Lasers in endoscopic gastrointestinal surgery

The Evaluation of Laser Application in Surgery: A Review Article

There are several types of surgeries which use lasers in the operating room. Surgeons use lasers in general surgery or surgical specialties to cut, coagulate, and remove tissue. In modern medicine, the application of laser therapy is an attractive subject due to its minimal invasive effect. Today lasers are widely used in the treatment and diagnosis of many diseases such as various cancers, lithotripsy, ophthalmology, as well as dermatology and beauty procedures. Depending on the type of lasers, the wavelength and the delivery system, most lasers have replaced conventional surgical instruments for better wound healing results. Over time, by using many different tools and devices, new lasers have been created; as a result, they are used in a wide range of medical special cases. In this review, laser applications in surgery and its beneficial effects compared to previous surgeries with the aim of providing appropriate therapeutic and non-invasive solutions with minimal side effects after surgery are investigated.

Acute Gastrointestinal Bleeding

A greater understanding of the pathophysiology of gastrointestinal bleeding has been accompanied by a rapid advancement in therapeutic technology. Newer endoscopic and radiologic techniques are being tested to determine their appropriate uses, but pharmacologic therapy has yet to be proved beneficial. A discussion of the newer as well as some traditional therapies is presented.

Applications of endoscopic surgery in pediatric patients

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been few reports of the use of this technology in the pediatric population. Because of their minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal for this age group. Here we present our experience with endoscopic pediatric plastic surgery. From February of 1995 to August of 1997, 104 patients underwent 139 procedures utilizing 5- and 10-mm endoscopes. There were 58 male and 46 female patients. The mean age at surgery was 5.6 years (range, 3 weeks to 19 years). The most common type of procedures performed were insertion of tissue expanders (n = 34), excision of benign head and neck masses (n = 27), torticollis release (n = 20), excision of vascular lesions (n = 13), and miscellaneous procedures, (n = 10). There were 26 complications in 139 procedures (19 percent). Seventeen (65 percent) were in the tissue expander group. The rest were scattered among the groups with other diagnoses. Although there did not appear to be a specific type of complication associated with endoscopy, 77 percent occurred in the first 2 months of our study. This suggests a relatively steep technical learning curve. These results demonstrate that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds, with complication rates that are comparable with those of conventional open surgical treatment.

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.

Acute lower gastrointestinal bleeding

Lower gastrointestinal bleeding ranges from occult blood loss to massive hemorrhage and shock. There are many causes but diverticulitis and angiodysplasia remain the most common sources of major hemorrhage. This article emphasizes the cause and evaluation of moderate to severe acute lower gastrointestinal bleeding.

Endoscopic laser applications in the gastrointestinal tract

The Nd:YAG and, to a lesser degree, the argon laser have become valuable tools for the surgical endoscopist. Over the last 10 years, the impetus for application of these expensive instruments has changed from what the laser can do to what the laser can do better than less expensive technology. Whereas a few controlled randomized studies suggest that the Nd:YAG laser is better than no therapy and equivalent to other heat-producing instruments for control of upper gastrointestinal bleeding, such studies do not exist for other laser applications. Despite the lack of such studies, we remain convinced that, where available, lasers are the instrument of choice for palliation of unresectable mucosal-based cancers, coagulation of arteriovenous malformations, and ablation of certain adenomatous polyps in selected patients. New techniques on the horizon include the use of endoscopic photo-dynamic therapy for treatment of gastrointestinal cancers and endoscopic laser fragmentation of large common bile duct stones. The potential role for a nonthermal "endoscopic scalpel" is questionable because most gastrointestinal tissues are well vascularized; however, a pulsed laser capable of cutting and coagulation, such as the holmium:YAG laser, may be of some value for incisional endoscopic procedures.

