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.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Hemorrhoidal disease (HD) is frequent, with an estimated prevalence of 4.4% among the US population [1]. HD is the consequence of an increased inflow into the superior rectal artery, which causes dilatation of the hemorrhoidal plexus. Moreover, degradation of the supportive tissue results in sliding down of hemorrhoids [2]. Hemorrhoids are classified as grade I when they are seen during anoscopy as congested veins, grade II when they prolapse but spontaneously reduce, grade III when they prolapse and need manual reduction, and grade IV when they are irreducible [3]. HD, defined as symptomatic hemorrhoids, can present with pain, itching, bleeding, discharge, or prolapse [4].
Initial treatment of HD consists of lifestyle modifications and administration of phlebotonics. After failure of conservative management, HD is treated with interventional therapies [4]. Open hemorrhoidectomy (HC) was first described in 1937 by Milligan-Morgan [5] and is still considered as the gold standard interventional therapy for advanced stages of HD. However, significant postoperative pain and complications were associated with excision of hemorrhoidal tissue. Therefore, various non-excisional therapies have been developed, such as rubber band ligation (RBL), mucopexy (MP), and more recently laser therapies [4, 6].
Anzeige
Non-excisional laser therapy was initially described in 1998 by Barr et al. [7] with an experimental animal study. Administration of a pulsed laser energy to the submucosal pig rectal tissue allowed coagulation of vessels, with limited damage to the surrounding tissue. Latter, non-excisional laser therapy was applied in humans, with laser hemorrhoidoplasty (LH) first described in 2007 by Karahaliloglu et al. [8]. During LH, a laser fiber is introduced through a skin incision at the hemorrhoidal base, and hemorrhoidal cushions are coagulated. Hemorrhoidal laser procedure (HeLP) constitutes another non-excisional laser therapy for the treatment of HD, first described in 2009 by Salfi et al. [9]. During this procedure, a Doppler identifies the terminal branches of the superior rectal artery, which are coagulated with a pulsed laser energy. Both techniques allow obliteration and retraction of the hemorrhoidal plexus. Moreover, they were shown to be safe and effective for the treatment of HD [8, 9].
Therefore, non-excisional laser therapies constitute interventional therapies for the treatment of HD. However, their recommendation is based on low level of evidence [4, 6]. For the purpose of strengthening the evidence for the benefits of laser therapies, we aimed to systematically review the outcomes of LH and HeLP for the treatment of HD. According to population, intervention, comparison, outcome (PICO) framework, our question was: in patients with HD undergoing non-excisional laser therapies, what are the postoperative outcomes?
Materials and methods
This systematic review adheres to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement [10] (Supplementary Table 1).
Literature search and study selection
Human studies written in English published before April 17th, 2020 were looked for in MEDLINE/Pubmed, Web of science, Embase, and Cochrane. The search strategy was designed and independently conducted by two authors (GL, EL). The following medical search headings and keywords were used: “hemorrhoids” in MeSH terms; and “haemorrhoid*” OR “hemorrhoid*” OR “hemorrhoidal disease” OR “haemorrhoidal disease” AND “laser” OR “laser hemorrhoidoplasty” OR “hemorrhoidal laser procedure” in non-MeSH terms. The reference lists of included articles were further screened for additional eligible publications.
Anzeige
Outcomes of interest
The aim of the study was to systematically review the outcomes of laser therapies for the treatment of HD, including LH and HeLP.
Primary endpoints were the surgical indicators of postoperative outcomes, including
Improvement, defined as postoperative decrease of HD symptoms or grade adapted from the Goligher classification [3];
Persistence, defined as postoperative presence of symptoms or prolapse;
Resolution, defined as postoperative absence of symptoms or prolapse;
Recurrence, defined as reappearance of HD, after a resolution;
Reoperation, defined as any procedure performed for HD after the laser therapy.
Secondary endpoints included
Perioperative characteristics;
Postoperative pain and return to normal activities;
Intraoperative and postoperative complications, defined as any deviation from the normal postoperative course. Therefore pain, tenesmus, and dyschezia that resolved spontaneously without treatment were not considered as complications.
