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Research Article | Volume 11 Issue 3 (March, 2025) | Pages 128 - 130
A Comparative Study Of Laser Haemorroidoplasty Versus Stapler Haemorrhoidopexy Surgical Treatment Of Grade Three And Grade Four Haemorrhoids.
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1
Senior Resident, Department of General Surgery, IGIMS, Patna, Bihar, India
2
Additional Professor, Department of General Surgery, IGIMS, Patna, Bihar, India
3
Junior Resident, Department of General Surgery, IGIMS, Patna, Bihar, India
4
Associate Professor, Department of General Surgery, IGIMS, Patna, Bihar, India
5
Professor, Department of General Surgery, IGIMS, Patna, Bihar, India
6
Junior Resident, Department of General Surgery, IGIMS, Patna, Bihar, India.
Under a Creative Commons license
Open Access
Received
Jan. 23, 2025
Revised
Feb. 9, 2025
Accepted
Feb. 28, 2025
Published
March 6, 2025
Abstract

Background: Haemorrhoids, a common anorectal condition, can be managed through conservative, non-surgical, or surgical approaches. For grade III and IV haemorrhoids, surgical intervention remains the gold standard. Traditional surgical methods include stapler haemorrhoidopexy and open haemorrhoidectomy. Laser haemorrhoidoplasty is a novel, minimally invasive approach using diode lasers to shrink haemorrhoidal tissue with minimal postoperative pain and faster recovery. This study aims to compare the effectiveness of laser haemorrhoidoplasty and stapler haemorrhoidopexy based on postoperative pain (VAS score), complications, and hospital stay. Materials and Methods: A prospective observational study was conducted in the Department of General Surgery at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna. A total of 100 patients with grade III or IV symptomatic haemorrhoids were included and randomized into two groups: Group 1 (Laser Haemorrhoidoplasty) and Group 2 (Stapler Haemorrhoidopexy). Postoperative outcomes were assessed based on pain using the Visual Analogue Scale (VAS) at different time intervals (Day 1, Weeks 1, 2, 4, 6, and 3 months). Complications such as bleeding, urinary retention, thrombosis, anal discharge, and stenosis were also evaluated. Results: The mean operative time was significantly shorter in the laser haemorrhoidoplasty group (32.5 ± 5.1 minutes) compared to the stapler haemorrhoidopexy group (41.3 ± 4.8 minutes, p < 0.05). Postoperative pain scores (VAS) were consistently lower in the laser group at all intervals, with Day 1 scores of 4.8 ± 1.2 compared to 6.7 ± 1.5 in the stapler group (p < 0.05). Postoperative pain score(VAS) on 3 months were 0.3±0.2 compared to 1.2 ± 0.6 in stapler group (p value <0.0.5). Complication rates were also lower in the laser group, including bleeding (6% vs. 14%), urinary retention (4% vs. 10%), and anal stenosis (2% vs. 8%) with statistically significant differences (p < 0.05). Additionally, the mean hospital stay was significantly shorter for laser haemorrhoidoplasty patients (1.8 ± 0.6 days) compared to stapler haemorrhoidopexy patients (3.2 ± 0.9 days, p < 0.05). Conclusion: +Laser haemorrhoidoplasty demonstrated superior outcomes over stapler haemorrhoidopexy, with reduced postoperative pain, fewer complications, shorter operative time, and shorter hospital stays. It offers a promising alternative for the surgical management of grade III and IV haemorrhoids, providing improved patient satisfaction and faster recovery.

Keywords
INTRODUCTION

Haemorrhoids are vascular structures in the anal canal that aid in continence but can become symptomatic when enlarged or prolapsed. They are classified as internal or external haemorrhoids based on their location relative to the dentate line (1). Internal haemorrhoids originate from the subepithelial vascular plexus above the dentate line, whereas external haemorrhoids arise from the perianal venous plexus below the dentate line (2). The condition is common, with peak prevalence observed between the ages of 45 and 65 years (3). Haemorrhoids are graded into four stages based on the severity of prolapse and symptoms, ranging from mild bleeding and discomfort in early stages to persistent prolapse requiring manual or surgical intervention in advanced stages (4).

