Assessment of Long-Term Clinical Outcomes Following Laser Proctology and Conventional Hemorrhoidectomy

Hemorrhoidal disease is one of the most commonly encountered benign anorectal disorders in surgical practice and is known to have a significant impact on the quality of the patient's life around the world. It is caused by pathological enlargement and distal displacement of the normal anal cushions, and often presents with symptoms of rectal bleeding, prolapse, pain, pruritus, mucus discharge and defecation discomfort (1). Conservative management (dietary modifications, increased fibre content and pharmacological therapy) may be useful for alleviating symptoms in early disease, but surgery is the treatment of choice for patients who are suffering from Grade III and Grade IV hemorrhoids in advanced disease and/or have persistent symptoms despite medical management (2).

Until now, the effectiveness of the conventional hemorrhoidectomy procedures in symptom control and the relatively low recurrence rates (3) have made them the gold standard for definitive treatment of hemorrhoidal disease. Even though they have proven to be clinically effective, however, these procedures have been known to cause significant postoperative pain, urinary retention, delayed wound healing, bleeding and extended recovery periods which may affect patient satisfaction and return to normal daily activities (4). Pain following traditional hemorrhoid surgery is still one of the most difficult problems in anorectal surgical management and has continued to be a constant area of investigation for alternative surgical approaches.

In the last decade there has been a growing use of minimally invasive techniques in proctology, especially in the light of laser-based techniques. Laser hemorrhoidoplasty (LHP) has become a new surgical approach that is based on laser energy to cause submucosal tissue shrinkage without damaging surrounding tissues (5). A major advantage of the procedure is its ability to reduce tissue trauma, postoperative pain, hospital stay and recovery process as compared to traditional excisional hemorrhoidectomy (6). Laser surgery has been reported to yield good early postoperative results, such as decreased need for analgesics and a better patient experience (7).

Although these benefits are present, there are concerns about the long-term efficacy of laser treatments, especially the recurrence rate and sustained symptom control. In the opinion of some investigators, laser hemorrhoidoplasty might be associated with improved early recovery, but hemorrhoidectomy may still be superior in terms of longterm disease resolution as it removes all hemorrhoidal tissue (8). Furthermore, the cost of the procedures and steep learning curve of minimally invasive procedures may restrict the use of lasers broadly, particularly at low and middle income health care facilities (9).

Comparative studies and systematic reviews have shown conflicting results on the superiority of laser proctology over the classic hemorrhoid surgery (10,11). Many studies have shown that laser procedures are more beneficial in terms of recovery from surgery and satisfaction with surgery, but there is mixed evidence regarding long-term clinical outcomes. In addition, there are very few regional data from health systems in South Asia, and varying health systems, surgical practices, and postoperative care can impact surgical outcomes.

The present study is therefore designed to evaluate and compare long term clinical results of laser proctology and traditional surgical techniques of hemorrhoid surgery based on patient reported satisfaction and retrospective hospital data and secondary literature evidence. The objective of this study is to give a fair review of both surgical methods and pay particular attention to the aspects of recovery, complications, and recurrence, as well as overall satisfaction with the surgery.

Overall, 120 patients with symptomatic Grade II–IV hemorrhoids were enrolled in the study. The patients were divided into two groups: laser hemorrhoidoplasty (n=60) and conventional hemorrhoidectomy (n=60). All patients who were included underwent a minimum follow-up of 12 months and were suitable for final outcome analysis.

Baseline Demographic and Clinical Characteristics

There were no statistically significant differences between their demographic and baseline clinical parameters. The mean age of the patients in the laser group was 41.8 ± 10.4 years compared to 43.2 ± 11.1 years for the conventional surgery group (p=0.48). In both groups, male patients outnumbered their female counterparts.

Grade III hemorrhoids constituted the most common presentation, accounting for 51.7% of total cases. The prevalence of associated comorbidities including diabetes mellitus and hypertension was similar between the two groups and did not significantly influence surgical outcomes.

Table 1: Baseline Demographic and Clinical Characteristics of Patients

There was good comparability between both study groups when examining baseline variables.

Operative and Early Postoperative Outcomes

The mean operative time for the laser hemorrhoidoplasty group was significantly less than that of the conventional surgery group (28.6 ± 7.4 minutes vs 41.2 ± 9.1 minutes, p<0.001). Patients who underwent laser surgery also had lower estimated blood loss during surgery.

Visual Analog Scale (VAS) scores showed significantly reduced pain in the laser group the first week after surgery. In the laser group, the mean pain score was 3.1 ± 1.2, while for the conventional hemorrhoidectomy group, it was 6.4 ± 1.5 (p<0.001).

In the same manner, the hospital stay was significantly shorter for those who had laser treatment. The majority of laser-treated patients were released within 24 hours, while the conventional surgery patients often needed a more extended period of post-operative monitoring and pain management.

Patients treated with laser therapy were able to return to normal daily activities and work much sooner than the patients in the conventional hemorrhoidectomy group.