Inclusion criteria
Original publications were eligible only if they fulfilled the following criteria: (i) they reported outcomes of laser therapy for HD and (ii) they reported at least one of the primary endpoint. Articles were included regardless of the design and the size of the study population.
Exclusion criteria
The exclusion criteria were as follows: studies reporting (i) laser hemorrhoidectomy or infrared therapy; (ii) laser therapy performed with an associated procedure or for another anorectal pathology than HD; and (iii) conference abstracts, protocols, and editorials.
Data extraction
Two reviewers (GL, EL) extracted the following data: general and methodological information of the study, baseline characteristics of the study population, surgical indicators of postoperative outcomes, perioperative characteristics, complications, postoperative pain, and return to normal actives. Details of extracted data are reported in the Supplementary Table 2.
Results
Literature search and study characteristics
The initial search identified 1031 studies. After title and abstract review, 901 studies were excluded. The remaining 130 studies were fully reviewed. Of these, 117 were excluded because they reported laser hemorrhoidectomy (42 studies), infrared therapy (68 studies), associated procedure (three studies), or laser therapy for other pathology than HD (four studies). Reviewing of references identified one study [9]. Finally, 14 studies [8, 9, 11‐22] published between 2007 and 2020 were eligible for our review: seven studies [8, 11‐16] reported LH, and seven studies [9, 17‐22] reported HeLP (Fig. 1). There were 10 cohorts (seven prospective [11, 12, 17‐21], two retrospective [8, 9], one not specified [13]), three randomized controlled trials (RCT) comparing LH with HC [14‐16] and MP [16], and one RCT comparing HeLP with RBL [22]. Of the 1540 patients included in these studies, majority were classified as suffering from grades II and III HD (35.8% and 33.6%, respectively), while grades I and IV HD patients were less frequent (5.1% and 0.4%, respectively, grade unavailable for 25.1% of cases). The studies’ characteristics and patient demographic details are depicted in Table 1.
Fig. 1
Preferred reporting items for systematic review and meta-analyses (PRISMA) flowchart showing selection of publications for review
Table 1
Characteristics of included studies
Author
Year of publication
Journal of publication
Country
Study design
Mono-/multicentric
Study period
Sample Size (n)
Age (mean in years ± SD)
Sex (n)
Hemorrhoidal grade
Male
Female
I
II
III
IV
Laser hemorrhoidoplasty
Karahaliloglu et al. 8
2007
Coloproctology
Turkey
ORC
Monocentric
2005
106
20–80a
-
-
74
32
0
0
Jahanshahi et al. 11
2012
Polish Journal of Surgery
Iran
OPC
Monocentric
2010–2011
341
-
219
122
0
127b
94b
2b
Brusciano et al. 12
2019
Uptades in Surgery
Italy
OPC
Monocentric
2018
50
42 ± 12.6
28
22
0
5
45
0
Plapler et al. 13
2009
Photomedicine and Laser Surgery
Brazil
-
Monocentric
-
15 LH10 open HC
25–45a
-
-
-
0
-
-
0
Naderan et al. 14
2016
Journal of Investigative Surgery
Iran
