Laser surgery in colonic and anorectal lesions

A new method for hemorrhoid surgery: intrahemorrhoidal diode laser, does it work?

OBJECTIVE

This study aimed to describe the clinical results of intrahemorrhoidal application of a diode laser.

BACKGROUND DATA

Hemorrhoids are a common source of pain, and no surgical technique achieves a painless outcome. Endovascular laser therapy for varicose veins as described in an experimental study is a method that could be used in the treatment of hemorrhoids, but there are few clinical trials described in the literature.

MATERIALS AND METHODS

Fifteen patients with second and third degree hemorrhoids underwent intrahemorrhoidal laser therapy. After the piles were identified, a fiber was introduced into each and it was irradiated with laser energy (810 nm, 5 W, frequency of 5 Hz, energy density of 19 J/cm(2), total energy of 4-10 J).

RESULTS

The piles were immediately partially reduced, and clinical examination 7, 14, 21, and 28 d after surgery showed complete healing in nine patients (60.4%) and partial resolution in five patients (33%). In one patient (6.6%) the treatment failed. Mean pain intensity throughout the study period, measured by a visual analog scale (0-10), was 0.84 +/- 1.13 (mean +/- SD). Major complications were burn lesions (n = 4) and residual plicoma (skin tag) (n = 5). Ten control patients underwent an open "cold scalpel" hemorrhoidectomy. Their pain intensity was 1.78 +/- 0.68 (mean +/- SD). There was a significant statistical difference (p = 0.018) between groups.

CONCLUSION

The diode laser energy delivered into small to median hemorrhoidal piles caused little pain and led to a partial to complete resolution within a short time compared to open hemorrhoidectomy. Some adjustments must be made to prevent burning lesions and residual plicoma. Although it is not a good method for big piles, this technique opens new possibilities for surgical treatment of hemorrhoidal disease.

Surgical treatment of haemorrhoidal disease with CO2 laser and Milligan-Morgan cold scalpel technique

OBJECTIVE

To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan-Morgan technique using either the CO(2) laser or cold scalpel.

METHODS

Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B). Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption.

RESULTS

Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P =0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction.

CONCLUSION

There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.

Effects of various laser wavelengths and energy levels on pig rectal submucosal tissue

This phase I animal study attempts to develop a nonexcisional method of treating hemorrhoidal varicosities submucosally using interstitial laser beam. Three laser wavelengths at four energy levels were applied interstitially to pig rectal submucosa to evaluate the effects on the vasculature, mucosa, and the muscle. As expected YAG laser caused a "cooking" of the tissue with necrosis and abscess formation. KTP laser was intermediate in its effect, causing less mucosal injury and muscle necrosis. Pulse dye laser had more specific effects on the vessels with little damage to the mucosa or muscle layers. Further studies using pulse laser are warranted as a possible nonexcisional interstitial treatment for hemorrhoids.

Characteristics of Nd:YAG sculptured contact probes after prolonged laser application

This study analyzed the functional and structural characteristics of cone, hemisphere, and modified sculptured contact fibers (1,000 microns) after 1 hour of continuous Nd:YAG laser application. Continuous laser application was performed on live porcine tissue using 20 watts of power. The fiber's appearance under a microscope as well as the power output was recorded after 0, 5, 10, 20, 30, 45, and 60 minutes of continuous laser application. (N = 3 for each fiber). At time 0, all fibers transmitted from 49 to 56% of the initial 20 watts (W); power transmission decreased to less than 9% relative power transmission after 20 minutes and then plateaued. The fibers exhibited severe distortion and carbonization of the surface where laser had been applied with evidence of quartz melting and shattering after only 10 minutes. By 30 minutes of laser application, all three fibers were fractured and essentially indistinguishable from one another; moreover, the fibers exhibited similar power transmission, and cutting and coagulation activity, as determined by a panel of independent, double-blinded surgeons. These data lead us to conclude that 1) Nd:YAG contact laser effects result from thermal heating of the fiber tip with subsequent tissue injury, 2) the unique structural configuration of the fiber's sculptured tip are lost after several minutes of laser application without appreciable change in functional integrity, and 3) fibers may be manually fractured allowing for multiple uses without significant sacrifice of power transmission or surgical utility.

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.

Superiority of Nd:YAG laser to cryosurgery in the treatment of rectal carcinoma

Laser coagulation (LC) by Nd:YAG laser and cryodestruction (CD) by insulated cryoprobe were done in 52 patients with carcinoma of the rectum (LC = 27, CD = 25). The patients were divided into four groups: group I, inoperable rectal carcinoma because of advanced stage of malignancy, severe concomitant disease, old age (LC = 14, CD = 12); group II, patient refused permanent colostomy (LC = 4, CD = 3); group III, polypoid lesion fulfilled the criteria of local excision (LC = 3, CD = 2); group IV, local recurrence after anterior resection (LC = 6, DC = 8). The mean hospital stay was 8.11 +/- 5.6 days for LC and 12.8 +/- 8.7 days for CD (p less than 0.05). For LC minimal or no sedation was needed, but for CD general anesthesia (n = 3) was occasionally necessary. Significant improvement was achieved in 85.18% (n = 23) of cases with LC and 56% (n = 14) of cases with CD (p less than 0.05). Complications after LC were mild (n = 7) to moderate (n = 3) and after CD they were moderate (n = 11) to severe (n = 2). Almost every patient with CD complained of moderate to severe discharge of malodorous necrotic tissue for a period of 2 weeks or more. In groups I, II, and IV patients with LC enjoyed a longer (81.08 +/- 47.48 days) trouble-free period than those with CD (43.3 +/- 13.45 days) (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

A new method for the detection of viable cells in tissue sections using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT): an application in the assessment of tissue damage by surgical instruments

This report describes a new method using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) to visualize live viable tissue at the microscopic level. The visualization of the MTT stained tissue provides a metabolic assessment of tissue damage, and can be utilized as an extension of conventional hematoxylin-eosin (H & E) staining. In this report, several tissues were studied with MTT and H & E staining after incisions had been made by a variety of surgical dissecting instruments. A marked improvement in the detection of tissue damage was seen using MTT, regardless of how the damage was caused, i.e., physical, heat, or photon energy. In addition, a distinct zone of damage not noted on conventionally prepared and stained tissues is readily apparent. Thus MTT staining will have utility in both clinical and research studies, concerned with assessing the viability of tissues.

Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser

PURPOSE

Recently, laser technology has been advocated for the treatment of hemorrhoids. However, there has been little scientific evaluation of the use of the Nd:YAG laser for excisional treatment of hemorrhoidal disease. The purpose of this study was to perform a prospective randomized study of the Nd:YAG laser vs. scalpel excision, when performing a standard Ferguson-closed hemorrhoidectomy.

METHODS

Patients presenting for internal-external hemorrhoidectomy were eligible for study. Hemorrhoidectomies were performed under epidural or caudal blocks. The standard Ferguson closed hemorrhoidectomy technique was used. Data evaluated included: age, sex, estimated blood loss, operative time, postoperative pain scores, postoperative analgesic use, wound healing, and time for return to work. Eighty-six patients were eligible for study (laser, N = 51; scalpel, N = 35).

RESULTS

There were no significant differences between the groups, except for a greater degree of wound inflammation and dehiscence at the 10 day postoperative visit for the laser group (laser, 1.7 +/- .2; scalpel, 0.8 +/- .2; P < 0.05, t-test). The use of the Nd:YAG laser added $480 per case; as a result, the treatment cost for the laser group was $15,360 higher than that of the conventional group.

CONCLUSION

The results indicate that there are no patient care advantages associated with the use of the Nd:YAG laser for excisional hemorrhoidectomy compared with scalpel excision. As new technology becomes available, surgeons must rigorously assess therapeutic efficacy and cost-benefit ratio before deciding to employ this technology for patient care.

Hemorrhoidectomy--laser vs. nonlaser: outpatient surgical experience

Two hundred twenty-six patients underwent operative hemorrhoidectomy by a single surgeon in a three-year period. In 170 patients (75.2 percent), the operation was performed utilizing the CO2 laser. Standard closed hemorrhoidectomy was done in the rest. Patients were monitored prospectively for postoperative pain, wound healing, and complications. The feasibility of undergoing operative hemorrhoidectomy as an outpatient was also monitored. No differences were seen between laser and nonlaser hemorrhoidectomy. Outpatient surgery was done in over 72 percent of the patients without any added risk to them.

Hemorrhoidectomy with lasers and other contemporary modalities

Hemorrhoids should be classified so that the treatment can be individualized. Minor or asymptomatic hemorrhoids usually do not require any treatment. Diet modification is a useful adjunct in all degrees of hemorrhoids. Fixation procedures may be employed in the office for first-, second-, and minor third-degree hemorrhoids. These techniques are valuable in elderly and poor-risk patients. Excisions may be performed by standard instruments or lasers with good results. These techniques may be employed with local anesthesia and in an outpatient setting. Lasers may be effective as either a fixation device or an excisional tool. The problem is cost and maintenance of the equipment and the cost of the disposable apparatus. If the equipment is already available or can be shared for multidisciplinary use, hemorrhoidectomy can be accomplished in a cost-effective manner with excellent results.

Endoscopic laser therapy for neoplastic lesions of the colorectum

Surgical resection is the therapy of choice for most colorectal neoplasms. Endoscopic laser therapy (ELT) is a recently developed alternative for treatment of colorectal neoplasms and is applicable in a variety of clinical circumstances in which nonoperative treatment is preferable. The experience with ELT using the Nd:YAG (neodynium:yttrium-aluminum-garnet) laser in 42 patients was analyzed. The diagnosis was colorectal adenocarcinoma in 32 patients (76%) and neoplastic polyps in 10 (24%). ELT was undertaken either as a palliative treatment for malignant disease (60%), with curative intent for benign disease (26%), or as a temporizing measure (14%) in a total of 84 treatment sessions. Successful palliation or cure was achieved in 40 patients (95%) with 4 minor complications (9%) and no procedure-related deaths. This experience confirms ELT as an effective alternative to surgical therapy in the palliative, curative, or interim treatment of certain colorectal neoplasms in patients with prohibitive operative risk, limited anticipated survival, incurability, or diffidence toward operation.

Reduced tumor cell transfer with contact neodymium-yttrium-aluminium garnett laser scalpels

The local recurrence of tumor growth after surgery is thought, in part, to be a consequence of seeding of tumor cells from the primary lesion. This study was directed at determining if the contact Nd:YAG laser provides any advantage over the use of traditional scalpel dissection for tumor resection. Five human tumor tissue culture cell lines were studied in this report. They included MCF-7 (breast), HeLa (cervical), SW-780 (bladder), HT29 (colon), and A549 (lung). Using a scalpel blade or contact laser scalpel (with or without laser energy), the ability to transfer viable cells from dense cell stocks to new tissue culture wells was tested. Using the A549 cell line, the extent that these instruments were able to "seed" tumor cells was also assessed in a soft agar, in vitro, "incision" model. Results from these studies suggest that the contact laser scalpel has a significantly lower potential to transmit tumor cells, when compared to traditional scalpel blades.