Table 2: Operative and Early Postoperative Outcomes

These results showed that laser hemorrhoidoplasty had a positive effect on recovery in the short term and also on the postoperative morbidity.

Postoperative Complications

Both treatment groups had postoperative complications but the incidence was generally less in the laser group.

Five laser-treated patients (5.0%) and 13.3% of the patients who had traditional surgery had postoperative bleeding. The conventional hemorrhoidectomy group also had a higher incidence of wound infection and urinary retention. But serious issues such as anal narrowing and bowel incontinence occurred in few of the patients in either group.

No deaths and no life-threatening complications were noted during the study.

Table 3: Postoperative Complications

While there were no significant differences reported for any of the complication subcategories, there appeared to be a general improvement in the incidence of complications after the laser procedures.

Long-Term Clinical Outcomes and Recurrence

Long term follow up showed good symptom management for both groups. Recurrence was slightly higher for those patients who received laser hemorrhoidoplasty, however.

In the laser group, 7 patients (11.7%) had recurrence during the follow-up period, while 5 patients (8.3%) had recurrence in the conventional surgery group. The difference was not significant, p=0.41.

The long-term disease control was marginally superior in patients undergoing conventional hemorrhoidectomy.Patients undergoing conventional hemorrhoidectomy had slightly better long-term disease control, especially in those with advanced Grade IV hemorrhoids. However, there was still a significant improvement in symptoms in both groups.

Conventional surgery patients were more likely to have a persistent postoperative discomfort after 6 months.

Table 4: Long-Term Clinical Outcomes

Conventional surgery appeared to offer slightly lower recurrence rates, but laser hemorrhoidoplasty proved to be clinically effective with good long-term relief of symptoms, the findings suggested.

Patient Satisfaction Survey Findings

To assess the patient-reported outcomes and quality of life improvement, a supplementary postoperative satisfaction survey was carried out on 25 patients who were randomly selected.

The patients who received the laser treatments expressed greater levels of satisfaction, especially related to pain management, early return to normal activities, and having no pain during the recovery period. A vast majority of laser treated patients reported that the treatment was comfortable and they would recommend it to others.

Patients who underwent conventional hemorrhoidectomy admitted that they experienced long-term symptom relief; however, they often complained of long postoperative discomfort and recovery periods.

Table 5: Patient Satisfaction Survey Outcomes

Results of the survey pointed to greater patient preference for minimally invasive laser procedures because of less post-operative discomfort and better post-operative experience.

Overall Findings

The present study showed that laser hemorrhoidoplasty had better short-term postoperative outcomes in terms of pain, hospital stay, recovery and patient satisfaction. Conventional hemorrhoidectomy, on the other hand, remained slightly less prone to recurrence, and long-term symptom control was achieved – particularly in cases of advanced hemorrhoidal disease.

Both surgeries were successful and safe, with laser proctology providing distinct benefits in terms of patient comfort and recovery.

The present study compared the long term clinical results of laser proctology with those of the conventional procedures for the treatment of symptomatic hemorrhoidal disease. The results showed that laser hemorrhoidoplasty was significantly less painful in the postoperative period, required significantly less hospital stays, allowed patients to return to their normal activities much earlier and was significantly more satisfactory than hemorrhoidectomy. However, there were slightly lower recurrence rates for conventional surgical techniques in longer term follow-up. The results underscore the continued clinical significance of traditional hemorrhoidectomy in the clinical management of advanced proctology and its increasing importance in the field of minimally invasive procedures.

The postoperative pain is one of the most important postoperative concerns after hemorrhoid surgery and is a contributing factor to patient recovery and quality of life. With the present study, patients who had undergone laser hemorrhoidoplasty had markedly less pain during the first week after surgery than did the patients who had had conventional surgery. This result is consistent with previously published comparative studies which showed decreased tissue trauma and decreased nociceptive stimulation with laser-based procedures (1,2). The fact that the laser incisions are limited to a sub mucosal level of coagulation, without extensive tissue removal, may be a factor in the lesser postoperative discomfort seen in laser biopsied patients.

The reduced hospital stay and earlier return to work observed in the laser group is also consistent with the results of more recent systematic reviews and meta-analyses (3). In today's surgical landscape, a quick recovery following surgery has become a vital consideration, driven by the increasing demands of patients, economic factors, and the need to optimize healthcare resources. In the present study, the time for patients to return to normal activity was around a week earlier for those who underwent laser procedures as compared to those who underwent a conventional hemorrhoidectomy. This disparity has implications with a significant socioeconomic impact especially for working age individuals and health care systems with limited availability of hospital beds.

Some differences in the rate of complications were not significant, but the laser group showed less bleeding, urinary retention, and wound infection following surgery. This is similar to other previous studies that have compared minimally invasive hemorrhoid procedures with excisional procedures (4). The lower incidence of postoperative morbidity in laser surgery may be due to the decreased thermal damage to surrounding tissues and maintenance of the integrity of the anoderm. Moreover, the reduced blood loss during surgery in laser-treated patients corroborates the hemostatic benefits of laser energy during anorectal surgery.