RCT
Monocentric
2011–2012
30 LH30 open HC
43.7 ± 13.744.3 ± 11.3
1311
1719
0
1310
1720
0
Alsisy et al. 15
2018
Menoufia Medical Journal
Egypt
RCT
Monocentric
2016–2017
30 LH30 open HC
34.7 ± 10.233.7 ± 10.2
1815
1215
0
13
17
17
13
0
Poskus et al. 16
2020
International Journal of Colorectal Disease
Lithuania
RCT
Monocentric
2016–2018
40 LH
41 MP
40 HC
47 ± 13
49 ± 13
45 ± 12
27
22
21
13
19
19
0
10
10
7
30
31
33
0
Hemorrhoidal laser procedure
Salfi et al. 9
2009
Coloproctology
Italy
ORC
Monocentric
2005–2006
200
21–81a
72
128
0
-
-
0
Giamundo et al. 17
2011
Surgical Endoscopy
Italy
OPC
Monocentric
2009–2010
30
47 ± 12.6
16
14
0
14
16c
0
Crea et al. 18
2014
The American Journal of Surgery
Italy
OPC
Monocentric
2010–2012
97
47 (28–74)d
53
44
0
51
46c
0
De Nardi et al. 19
2016
Techniques in Coloproctology
Italy
OPC
Multicentric
2012–2014
51
44d (18–70)d
36
15
0
29
22c
0
Boarini et al. 20
2017
Journal of Inflammatory Bowel Diseases & Disorders
Brazil
OPC
Monocentric
2011–2014
55
45.5 (22–67)d
27
28
44
11c
0
Giamundo et al. 21
2018
Techniques in coloproctology
Italy
OPC
Multicentric
2016–1017
284
47.5 (17–77)d
183
101
5
174
101c
4c
Giamundo et al. 22
2011
Disease of the colon and rectum
Italy
RCT
Multicentric
2009–2010
30 HeLP
30 RBL
47d
44d
13
12
17
18
0
20
19
10c
11c
0
SD standard deviation, ORC observational retrospective cohort, “-” not available, OPC observational prospective cohort, LH laser hemorrhoidoplasty, HC hemorrhoidectomy, RCT randomized controlled trial, MP mucopexy, HeLP hemorrhoidal laser procedure, RBL rubber band ligation
aExpressed as range
b118 additional mixed grades of hemorrhoids were included
cSevere prolapses were excluded
dExpressed as median (with range)
×
Perioperative characteristics
Laser hemorrhoidoplasty
LH was performed under general anesthesia [11, 14, 16], spinal anesthesia [11, 15], local anesthesia with [12, 13] or without [8] sedation, or without anesthesia [8] (Table 2). Antibioprophylaxis was administered in three studies [12, 14, 16]. The operation time was reported in three observational cohorts [8, 11, 12] and three RCTs [14‐16], which ranged from 5 [11] to 40.4 min [14]. Moreover, the three RCTs [14‐16] showed a significantly shorter operation time with LH versus open HC (mean 33.1 min ± 7.3 versus mean 52.6 min ± 15.6, p < 0.001 [14]; mean 30.6 min ± 4.9 versus mean 50.5 min ± 12.1, p < 0.001 [15]; mean 15 min ± 5.6 versus mean 29 min ± 10.3, p < 0.001 [16], respectively). Four studies [11‐13, 15] described the hospitalization duration, which ranged from 3 [13] to 48 h [12] and was similar to open HC [15].
Table 2
Perioperative characteristics of laser hemorrhoidoplasty
Study
Preoperative enema
Antibioprophylaxis (molecule)
Anesthesia (% with topical, local, spinal, sedation, general, or without anesthesia)
Laser technique
Number of hemorrhoidal columns (%)
Operation time (mean in minutes ± SD)
Hospitalization duration (mean in hours ± SD)
Wavelength (nm), power (W), duration (s), pause (s)
Number of shots per hemorrhoidal node
I
II
III
Karahaliloglu et al. 8
-
-
81.1% local (Prilocain), 18.9% without
