should be conducted in order to better evaluate this procedure and compare it to the current paradigm.

Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff

AIM

Guidelines benefit patients and clinicians by distilling evidence into easy-to-read recommendations. The literature around the management of haemorrhoids is immense and guidelines are invaluable to improve treatment integrity and patient outcomes. We identified current haemorrhoid guidelines and assessed them for quality and consistency.

METHODS

A systematic search of the literature from January 2011 to October 2021 was carried out. Guidelines identified were assessed for quality using the AGREE II instrument and for consistency in terms of tabulated treatment recommendations.

RESULTS

During this period nine guidelines were identified worldwide. The general quality was poor with only one guideline considered of high enough quality for use. In general, expert selection criteria for guideline development groups were vaguely defined. There were inconsistencies in the interpretation of the published evidence leading to variation in treatment recommendations.

DISCUSSION

Fewer, higher quality guidelines, with more consistent results, are needed. Particular attention should be given to defining the selection of experts involved.

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

Preliminary Results of the First 50 Patients Undergoing Sclerotherapy for II-Degree Hemorrhoidal Disease Using an Automated Device

Background

Sclerotherapy is defined as the injection of sclerosant agents causing fibrosis and scarring of the surrounding tissue. It is currently employed for the treatment of I-III degree hemorrhoidal disease (HD). The aim of this study is to investigate the use of a new automated device for the injection of 3% polidocanol foam.

Methods

This is an observational study including 50 patients who underwent a sclerotherapy procedure with 3% polidocanol foam for II-degree HD according to Goligher classification. Patients were evaluated through validated scores [Giamundo score, Hemorrhoidal Disease Symptom Score (HDSS), Short Health Scale (SHS-HD) and Vaizey score]. Follow-up was conducted until 3 months from the procedure.

Results

Complete resolution of bleeding was achieved in 72% and 78% of patients, respectively, at 1 week and after 3 months from the procedure. Forty eight percent of patients were symptom free after the last follow-up visit (HDSS = 0). No major surgical complications were reported. Three patients out of 36 successfully treated, recurred, and needed a second sclerotherapy injection, which was successful in 2 of them.

Conclusion

These preliminary results of 3% polidocanol foam injection on 50 patients suggest the efficacy and reproducibility of the technique with this new device in the short-term follow-up.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM)

Background

The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids.

Methods

A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year.

Results

There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125).

Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred.

Conclusions

Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

Laser utility in the treatment of hemorrhoidal pathology: a review of literature

Hemorrhoidal disease is a common reason for consultation in proctology. It can be treated in several ways (medical, endoscopic, and surgical). Laser treatment has been described since 1960 and has developed in recent years. The purpose of this literature review was to study the results of laser treatment of hemorrhoids and to compare them with those of surgical methods. We performed a systematic search of the literature by querying the Medline, Google Scholar, and Cochrane Library databases. Retrospective studies and case reports were excluded. We selected 11 studies both techniques HeLP (hemorrhoid laser procedure) and LHP (laser hemorrhoidoplasty procedure). The total number of patients was 1179 including 1059 patients treated with laser and 120 treated surgically within the context of comparative studies. The age of the patients varies between 18 and 74 years old. HeLP laser treatment was significantly superior to surgical treatment in terms of postoperative pain (p < 0.001), hemorrhoidal disease downgrading (p < 0.001), and postoperative satisfaction (p < 0.001). Similarly, LHP laser treatment was significantly superior to surgical treatment in terms of operative duration (p < 0.00001), intraoperative bleeding (p < 0.00001), postoperative pain at H12 and H24 (p < 0.00001 and p = 0.0003), and postoperative bleeding rate (p < 0.001). The laser represents a revolution in the field of proctology mainly in the treatment of hemorrhoidal pathology. It is a safe, effective, and less painful mini-invasive technique. More rigorous studies will be needed to better evaluate this technique.

Non-excisional laser therapies for hemorrhoidal disease: a systematic review of the literature

Non-excisional laser therapies are emerging treatment for grades II and III hemorrhoidal disease (HD). However, so far, their efficiency is based on low-level evidence. Therefore, we aimed to systematically review the efficiency of non-excisional laser therapies for HD. MEDLINE/Pubmed, Web of science, Embase, and Cochrane were searched from database implementation until the April 17th, 2020. We included studies reporting at least one of surgical indicators of postoperative outcomes of laser therapies, encompassing laser hemorrhoidoplasty (LH) and hemorrhoidal laser procedure (HeLP). Fourteen studies describing LH and HeLP were included, representing 1570 patients. The main intraoperative complication was bleeding (0-1.9% of pooled patients for LH, 5.5-16.7% of pooled patients for HeLP). Postoperative complications occurred in up to 64% of patients after LH and 23.3% after HeLP. Resolution of symptoms ranged between 70 and 100% after LH and between 83.6 and 90% after HeLP. Moreover, four randomized controlled trials included in our review reported similar resolution after LH compared with hemorrhoidectomy or mucopexy and after HeLP compared with rubber band ligation. Recurrence rate was reported to range between 0 and 11.3% after LH and between 5 and 9.4% after HeLP. When compared with hemorrhoidectomy, LH showed conflicting results with one randomized controlled trial reporting similar recurrence rate, but another reporting decreased recurrences associated with hemorrhoidectomy. Laser therapies showed lower postoperative pain than hemorrhoidectomy or rubber band ligation. LH and HeLP are safe and effective techniques for the treatment of grades II and III HD.

Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review

BACKGROUND

Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment.