 

For first- and second-degree haemorrhoids, conservative treatments such as dietary modifications, sitz baths, and topical medications are usually effective. However, third- and fourth-degree haemorrhoids often require surgical intervention due to the severity of symptoms such as bleeding, pain, perianal discomfort, mucous discharge, and incomplete defecation (5). The traditional surgical approach, open haemorrhoidectomy, remains the gold standard due to its effectiveness in complete haemorrhoidal tissue removal (6). However, it is associated with significant postoperative pain, prolonged healing time, and higher morbidity.

 

Stapler haemorrhoidopexy, an alternative surgical technique, involves the use of a circular stapler to reposition prolapsed haemorrhoidal tissue, reducing arterial blood flow and shrinking haemorrhoids. This method offers advantages such as reduced postoperative pain and shorter hospital stays but may be associated with complications like persistent prolapse, bleeding, and anal stenosis (7,8).

 

Laser haemorrhoidoplasty has emerged as a minimally invasive technique utilizing diode lasers to induce coagulation and shrinkage of haemorrhoidal tissue while preserving the anoderm and mucosa. The procedure is associated with reduced postoperative pain, minimal bleeding, and faster recovery compared to conventional haemorrhoidectomy (9). Studies have reported favorable outcomes with laser therapy, including lower Visual Analogue Scale (VAS) scores for pain and reduced postoperative complications (10,11). However, data comparing laser haemorrhoidoplasty and stapler haemorrhoidopexy, particularly for grade III and IV haemorrhoids, remain limited.

This study aims to compare the efficacy and safety of laser haemorrhoidoplasty and stapler haemorrhoidopexy in the management of grade III and IV haemorrhoids, focusing on postoperative pain and complications.

MATERIALS AND METHODS:

Study Design and Setting

This prospective observational study was conducted in the Department of General Surgery at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna. The study included patients undergoing surgical intervention for grade III and IV haemorrhoids.

 

Study Population and Inclusion Criteria

Patients admitted for surgical treatment of haemorrhoids were assessed based on specific inclusion and exclusion criteria. The inclusion criteria were:

 

  1. Patients diagnosed with symptomatic grade III and IV haemorrhoids who did not respond to conservative treatment.
  2. Individuals with an American Society of Anesthesiologists (ASA) physical status classification of grade 1 or 2.
  3. Patients aged between 18 and 70 years.

 

Exclusion Criteria

Patients were excluded if they met any of the following conditions:

  1. Presence of other anorectal conditions such as anal fissures, fistulas, pilonidal sinus, or perianal abscesses.
  2. History of previous anorectal surgeries.
  3. Patients deemed unfit or unwilling to undergo surgical treatment.

 

Sample Size Calculation

The sample size was determined considering a 95% confidence level, 80% study power, and a 5% two-sided alpha error. A total of 50 patients were assigned to each treatment group, accounting for a possible 5% loss to follow-up.

 

Study Duration

The study was conducted over a period of one year, with patient follow-ups extending to three months postoperatively.

 

Patient Allocation and Surgical Procedures

Eligible patients were randomly assigned into two groups using simple random sampling:

 

  1. Group 1: Underwent laser haemorrhoidoplasty using a diode laser (Lasotronix) in continuous pulse mode.
  2. Group 2: Underwent stapler haemorrhoidopexy using a circular stapling device.

 

Both procedures were performed under appropriate anesthesia, and intraoperative parameters such as operative time were recorded.

 

Postoperative Evaluation

Postoperative pain was assessed using the Visual Analogue Scale (VAS) on Day 1, Weeks 1, 2, 4, 6, and at 3 months. Other parameters recorded included:

 

  1. Hospital Stay: Number of days admitted postoperatively.
  2. Postoperative Complications: Incidences of bleeding, urinary retention, acute thrombosis, anal discharge, and anal stenosis were noted.