Angiodysplasia. Natural history and efficacy of therapeutic interventions

Angiodysplasia, a disease for which the optimal treatment is uncertain, is a frequent cause of lower intestinal bleeding among older patients. To study the natural history of angiodysplasia and compare the efficacy of medical therapy, endoscopic electrocoagulation, and surgery, the course of 101 patients evaluated from 1974 through 1983 at the Massachusetts General Hospital was reviewed. Angiodysplasia caused bleeding that ranged from occult blood in stools to massive hemorrhage and was also observed incidentally in nonbleeding patients. Patients were followed for up to 10 years (mean of 22 months). Rebleeding was defined as evidence of hemorrhage requiring hospital admission, transfusion, or surgery. Thirty-one patients were treated surgically, 19 patients were treated endoscopically, and 36 patients were treated medically. Using life table analysis we observed similar rebleeding rates among medically and endoscopically treated groups. The surgically treated group had a frequency of rebleeding less than half that of the other groups (P = 0.15). A multivariate regression analysis failed to identify any factors other than coagulopathy to explain the different incidence of rebleeding in the patients treated by endoscopic electrocoagulation and surgery.

Quantitation of colonic injury from argon laser, neodymium: YAG laser and monopolar electrocautery applied to flat mucosa and small sessile polyps of the canine colon

This study determined the optimum laser energy for ablation of colonic mucosal lesions and small sessile polyps in the canine colon. Neodymium (Nd):YAG laser, argon laser, and monopolar electrocautery were applied to exposed canine colonic mucosa for various application times at various power settings. At the minimum energy level necessary to ablate mucosa, the Nd:YAG laser caused greater muscularis injury than the argon laser and monopolar electrocautery. At higher energy levels, monopolar electrocautery and Nd:YAG laser caused greater muscularis injury than argon laser. Small surgically created polyps in the canine colon were ablated endoscopically with the three energy sources. Single-session complete polyp ablation occurred most frequently with Nd:YAG laser and least frequently with argon laser. The depth of tissue injury beneath polyp ablation sites was least with argon laser and greatest with Nd:YAG laser. This study suggests that the argon laser is safer than the Nd:YAG laser or monopolar electrocautery for coagulation of flat colonic mucosal lesions. Although the argon laser is safer for the coagulation of small sessile colonic polyps, it may be less effective than monopolar electrocautery or the Nd:YAG laser for the single-session fulguration of polyps greater than 5 mm in diameter.

Laser surgery in colonic and anorectal lesions

Endoscopic laser therapy for diseases of gastrointestinal tract in general, and lesions of colon, rectum, and anus in particular, is in its infancy. Advances are expected to be made to define those lesions that are amenable to lasers and those that are not. In this process, it is hoped that the relative merits and demerits of the various modes of endoscopic therapy might be brought to light. With the advent of contact Nd:YAG laser technology, it is increasingly realized that such a mode of operation could be used to great advantage in both endoscopic and open surgery related to lower-gastrointestinal tract diseases. Furthermore, contact Nd:YAG laser therapy definitely appears to be efficient and safe and compares favorably with other therapies available. How such an effective modality should be sequenced in combination with other available therapies has yet to be worked out. There is more to be done in this arena, which holds high promises.

Endoscopic laser surgery in the colon and rectum

The first applications of laser energy in the gastrointestinal tract occurred barely a decade ago. Since then, endoscopic laser therapy has become widespread in the management of colonic and rectal disease. Applications have been developed for the palliative therapy of obstructing or bleeding malignancies, for the management of some benign and premalignant mucosal diseases and for certain anatomic problems such as anastomotic strictures. Recurrent bleeding from mucosal vascular lesions can be controlled with laser therapy. Methods for treating anorectal disorders also are evolving. The continuing development of new endoscopic systems for increasing ease of access to the gastrointestinal tract all point to ever-increasing applications for laser therapy in colonic and rectal surgery.

The use of laser in rectal surgery

Ten patients with rectal tumors were treated by surgical excision of the tumor using a CO2 laser Sharplan 733 CO2 laser, Laser Industries Ltd., Israel. The laser permitted sharp excision, evaporization, or fulguration of tissue. Good hemostasis was achieved. Anesthesia was unnecessary in cooperative, calm patients. There was no mortality or morbidity related to the procedure. In five patients with villous adenoma the tumor was resected with one recurrence as yet (followup 4-16 months). Five patients with inoperable carcinoma were treated for palliation with good results. Our preliminary results indicate that the CO2 laser can be a useful asset in rectal tumor surgery, especially in elderly, moribund patients and in the definite treatment of benign tumors of the rectum.