980, 15, 3, -
≥ 6a
-
6.8
-
Jahanshahi et al. 11
-
-
100% general or spinal
980, 15, 3, -
1a
-
10 (5–15)b
18
Brusciano et al. 12
-
Yes (Ceftriaxone)
100% local (Ropivacaine) + sedation (Propofol)
1470, 8, 3, -
10–12
0
16%
84%
14
48
Plapler et al. 13
-
No
LH: 100% local (Xylocaine) + sedation (Propofol)
Open HC: -
810, 5, -, -
-
0
-
40%
-
60%c
-
-
3
Naderan et al. 14
-
Yes (Ceftriaxone + Metroniadzole)
LH: 100% general
Open HC: 100% general
980, 15, 1.2, 0.6
3a
25%
20%
75%
80%
0
33.1 ± 7.3
52.6 ± 15.6d
-
Alsisy et al. 15
-
-
LH: 100% spinal
Open HC: 100% spinal
980, 15, 1.2, 0.6
3a
50%
40%
40%
43.3%
10%
16.7%
30.6 ± 4.9
50.5 ± 12.1d
26.4 ± 7.2
28.8 ± 9.6
Poskus et al. 16
No
Yes (Cefazolin + Gentamycin + Metronidazole)
LH: 100% general
MP: 100% general
Open HC: 100% general
1470, 8, 3, 1
-
-
15 ± 5.6
16 ± 5.6
29 ± 10.3d
-
nm nanometer, W watt, s second, SD standard deviation, “-” not available, LH laser hemorrhoidoplasty, HC hemorrhoidectomy, MP mucopexy
aAdditional shots were given in case of larger hemorrhoids
bExpressed as range
cOne circular prolapse was classified as III columns
dThe difference was statistically significant
Hemorrhoidal laser procedure
HeLP was performed under topical anesthesia [19, 21], local anesthesia [21], spinal anesthesia [21], sedation [19‐21], or without anesthesia [9, 17, 18, 20, 22] (Table 3). Four studies prescribed preoperative enema [18, 19, 21, 22] and/or antibioprophylaxis [18‐21]. The operation time ranged from 7 [20, 21] to 40 min [18] and was similar to RBL [22] (HeLP: median 10 min, range 7.8–11.2 versus RBL: median 8 min, range 5.8–9.6, p = 0.96). Hospitalization duration was up to 24 h [17‐20], but was not described in three studies [9, 21, 22].
Table 3
Perioperative characteristics of hemorrhoidal laser procedure
Study
Preoperative enema
Antibioprophylaxis (molecule)
Anesthesia (% with topical, local, spinal, analgesia, sedation, general, or without anesthesia)
Laser technique
Operation time (mean in minutes ± SD)
Hospitalization duration (mean in hours)
Wavelength (nm), power (W), duration (s), pause (s)
86.6% topical (Lidocaine/Prilocarpine), 1.4% spinal or local, 12.0%: sedation (Midazolam)
980, 13, 1.2, 0.6
5 + 3b
12
15.5 (7–31)d
-
Giamundo et al. 22
Yes
-
HeLP: 100% without
RBL: 100% without
980, 13, 1.2 0.6
5
-
10 (7.8–11.2)d
8 (5.8–9.6)d
-a
nm nanometer, W watt, s second, SD standard deviation, “-” not available, HeLP hemorrhoidal laser procedure, RBL rubber band ligation
aDuration of the hospitalization not mentioned, but performed as outpatient procedure
bAdditional shots were given in case of persisting Doppler signal
cExpressed as range
dexpressed as median (with range)
Postoperative pain and return to normal activities
Postoperative pain was significantly lower after LH compared with HC [13, 15, 16] and resulted in a shorter return to normal activities [15, 16]. Early postoperative visual analog score (VAS) was also decreased with HeLP compared with RBL [22] (mean 1.1 versus 2.9, p < 0.001, respectively). Details of postoperative pain and return to normal activities are depicted in Table 4.