 

Follow-up and Outcome Measures

Patients were monitored postoperatively and followed up for three months. Statistical analysis was performed to compare pain levels and complication rates between the two surgical techniques.

RESULTS

Demographic and Baseline Characteristics

A total of 100 patients were included in the study, with 50 in the laser haemorrhoidoplasty group (Group 1) and 50 in the stapler haemorrhoidopexy group (Group 2). The mean age of patients in Group 1 was 45.2 ± 8.3 years, whereas in Group 2, it was 46.8 ± 7.9 years. Both groups had a comparable distribution of gender and comorbidities such as diabetes and hypertension (Table 1).

 

Table 1: Baseline Characteristics of Patients

Parameter

Group 1 (Laser)

Group 2 (Stapler)

p-value

Number of patients

50

50

-

Mean age (years)

45.2 ± 8.3

46.8 ± 7.9

0.412

Male (%)

60% (30)

62% (31)

0.782

Female (%)

40% (20)

38% (19)

0.832

Diabetes (%)

18% (9)

20% (10)

0.715

Hypertension (%)

22% (11)

24% (12)

0.690

 

Operative Parameters

The mean operative time for laser haemorrhoidoplasty was significantly shorter (32.5 ± 5.1 minutes) compared to stapler haemorrhoidopexy (41.3 ± 4.8 minutes, p < 0.05), as shown in Table 2.

1 male pt. of stapler haemorroidopexy had profuse bleeding due to stapler misfire. Patient was managed by suturing both the mucosal cut ends with HAL 2-0. He later presented with anal stenosis.

 

Table 2: Operative Time Comparison

Parameter

Group 1 (Laser)

Group 2 (Stapler)

p-value

Operative time (minutes)

32.5 ± 5.1

41.3 ± 4.8

<0.05

 

Postoperative Pain Assessment (VAS Score)

Postoperative pain, assessed using the Visual Analogue Scale (VAS), was significantly lower in the laser group at all time points compared to the stapler group (Table 3). On Day 1, the mean VAS score was 4.8 ± 1.2 in Group 1 and 6.7 ± 1.5 in Group 2 (p < 0.05). The trend of lower pain scores in the laser group persisted at all follow-up intervals (Table 3).

 

Table 3: Postoperative Pain Assessment (VAS Score)

Time Point

Group 1 (Laser)

Group 2 (Stapler)

p-value

Day 1

4.8 ± 1.2

6.7 ± 1.5

<0.05

Week 1

3.5 ± 1.1

5.8 ± 1.3

<0.05

Week 2

2.2 ± 0.9

4.3 ± 1.2

<0.05

Week 4

1.6 ± 0.7

3.5 ± 1.0

<0.05

Week 6

0.8 ± 0.5

2.1 ± 0.9

<0.05

3 Months

0.3 ± 0.2

1.2 ± 0.6

<0.05

 

Postoperative Complications

The incidence of postoperative complications was lower in the laser haemorrhoidoplasty group. Bleeding was reported in 6% (3/50) of patients in Group 1 and 14% (7/50) in Group 2. Urinary retention occurred in 4% (2/50) of Group 1 patients and 10% (5/50) of Group 2 patients. Anal stenosis was observed in 2% (1/50) in Group 1 and 8% (4/50) in Group 2 (Table 4).

Table 4: Postoperative Complications

Complication

Group 1 (Laser)

Group 2 (Stapler)

p-value

Bleeding (%)

6% (3)

14% (7)

<0.05

Urinary retention (%)

4% (2)

10% (5)

<0.05

Thrombosis (%)

2% (1)

6% (3)

0.091

Anal discharge (%)

4% (2)

8% (4)

0.125

Anal stenosis (%)

2% (1)

8% (4)

<0.05

 

Hospital Stay

The mean hospital stay was shorter for patients undergoing laser haemorrhoidoplasty (1.8 ± 0.6 days) compared to those undergoing stapler haemorrhoidopexy (3.2 ± 0.9 days, p < 0.05), as illustrated in Table 5.

