Laser Destruction or Sclerotherapy in the Treatment of Grade 2–3 Hemorrhoids

Aim: to improve treatment outcomes in patients with grade 2–3 hemorrhoids.

Materials and methods. Currently 91 patients with grade 2–3 hemorrhoids who met the inclusion criteria are enrolled in a single-center prospective randomized study. Of these, 48 patients underwent transdermal laser submucosal destruction of internal hemorrhoidal nodes using a water-absorbing laser with a wavelength of 1940 nm according to our proposed technique. Forty-three patients underwent sclerotherapy of internal hemorrhoidal nodes using the traditional method (injections of 3 % polidocanol (Aethoxysklerol®, Kreussler Pharma) into three internal hemorrhoidal nodes in a single session). Due to intraoperative bleeding, one patient was excluded from the laser group and underwent hemorrhoidectomy. The primary endpoints of the study were the absence of cavernous tissue in internal hemorrhoidal nodes one month after surgery and the frequency of disease recurrence 6–12 months postoperatively. The effectiveness of the technique was assessed using anoscopy and rectal ultrasound with spectral Doppler imaging at 1, 3, 6, and 12 months after surgery. During the same periods, quality of life and severity of hemorrhoidal symptoms were evaluated using the SF-36 scale and a clinical symptom scoring system. In the first 7 days after surgery, pain intensity was assessed using the Visual Analog Scale (VAS). To evaluate the potential impact of these minimally invasive techniques on rectal sphincter function, sphincterometry was performed in all patients before and one month after surgery. Intraand postoperative complications, as well as recurrence rates, were recorded over a 12-month follow-up period in both groups.

Results. In the group of transdermal laser submucosal destruction, the pain intensity on postoperative day 7 was 0 points on the VAS in 28 patients (59.6 %), while in the sclerotherapy group, this was observed in 31 (72.1 %) patients. Intraoperative complications occurred only in the main group: 1 (2.1 %) patient experienced bleeding, and 4 (8.5 %) patients developed submucosal hematomas. In the early postoperative period, thrombosis of external hemorrhoidal nodes occurred in 3 (6.4 %) patients in the main group and in 1 (2.3 %) patient in the control group. On days 5–7 after the procedure, mucosal ulceration at the site of the internal hemorrhoidal node was observed in one patient from each group; both cases were managed conservatively. Internal hemorrhoidal nodes, which had been identified prior to the intervention, were no longer visualized one month after treatment in 45 (95.7 %) patients in the main group and 36 (83.7 %) patients in the control group, as confirmed by both anoscopy and transrectal ultrasonography. This effect persisted consistently at 3, 6, and 12 months postoperatively. Spectral wave Doppler imaging demonstrated a sustained reduction in blood flow through the terminal branches of the superior rectal artery by a factor of 4 in the main group and by a factor of 3 in the control group up to 12 months post-intervention. Sphincterometric evaluation revealed no significant changes in anorectal sphincter function compared to preoperative values. At 6 months postoperatively, 1 (2.3 %) patient in the control group was diagnosed with recurrent hemorrhoidal disease. Analysis indicated that the recurrence was associated with an insufficient volume of the sclerosing agent administered.

Conclusion. The preliminary results of the study demonstrate higher efficacy of laser submucosal destruction compared to sclerotherapy in the treatment of grade 2–3 hemorrhoids. During the 12-month follow-up period, no cases of recurrence of hemorrhoidal symptoms were observed in the laser group, whereas 1 (2.3 %) case of recurrence occurred in the sclerotherapy group six months after the procedure. However, it should be noted that laser destruction is a more invasive technique compared to sclerotherapy, as evidenced by a higher incidence of intraand postoperative complications and the requirement for anesthesia during the procedure.