Table 4
Postoperative pain and return to normal activities
Study
Pain
Postoperative analgesia
Return to normal activities (mean in days ± SD)
Score (mean VAS scale from 0 to 10 ± SD)
Timepoint
Laser hemorrhoidoplasty
Karahaliloglu et al. 8
-
-
-
Jahanshahi et al. 11
-
-
-
Brusciano et al. 12
2 (0–3)a
0
0–3 days
4 days
-
1-2a
Plapler et al. 13
LH/HC
0.8 ± 1.1/1.8 ± 0.7c
0–28 days
Diclofenacb
-
Naderan et al. 14
LH/HC
5.7 ± 1.5/5.2 ± 1.3
4.2 ± 1.4/5.2 ± 1.2
2.9 ± 1.5/4.1 ± 1.3
1.6 ± 1.5/2.7 ± 1.5
6 h
12 h
18 h
24 h
Morphine (in the recovery room)b
-
Alsisy et al. 15
LH/HC
2 (1–8)a/6 (3–10)a, c
1 day
Oral analgesiab
7.5 ± 1.8 vs 22.9 ± 3.9c
Poskus et al. 16
LH/MP/HC
3.1/2.7/5.0c
-
-
15 (5–14)a vs 24 (9–30)a vs 30 (14–35)a, c
Hemorrhoidal laser procedure
Salfi et al. 9
-
-
-
Giamundo et al. 17
1.4 ± 1.7
0–3 days
-
-
Crea et al. 18
0 (0–2)d, e
0 (0–2)d, e
1 week
1 month
-
Immediately
De Nardi et al. 19
0.1 (0–1)a, e
0.1 (0–2)a, e0.0e
3 months
12 months
24 months
Paracetamolb
0–3a
Boarini et al. 20
1.4 (0–3)a
0–2 h
-
-
Giamundo et al. 21
1.1 (0–5)d
0.9 ± 0.8
1.1 ± 1.0
2 weeks
6 months
12 months
Paracetamolb
-
Giamundo et al. 22
HeLP/RBL
1.1 (0–2)d/2.9 (1–5)c, d
0.8 (0–2)d/1.0 (0–3)d
1–3 days
2 weeks
-
-
VAS visual analog scale, SD standard deviation, “-” not available, LH laser hemorrhoidoplasty, HC hemorrhoidectomy, MP mucopexy, HeLP hemorrhoidal laser procedure, RBL rubber band ligation
aExpressed as range
bAdministered on request
cthe difference was statistically significant
dExpressed as median (range)
eVAS scale ranged from 0 to 3
Anzeige
Intraoperative and postoperative complications
Intraoperative complications
Bleeding was the only intraoperative complication reported. It was reported by four studies [8, 12, 14, 15] describing LH and for all studies [9, 17‐22] describing HeLP (Table 5). Its incidence ranged from 0 [12] to 1.9% [8] and from 5.5 [20] to 16.7% [22], respectively. Two RCTs [14, 15] reported a significant lower blood loss volume during LH versus HC (mean 12.4 ml ± 4.5 versus 22.8 ml ± 8.3, p < 0.001 [14]; mean 15.5 ml ± 4.8 versus mean 36.5 ml ± 7.2, p < 0.001 [15], respectively). However, in the RCT by Giamundo et al. [22], the intraoperative blood loss was similar for HeLP versus RBL (16.7% versus 10%, p = 0.12, respectively).
Table 5
Intraoperative and postoperative complications of laser procedures
Study
% of intraoperative complications (treatment for the complication if reported)
% of postoperative complications (treatment for the complication if reported)
Follow-up (in months)
Bleeding
Bleeding
Hemorrhoidal thrombosis
Infection
Urinary retention
Other
Overall
Laser hemorrhoidoplasty
Karahaliloglu et al. 8
1.9% (Ø)
0
0
0
0
Mucosal damage: 0.9% (ligature)
0.9%
12
Jahanshahi et al. 11
-
0.6% (suture)
0
0.6%
0
Edema: 2.3%
3.5%
12
Brusciano et al. 12
0
64% (Ø)b
0
0
0
64%
8.6a
Plapler et al. 13
LH
HC
-
0
0
0
0
Burn lesion: 26.7%
Plicoma/skin tag: 33.3%
0
60%
0%
1
Naderan et al. 14
LH
HC
12.8 ± 4.5
22.8 ± 8.3c, d
10% (cons.)
30% (cons.)
6.7% (cons.)
0%
0
3.3%
10%
20%
40%
12
Alsisy et al. 15
LH
HC
15.5 ± 4.8
36.5 ± 7.2c, d
0
3.3% (packing and hemostatic drug)
10% (cons.)