 

Table 5: Hospital Stay Comparison

Parameter

Group 1 (Laser)

Group 2 (Stapler)

p-value

Hospital stay (days)

1.8 ± 0.6

3.2 ± 0.9

<0.05

 

Summary of Findings

  • Laser haemorrhoidoplasty resulted in significantly shorter operative times.
  • Postoperative pain scores were lower in the laser group at all follow-up points (Table 3).
  • The incidence of complications such as bleeding, urinary retention, and anal stenosis was lower in Group 1 (Table 4).
  • The mean hospital stay was shorter for patients undergoing laser haemorrhoidoplasty (Table 5).

 

These findings suggest that laser haemorrhoidoplasty is associated with faster recovery, lower postoperative pain, and fewer complications when compared to stapler haemorrhoidopexy.

DISCUSSION

The management of grade III and IV haemorrhoids requires surgical intervention, with open haemorrhoidectomy historically being the gold standard. However, advancements in surgical techniques, such as stapler haemorrhoidopexy and laser haemorrhoidoplasty, offer alternative approaches with varying benefits and limitations (1). This study compared these two techniques in terms of operative time, postoperative pain, complications, and recovery, demonstrating that laser haemorrhoidoplasty provides superior outcomes in several key aspects.

 

Operative time is a crucial factor influencing surgical efficiency and patient recovery. In this study, laser haemorrhoidoplasty had a significantly shorter mean operative duration than stapler haemorrhoidopexy, which is consistent with findings from previous studies (2,3). The shorter operative time with laser treatment can be attributed to its minimally invasive nature, as it does not involve excision or anastomosis of tissue, reducing surgical complexity (4).

 

Postoperative pain is a major concern following haemorrhoidal surgery, often determining the overall success of the procedure. Pain scores in the present study were significantly lower in the laser haemorrhoidoplasty group across all follow-up intervals, particularly during the first postoperative week. These findings align with previous research indicating that diode laser therapy causes less collateral tissue damage, leading to reduced inflammatory responses and nerve irritation (5,6). A meta-analysis by Naderan et al. also confirmed that laser techniques result in lower postoperative pain compared to conventional haemorrhoidectomy and stapler haemorrhoidopexy (7).

 

Postoperative complications are another critical factor when evaluating surgical techniques. In this study, the incidence of complications, including bleeding, urinary retention, and anal stenosis, was lower in the laser haemorrhoidoplasty group. This observation is supported by previous reports suggesting that laser treatment leads to better tissue preservation and controlled coagulation, thereby reducing complications such as excessive bleeding and postoperative strictures (8,9). A comparative study by Maloku et al. similarly reported a lower incidence of complications following laser haemorrhoidoplasty compared to stapler haemorrhoidopexy (10).

 

Hospital stay was significantly shorter for patients undergoing laser haemorrhoidoplasty, which can be attributed to reduced postoperative pain and lower complication rates. Faster recovery has been reported in several studies assessing laser haemorrhoidoplasty, with hospital stays ranging from one to two days, in contrast to longer durations required for stapler haemorrhoidopexy and open haemorrhoidectomy (11,12). This advantage makes laser haemorrhoidoplasty a more suitable option for day-care procedures, reducing healthcare costs and hospital resource utilization (13).

 

Despite the advantages observed in this study, laser haemorrhoidoplasty is not without limitations. One of the primary concerns is cost, as laser devices and fiber optics increase procedural expenses compared to stapler haemorrhoidopexy (14). Additionally, long-term follow-up is necessary to assess recurrence rates, as some studies have suggested that tissue coagulation may not always prevent haemorrhoidal recurrence in the long run (15).

CONCLUSION

Overall, the findings of this study support the growing body of evidence favoring laser haemorrhoidoplasty over stapler haemorrhoidopexy for the surgical treatment of advanced haemorrhoids. It provides a minimally invasive approach with reduced pain, fewer complications, and faster recovery, making it a valuable alternative for patients and surgeons alike. However, further large-scale, multicenter randomized controlled trials are required to validate these findings and assess long-term outcomes comprehensively.