Although the results of the present study were satisfactory in the short term, slight recurrence rates were observed after laser hemorrhoidoplasty surgery as compared to conventional hemorrhoidectomy. While this difference was not significant, it is clinically significant and has been well debated in the literature. The conventional hemorrhoidectomy technique is one that completely removes hemorrhoidal tissue, which may offer more long-term disease control, especially for advanced grade IV hemorrhoids or gross prolapse (5). Laser hemorrhoidoplasty, on the other hand, mainly shrinks tissues, which could lead to a remaining vascular tissue and the reoccurrence of the hemorrhoids.

The same has been observed by several investigators after minimally invasive hemorrhoidal procedures (6). However, in the present study the recurrence rate was acceptable and comparable with previous reported rates. Additionally, the majority of the recurrent cases in the laser group were not severe, and they could be treated conservatively or as outpatients. So, recurrence should be considered in conjunction with patient-centered outcomes including quality of life, postoperative recovery, and comfort.

Laser proctology showed very favourable results for the patient when it came to satisfaction. The majority of patients who received the laser treatment said they were more comfortable during recovery and would recommend the treatment to a friend. This finding is in line with the trend in the world to less invasive surgical procedures, which minimize pain and shorten recovery after surgery. Today, the satisfaction of patients and their experience after the surgery are viewed as critical factors in the success of a procedure.

The present findings also have significant implications for healthcare practice in LMICs. Laser surgery provides definite postoperative benefits; however, specialized equipment, expense of the procedure, and the need for trained personnel for the treatment may restrict access in resource-limited health care settings (7). The conventional hemorrhoidectomy, which is a more cost-effective procedure and has proven to be effective in the long-term, is still widely used. Hence, the choice of procedure should depend on more factors than just “clinical outcomes” – institutional resources, surgeon experience and patient affordability are important considerations.

The findings of this study will help to provide regional information on the outcome of hemorrhoid surgery and help to fill the gap in limited comparative evidence available from the South Asian healthcare environment. Treatment outcomes could vary by population due to variations in postoperative care, patient follow-up adherence, healthcare infrastructure, and surgical skills. Thus, the local data is relevant in assessing the applicability of international surgical recommendations.

The results of this study need to be considered in light of a number of caveats. First, the design is retrospective, which would create a potential for selection bias, and reliance on the accuracy of available medical records. Second, the study was carried out at one centre with a small number of cases; this may make it difficult to interpret the results. Third, satisfaction results were partially dependent on subjective answers in the patient questionnaire and could be subject of recall bias. Postoperative results could also have been influenced by differences in surgical experience and technique. The study does offer clinically relevant comparative information on the short- and long-term outcomes of laser and conventional hemorrhoid surgery, however, even with these limitations.

Further larger multicenter trials with a standardized surgery protocol are suggested to assess the long-term recurrence, cost-effectiveness and quality-of-life of laser proctology. Further studies that evaluate the relative merits of the various minimally invasive techniques for hemorrhoids could further clarify treatment guidelines for the different stages of the disease.

Based on the results of this study, laser hemorrhoidoplasty seems to be a safe and effective minimally invasive surgical procedure alternative to conventional hemorrhoidectomy, especially in terms of postoperative recovery and satisfaction. However, traditional surgery still proves to be a long-term disease-control method and is a significant treatment option, particularly in the case of advanced hemorrhoidal disease.

In the present study, both laser proctology and conventional hemorrhoid surgery were found to be effective treatment options for patients suffering from hemorrhoidal symptoms and each treatment method had its own clinical advantages. LHP resulted in significantly less postoperative pain, hospital stay, faster return to normal everyday activities and higher patient satisfaction compared to a traditional hemorrhoidectomy. In the modern practice of proctology these results confirm the increasing tendency to prefer the less invasive surgical techniques.

Although laser surgery procedures had shown favourable short term recovery rates, the traditional hemorrhoidectomy continued to show slightly better recurrence rates and long term symptom control, especially for patients with advanced hemorrhoidal disease. The difference in recurrence rates between the two groups was not statistically significant, but the results indicate that, in some cases, conventional excisional surgery may be more effective in long-term tissue eradication.

The study also emphasized the need to consider patient recovery, comfort, long-term outcomes, and access to healthcare resources in choosing which surgical approach is ideal for the individual patient. Cost, equipment availability, and surgeon experience are still relevant factors in lower income health care facilities.

In summary, laser hemorrhoidoplasty seems to be a safe, effective and patient-friendly method of hemorrhoid surgery, particularly for patients who are seeking fewer postoperative symptoms and faster recovery times. However, conventional hemorrhoidectomy is still a good and clinically relevant procedure for the advanced and recurrent disease. Further multicentre, prospective studies at large scales are suggested to draw more definitive conclusions on the long-term recurrence, cost effectiveness and quality of life outcomes of both surgical interventions.

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