0
0
10% (antibiotherapy)
0
13.3%d
0
Anal stenosis: 13.3% (lateral sphincterotomy) d
10%
40%
3
Poskus et al. 16
-
0
0
0
0
0%
12
Hemorrhoidal laser procedure
Salfi et al. 9
8.5% (1% ligation, 7.5% laser)
0.5%e
0
0
0
0.5%
12
Giamundo et al. 17
13.4% (6.7% laser, 6.7% suture)
0
0
0
0
0%
5.8 (1–12)a
Crea et al. 18
12.4% (9.3% laser, 3.1% suture)
0
0
0
0
0%
15 (6–30)∏
De Nardi et al. 19
5.9% (2% laser, 3.9% suture)
7.8%
7.8%
0
0
15.6%
26.3 ± 9.1a
Boarini et al. 20
5.5% (laser)
20% (Ø)
0
0
0
20%
6
Giamundo et al. 21
8.8% (2.5% Ø or laser, 6.3% ligature or suture)
3.5% (flavonoid)
1.4%
0
0
Anismus: 1.4%
Sensation of incomplete evacuation: 3.1% (Ø)
9.4%
12
Giamundo et al. 22
HeLP
RBL
16.7%: (10% surgical, 6.7% laser)
10% (3.3% surgical)
23.3% (Ø)
26.7% (Ø)
0
0
0
23.3%
26.7%
6
“-” not available, cons. conservative, Ø = no treatment
aExpressed as mean ± SD or (range)
bPost-defecatory bleeding only, and stopped spontaneously from the 7th postoperative day, 0% of spontaneous bleeding
cExpressed in volume (mean milliliters ± standard deviation)
dThe difference was statistically significant
eAdditional 11.0% of discharge was described. They were not considered as complications since it did not cause discomfort, and it disappeared within 30 days. Moreover, it was not specified whether the discharge consisted of blood or mucous
Postoperative complications
All studies reported postoperative complications (Table 5). The incidence of complications ranged between 0 [16] and 64% [11] after LH and between 0 [17, 18] and 23.3% [22] after HeLP. The most common reported complication was bleeding (range 0–64% after LH and 0–23.3% after HeLP), which resolved with suture [11], packing and/or haemostatic drug [15, 21], conservative therapy [14], or without treatment [12, 20, 22]. Further complications were thrombosis (range 6.7–10% after LH [14, 15], range 1.4–7.8% after HeLP [19, 21]), infection (up to 0.6% after LH [11], not reported after HeLP), and urinary retention (up to 3.3% after LH [14], not reported after HeLP). The latter was significantly increased after HC versus LH (13.3% versus 0%, p = 0.038, respectively) [15]. Other complications reported after LH included mucosal damage (0.9%, treated with ligature) [8], edema (2.3%) [11], burn lesion (26.7%) [13], and skin tag (33.3%) [13]. Other complications reported after HeLP included anismus (1.4%) [21] and sensation of incomplete evacuation (3.1%, which did not require any treatment) [21].
Surgical indicators of postoperative outcomes
Surgical indicators of postoperative outcomes are detailed in Table 6. The postoperative follow-up duration ranged between 1 [13] and 12 months [8, 11, 14, 16] after LH and between 1 [17] and a mean of 35.4 months [19] after HeLP.
Table 6
Surgical indicators of postoperative outcomes: improvement, persistence, resolution, recurrence, and reoperation
HD hemorrhoidal disease, “-” not available, LH laser hemorrhoidoplasty, HC hemorrhoidectomy, MP mucopexy, RBL rubber band ligation, THD transanal hemorrhoidal dearterialization, HeLP hemorrhoidal laser procedure, SH stapled hemorrhoidopexy
aSymptomatic recurrence, resolution, or persistence
bExpressed as mean ± standard deviation or (range)
cProlapse recurrence, resolution, or persistence
dThe difference was statistically significant
eExpressed as median (range)
eDescribed as persistence in the results section, but as persistence or recurrence in the discussion section
HD downgrading
HD downgrading for at least one grade derived from the Goligher classification was reported by four studies after HeLP [17, 18, 20, 22]. It was 80% at 6 months [20, 22], 77% at a mean of 5.8 months [17], and > 85% at 15 months [18]. In the RCT by Giamundo et al. [22], HD grade was significantly decreased after HeLP compared with RBL (80% versus 40% at 6 months, p < 0.001, respectively). No study reported HD downgrading after LH.