METHODS

We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed.

RESULTS

Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis.

CONCLUSION

Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial

BACKGROUND

Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure.

METHODS

Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis.

RESULTS

Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation.

CONCLUSIONS

The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed.

Superior rectal artery embolization for bleeding internal hemorrhoids

BACKGROUND

The aim of the present study was to evaluate clinical efficacy and safety of superselective embolization of the superior rectal artery (SRA) for the treatment of internal hemorrhoidal bleeding.

METHODS

Patients with stage II and stage III internal hemorrhoids, treated by interventional embolization of the SRA in our department between January 2017 and June 2019 were retrospectively evaluated. All patients suffering from disabling chronic hematochezia and some with relative contraindications for operation (n = 17) or rejection of conventional hemorrhoidectomy (n = 15). Superselective SRA branch embolization was performed using gelatin sponge particles (350-560 μm) and metallic coils (2-3 mm). This treatment process was planned by a multidisciplinary team consisting of proctologist, gastroenterologist and radiologist. The surgical efficacy, postoperative complications and follow-up outcomes were observed.

RESULTS

There were 32 patients (18 males, mean age 52 ± 12 years, range: 22-78 years), 12 (37%) with stage II hemorrhoids and 20 (63%) with stage III hemorrhoids. Embolization was successful in all patients, and bleeding symptoms resolved in 27 (84.4%) patients. The remaining 5 (15.6%) patients underwent either stapled hemorrhoidopexy (n = 4) or sclerotherapy (n = 1). Some patients experienced different degrees of pain (n = 4;12.5%), low fever (n = 11;34.4%), and tenesmus (n = 17;53.1%), which all spontaneously regressed without further treatment. All patients were followed up for at least 1 year. There were no serious complications, such as infection, intestinal ischemia or massive hemorrhage. Four patients (14.8%) had rebleeding during the first months of follow-up. All patients with re-bleeding were successfully treated with internal iliac arteriography and branch embolization and did not experience further bleeds after a minimum follow up 3 months follow-up.

CONCLUSIONS

The short-term efficacy of superselective SRA embolization for grade II-III internal hemorrhoids is good, and this method is safe and feasible.

[Submucosal laser ablation of internal hemorrhoids]

OBJECTIVE

To analyze efficacy and safety of submucosal laser ablation of internal hemorrhoids (SLT).

MATERIAL AND METHODS

Systematic review included 10 articles published in electronic databases PubMed, Cochrane Library, Elibrary until January 2019. There were only full-text publications from prospective clinical trials devoted to submucosal laser ablation in the treatment of hemorrhoids. Isolated SLT was used in 4 trials, combination with other minimally invasive procedures was reported in 6 reports.

RESULTS

SLT was predominantly used in the treatment of hemorrhoids grade 2-3. Efficacy of procedure was 91.1-100% after 6 months and 87.5-100% after 12 months. Intra- and postoperative complications included intraoperative bleeding (8.4%), perianal and external piles edema (8.2%), postoperative bleeding (2.7%), urinary retention (1.2%), anal fistula (0.6%), perianal abscess (0.14%).

CONCLUSION

Submucosal laser ablation is quite effective and safe option for treatment of hemorrhoids grade 2-3. However, further researches are required considering the absence of clear recommendations on laser beam parameters, indications for procedure and data on long-term outcomes.

Hemorrhoid laser procedure with suture-pexy (HeLPexx): a novel effective procedure to treat hemorrhoidal disease

BACKGROUND

The hemorrhoid laser procedure with suture-pexy (HeLPexx), consisting of Doppler-guided hemorrhoidal dearterialization with laser and the addition of anal mucopexy, is a novel non-excisional procedure to treat hemorrhoids. The aim of the present study was to describe the technique and report the clinical and long-term results.

METHODS

A prospective study was conducted on patients with grade III hemorrhoids who had HeLPexx from January 2012 to February 2018. Pre- and postoperative assessment included a thorough clinical examination, constipation and incontinence scoring systems and a symptom questionnaire which was administered at all patients before surgery and at each follow-up visit to evaluate bleeding, prolapse, manual reduction, discomfort or pain, and impact on quality of life. Each symptom had a score between 0 and 4, (0 indicates no symptoms and 4 indicates daily symptoms). The sum of the score for each symptom constituted the Hemorrhoid Symptom Score. Resolution of symptoms, pain, morbidity, need for further medical and/or surgical therapy were also recorded.

RESULTS

One hundred and seventy consecutive patients with grade III hemorrhoids [74 females; mean age 49.5 years (range 22-79) years] were included. Median length of follow-up was 36 (range 12-72) months. Postoperative morbidity included urinary retention (7 patients, 4.1%), bleeding not requiring transfusion (1 patient, 0.6%) and thrombosis of hemorrhoidal piles (2 patients, 1.2%). The mean postoperative pain VAS score at 1 week postoperatively was 1.8 ± 1.1 (range 0-5) and 12 (7%) patients used pain medications for more than 1 week postoperatively while none of the patients reported any pain by the end of the third week postoperatively. The Hemorrhoid Symptom Score significantly improved from 15.83 ± 3.04 to 1.3 ± 2.4 (p ≤ 0.001) and showed a statistically significant improvement in all items. Recurrent symptoms were reported in 12 patients (7%) who required further treatment. Severe chronic constipation prior to surgery was found to be a predictive factor of failure (p = 0.04).

CONCLUSIONS

HeLPexx appears to be safe and effective for treatment of symptomatic hemorrhoids. Further studies are needed to confirm our results.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.