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New techniques in treatment of hemorrhoids
Why ?
1. A very frequent disease -> big market
2. Painfull operation with troubles following the next weeks -> wish for a more pleasant method
Look after the anoderm !!
Light Amplification by Stimulated Emission of Radiation
Wave length of 193 nm (Eximer-Laser) to 10,6 µm (CO2-Laser)
Photochemical process Low intensityy (<1W/cm2) long radiation time (>100 sec)
Photothermical process Intensity >100 W/cm2 Photodynamic process Short radiation time (< 10 sec)
Photovaporisation Temperature > 100°C
Pulsed Laser: small dosis, but high concentration of energy (W/cm2)
Laser-‐Tissue-‐Interac.on depends on:
structure of .ssue
wave length of Laser
energy, dosis
method (pulse /con.nuous)
fiber, op.c
Laser-‐Tissue-‐Interaction
Laser
Tissue
Heat
Temperature 65 °C -‐ 99 °C >>100 W/cm2
High Temperature >100 °C
Coagula.on
Edema
Vaporisa.on
Carbonisa.on
Photothermic Reaction Photovaporisation
Short radia.on .me < 10 sec
Inflamma.on
Fibro.c reac.on And Shrinking
Thermodynamic Reaction
History of Laser in Proctology
1991 Laser with other
Wave length such as Nd:Yag Laser 1064nm
1989 First use of Co²
Lasers for Hemorrhoidectomy
Since 2000. special fiber optic laser with differnt
Wave length (808nm,940nm,
980nm,1470nm) in surgery
Characteris.cs of lasers fibres
Standard is bare fibre
Working mechanism: High temperatures on fibre 8p lead to hot neadle effect. Temperature gradient to surrounding 8ssue structures.
Charakteris.cs of LHP Fibre
Homogeneous radia8on on certain 8ssue region. No hot spots. No carbonisa8on.
Sharp, rugged silica 8p to penetrate the mucosa
Instrumente: • HeLP™ Doppler Probe • HeLP™ Laser Sonde mit Handgriff • HeLP™ Proktoskop • HeLP™ Proctoscope mit Arbeitskanal
HeLP™ : Hemorrhoid Laser Procedure
Influence of Laser Wavelength
Absorp.on of fiber op.c laser: 810-‐980 nm : absorp.on by hemoglobine and water Longer wavelength (1470 nm) more absorp.on by water
Better control of penetration depth
Procedure: Wavelength: 980 nm or better 1470 nm Energy: 8 - 15 Watt
Pulse: 1-3 sec single pulse or continuous pulse
Fiber type: bare fiber 0,6 mm, better radial fiber 1,8 mm Dosis : 150 -300 Joule / segment, depending on the size of the hemorrhoids Effects:
Absorption of the energy by the tissue-> destruction of the hermorrhoid vessels
Followed by fibrotic shrinking and reduction of hemorrhoid tissue
Principles:
Reduction of the hemorrhoid tissue, No complete distruction of hemorroids Obliteration of the hemorrhoid artery Preservation of the anoderm Removal of the prolapse by shrinking of the hemorrhoidal mass and fibrotic reconstruction
HeLP™ : Hemorrhoid Laser Procedure Laser Hemorrhoidoplasty (LHP)
LHP (n=332) Number of patients
OP-‐Time
Stadium
II-‐III segmental 227 68%
III circular 76 23%
IV 29 9%
Operation
LHP 217 65% 14,2 min
LHP + Mukopexia
115 35% 20,6 min
additional op.
Fissurectomia 22 7%
Fistulotomia 3 1%
Postoperative Bleeding
2 (0,6%)
Abscess 2 (0,6%)
Fistula 2 (0,6%)
Hemorrhoidal thrombosis
5 (1,5%)
Urinary troubles
7 (2,1%)
Necrosis 1 (0,3%)
Fibrome 26 (7,8%)
Recidive (II°) 7 (5,8%)
A. F. Karahaliloglu (2010) colocproctology 32:116-123
LHP (n=41) Op-‐Time Joule
stadium
II -‐ III segmental 29 200/Segment
III zirkulär 11 250/Segment
IV 1 280/Segment
operation
LHP 31 15 min
LHP + HAL 10 20 min
additional
Fissurectomia 7
Fistula excision 2
Polypectomia 1
Mariskectomia 12
Thrombectomia 3
Results V. Nutz, Center of Proctology, Cologne LHP: n = 41, m/f = 22/19, Age 25 bis 74 y. ( average. 44,8 y.)
Complications and Results after at least 8 weeks (n=31, m/f = 19/12)
Complications
Bleeding 1
Abscess or Fistula 0
Thrombosis 0
Nekrosis 2
Fibroma 3
Duration of treatment 3-‐28 days aver. 10
Unable to work 6-‐20 days aver. 9
Results after > 8 weeks
hemorrhoids II° 8
hemorrhoids III° 1
Advantages: Easy handling Preservation of anoderm Good coagulation of intraoperative bleeding Nearly no postoperative bleeding Short operation time, short down time No (or only very short) hospital stay Few postoperative pain No damage of the sphincter No stenosis No foreign material left (no clamp complications) Several repetitions possible Combination with or change for other procedure possible Disadvantages: Definitiv result not before 6-12 weeks Great expenses
HeLP™ : Hemorrhoid Laser Procedure Laser Hemorrhoidoplasty (LHP)