Symptom improvement
Improvement of HD symptoms was reported by four studies [9, 17‐19] after HeLP and ranged from 85% at a median of 15 months [18] to 91.7% at a mean of 5.8 months [17]. No study reported symptom improvement after LH.
Persistence
Symptomatic ± prolapse persistence was 0% at 3 months [15] and 7% of at a mean of 5.8 months [17] after LH. After HeLP, two studies [19, 21] reported 10% of recurrences up to 26 postoperative months.
Resolution
Resolution of hemorrhoidal prolapse was reported in 60.4% of patients at 1 month after LH [13] and 76.9% of patients at a mean of 26.3 months after HeLP [21]. After LH, resolution of symptoms was 100% at 3 months [15] and ranged between 70 [14] and 72.5% [16] at 12 months. The latter results were similar compared with HC or MP [14‐16]. In the other hand, resolution of symptoms after HeLP was statistically higher after HeLP versus RBL at 6 months (90% versus 53.3%, p < 0.001, respectively) [22]. Overall, symptomatic resolution ranged between 83.6% at 6 months [20] and 90.3% at 12 months [21]. Nevertheless, resolution rate was unavailable in three studies after LH [8, 11, 12] and in two studies after HeLP [9, 17].
Recurrence
After LH, two studies reported symptomatic recurrences, which ranged between 10 [16] and 11.3% [8] at 12 months. In the RCT by Poskus et al. [16], recurrence rates were significantly lower after HC, compared with LH and MP (0% versus 10% versus 22%, p < 0.004, respectively). No recurrence was reported after LH for three studies [11, 12, 15]. However, data on recurrence were unavailable for two studies [13, 14].
After HeLP, one study [17] reported a symptomatic recurrence rate of 8.3% at a mean of 5.8 months, and three other studies [9, 18, 19] reported recurrences from 5% at a median of 15 months to 9.4% at 12 months. Data on recurrence were unavailable for three studies [20‐22].
Reoperation
Data on reoperation were available in three studies after LH [8, 14, 15] and in two studies after HeLP [19, 21]. In the study by Karahaliloglu et al. [8], 54.7% of patients were reoperated with redo LH, for insufficient treated nodes between 1 and 3 months. Two other studies [14, 15] reported no need for reoperation after LH, with a follow-up of 3 to 12 months. After HeLP, up to 7.8% of cases were reoperated within 5 months [19], with redo HeLP, RBL, transanal hemorrhoidal dearterialization, stapled hemorrhoidopexy, or HC [19, 21].
Discussion
The present systematic review included 14 studies describing LH [8, 11‐16] and HeLP [9, 17‐22], representing 1570 patients with grades I to IV HD. Primarily, laser therapies seemed to be safe. The single intraoperative complication was bleeding (0–1.9% for LH, 5.5–16.7% for HeLP), managed with intraoperative laser, suture, or conservatively. Postoperative complications occurred up to 64% of patients after LH and up to 23.3% after HeLP. However, these complications were frequently minor, which did not require therapy or were treated with conservative measures. Only 0.9% of postoperative complications required surgical therapy [8]. Moreover, 64% of bleeding reported after LH [12] consisted of post-defecatory bleeding, which did not require treatment and spontaneously resolved after the 7th postoperative day. Compared with other non-excisional therapy for HD, the RCT by Giamundo et al. [22] showed similar intraoperative bleeding rate associated with HeLP versus RBL (16.6% versus 10%, p = 0.12). Compared with excisional therapy, two RCTs [14, 15] showed lower intraoperative blood volume loss associated with LH versus HC. Moreover, postoperative complications were decreased with LH (urinary retention: 0% for LH versus 13.3% for HC, p = 0.038; anal stenosis: 0% for LH versus 13.3% for HC, p = 0.038) [15].