1. Anosov I.S., Kostarev I.V., Kuzminov A.M., Mainovskaya O.A., Mudrov A.A., Achkasov S.I. et al. Hemorrhoids. Diagnosis and treatment. Moscow: GEOTAR-Media Publ., 2022. (In Russ.). DOI: 10.33029/9704-7148-7-GER-2022-1-216

2. Gallo G., Picciariello A., Armellin C., Lori E., Tomasicchio G., Di Tanna G.L., et al. Sclerotherapy for hemorrhoidal disease: Systematic review and meta-analysis. Tech Coloproctol. 2024;28(1):28. DOI: 10.1007/s10151-023-02908-w

3. Komporozos V., Ziozia V., Komporozou A., Stravodimos G., Kolinioti A., Papazoglou A. Rubber band ligation of symptomatic hemorrhoids: an old solution to an everyday problem. Int J Colorectal Dis. 2021;36(8):1723–9. DOI: 10.1007/s00384-021-03900-2

4. Nikshoar M.R., Maleki Z., Nemati Honar B. The clinical efficacy of infrared photocoagulation versus closed hemorrhoidectomy in treatment of hemorrhoid. J Lasers Med Sci. 2018;9(1):23–6. DOI: 10.15171/jlms.2018.06

5. Giamundo P., Braini A., Calabrò G., Crea N., De Nardi P., Fabiano F., et al. Doppler-guided hemorrhoidal dearterialization with laser (HeLP): Indications and clinical outcome in the long-term: Results of a multicenter trial. Surg Endosc. 2022;36(1):143–8. DOI: 10.1007/s00464-020-08248-2

6. Khitaryan A.G., Alibekov A.Z., Kovalev S.A., Orekhov A.A., BurdakovI.Yu., Golovina A.A., et al. Results of the use of intranodal laser coagulation in patients with chronic internal hemorrhoids stage III. Koloproktologia. 2021;20(1):33–40. (In Russ.). DOI: 10.33878/2073-7556-2021-20-1-33-40

7. Durgun C., Yiğit E. Laser hemorrhoidoplasty versus ligasure hemorrhoidectomy: A comparative analysis. Cureus. 2023;15(8):e43119. DOI: 10.7759/cureus.43119

8. Żywicka B., Rybak Z., Janeczek M., Czerski A., Bujok J., Szymonowicz M., et al. Comparison of a 1940 nm thuliumdoped fiber laser and a 1470 nm diode laser for cutting efficacy and hemostasis in a pig model of spleen surgery. Materials (Basel). 2020;13(5):1167. DOI: 10.3390/ma13051167

9. Kostarev I.V. Sclerosing treatment of hemorrhoids in combination with ultrasonic cavitation: Dissertation of Cand. Sci. (Med.). Moscow, 2009. (In Russ.).

10. Jahanshahi A., Mashhadizadeh E., Sarmast M.H. Diode laser for treatment of symptomatic hemorrhoid: A short term clinical result of a mini invasive treatment, and one year follow up. Pol Przegl Chir. 2012;84(7):329–32. DOI: 10.2478/v10035-012-0055-7

11. Brusciano L., Gambardella C., Terracciano G., Gualtieri G., Schiano di Visconte M., Tolone S., et al. Postoperative discomfort and pain in the management of hemorrhoidal disease: Laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids. Updates Surg. 2020;72(3):851–7. DOI: 10.1007/s13304-019-00694-5

12. Cheng P.L., Chen C.C., Chen J.S., Wei P.L., Huang Y.J. Diode laser hemorrhoidoplasty versus conventional Milligan — Morgan and Ferguson hemorrhoidectomy for symptomatic hemorrhoids: Meta-analysis. Asian J Surg. 2024;47(11):4681–90. DOI: 10.1016/j.asjsur.2024.04.156

13. Frolov S.A., Vyshegorodtsev D.V., Kuzminov A.M., Trubacheva Yu.L., Korolik V.Yu., Bogormistrov I.S., et al. Ilaser submucous destruction in the treatment of hemorrhoids. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2023;33(2):70–8. (In Russ.). DOI: 10.22416/1382-4376-2023-33-2-70-78