Secondarily, laser therapies are effective for the treatment of grades II and III HD, as shown by surgical indicators of postoperative outcomes. Resolution of symptoms ranged between 70 and 100% after LH and from 83.6 to 90% after HeLP. These rates are similar to the success rate of RBL reported in the literature. As shown by a retrospective study [23] of 750 patients with grades I to III HD treated with RBL, the success rate was 89%. Moreover, four RCTs included in our review reported similar resolution after LH compared with HC [14‐16] or MP [16] and after HeLP compared with RBL [22]. Another surgical indicator was the recurrence rate, reported between 0 and 11.3% after LH and between 5 and 9.4% after HeLP. In the literature, recurrence rate at 12 months was reported up to 5% after mucopexy [24] and up to 11.1% [25] after hemorrhoidal artery ligation ± mucopexy. Compared with HC, LH showed conflicting results with one RCT reporting similar recurrence rate [15], but another RCT reporting decreased recurrences associated with HC [16]. Another surgical indicator of postoperative outcome was the reoperation rate, reported in 54% of patients after LH [8]. However, Karahaliloglu et al. [8] were the first to report their experience with LH, and this high reoperation rate seemed to decrease with progress in the learning curve. Moreover, two other studies reported no need for reoperation after LH, at 3 and 6 months of follow-up [14, 15]. Nevertheless, a long-term follow-up is mandatory to identify recurrences and the potential need for further intervention.
Thirdly, laser therapies conferred the advantages of a quick return to normal activities and low postoperative pain. The latter is explained by the absence of excision of tissue below the dentate line, where pain fibers are present [26]. Compared with HC, two RCTs showed decreased postoperative pain score associated with LH [15, 16]. Compared with RBL, another RCT showed decreased postoperative pain associated with HeLP [22]. However, pain comparison between studies is hazardous as postoperative analgesia varied significantly among studies.
Anzeige
The main limitation of the study is the heterogeneity of included studies. Perioperative characteristics, such as preoperative enema, antibioprophylaxis, anesthesia, and laser techniques, varied significantly among studies. Moreover, while grades II and III HD are good candidates for laser therapies, some studies included grades I and IV HD [8, 11, 20, 21]. Another weakness is the small population size of included studies, with the largest cohort composed of 341 patients [11]. This resulted in a decreased statistical power. Moreover, rare complications may be unidentified.
In this review, surgical indicators were used as surrogates of postoperative outcomes. Nevertheless, they were irregularly reported among studies. Moreover, Giamundo et al. [21] reported 9.7% of symptomatic persistence in the results section, but this was latter mentioned as persistence and/or recurrence in the discussion section. Inconsistency with outcomes definition precluded a meticulous analysis. As demonstrated by a recent systematic review [27], assessment of treatment efficiency should emphasize the use of validated scoring systems. However, none of the included study used these scores.
Overall, laser therapies appeared to be safe and effective techniques for the treatment of HD. Moreover, the learning curve is quick and was estimated from three to five cases [14]. These techniques could be alternatives to RBL or hemorrhoidal artery ligation ± mucopexy for the treatment of grade II or III HD. Only one RCT compared HeLP with RBL [21] and future research should focus on the comparison between laser and other non-excisional therapies of HD. Another unanswered question is the utility of the Doppler for the laser procedure. As reported by two RCTs [28, 29], the Doppler use did not show benefits for the hemorrhoidal artery ligation technique. Finally, benefits of LH or HeLP should be compared.
Conclusions
To conclude, non-excisional laser therapies, including LH and HeLP, are safe and effective. They should be considered for the treatment of grades II and III HD unresponsive to conservative management.
Anzeige
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethics approval
Not applicable.
Consent to participate
Not applicable.
Consent for publication
Not applicable.
Code availability
Not applicable.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