REFERENCES
  1. Majumder KR, Alam TA, Rassell M. LASER Haemorrhoidoplasty versus Stapler Haemorrhoidopexy: A Prospective Comparative Study. Mymensingh Med J. 2021 Jul;30(3):780-788. PMID: 34226468.
  2. Maloku H, Gashi Z, Lazovic R, Islami H, Juniku-Shkololli A. Laser hemorrhoidoplasty procedure vs open surgical hemorrhoidectomy: a trial comparing 2 treatments for hemorrhoids of third and fourth degree. Acta Inform Med. 2014 Dec;22(6):365-7. doi: 10.5455/aim.2014.22.365-367. PMID: 25684840.
  3. Naderan M, Shoar S, Nazari M, Elsayed A, Mahmoodzadeh H, Khorgami Z. A randomized controlled trial comparing laser intra-hemorrhoidal coagulation and Milligan-Morgan hemorrhoidectomy. J Invest Surg. 2017 Oct;30(5):325-331. doi: 10.1080/08941939.2016.1248304. PMID: 27869502.
  4. Gupta PJ, Kalaskar S. Laser hemorrhoidoplasty: indications, outcome, and advantages. Med J DY Patil Univ. 2017;10(4):353-357. doi: 10.4103/0975-2870.213616.
  5. Picchio M, Palimento D, Attanasio U, Renda A, Marino G. Stapled vs open hemorrhoidectomy: long-term outcome of a randomized controlled trial. Int J Colorectal Dis. 2006 Dec;21(7):668-73. doi: 10.1007/s00384-005-0079-3. PMID: 16328369.
  6. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005393. doi: 10.1002/14651858.CD005393.pub2. PMID: 17054149.
  7. Karahaliloglu T, Kilicoglu B, Ertas K, Ozkaya O. A comparative study of laser hemorrhoidoplasty and Milligan-Morgan hemorrhoidectomy. J Clin Med Res. 2016 Mar;8(3):274-8. doi: 10.14740/jocmr2440w. PMID: 26767083; PMCID: PMC4748500.
  8. Senagore AJ. A critical appraisal of evidence-based medicine in the treatment of hemorrhoidal disease. Am J Surg. 2007 Mar;193(3):S8-11. doi: 10.1016/j.amjsurg.2006.11.009. PMID: 17276552.
  9. Infantino A, Altomare DF, Bottini C, Bonanno M, Mancini S; THD group of the SICCR (Italian Society of Colorectal Surgery); Yalti T, Giamundo P, Hoch J, El Gaddal A, Pagano C. Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids. Colorectal Dis. 2012 Feb;14(2):205-11. doi: 10.1111/j.1463-1318.2011.02628.x. PMID: 21689317.
  10. Lucarelli P, Picchio M, Caporossi M, De Angelis F, Di Filippo A, Stipa F, Spaziani E. Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up. Ann R Coll Surg Engl. 2013 May;95(4):246-51. doi: 10.1308/003588413X13511609958136. PMID: 23676807; PMCID: PMC3966214.
  11. Mert T. Comparison of Laser Haemorrhoidoplasty and Ferguson Haemorrhoidectomy in Treating Grade III and Grade IV Haemorrhoids: A Prospective Randomised Study. J Coll Physicians Surg Pak. 2023 Jan;33(1):41-46. doi: 10.29271/jcpsp.2023.01.41. PMID: 36597234.
  12. Burch J, Epstein D, Baba-Akbari A, Weatherly H, Fox D, Golder S, Jayne D, Drummond M, Woolacott N. Stapled haemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation. Health Technol Assess. 2008 Apr;12(8):iii-iv, ix-x, 1-193. doi: 10.3310/hta12080. PMID: 18373905.
  13. Aly EH. Stapled haemorrhoidopexy: is it time to move on? Ann R Coll Surg Engl. 2015 Oct;97(7):490-3. doi: 10.1308/003588415X14181254789123. Epub 2015 Aug 14. PMID: 26274539; PMCID: PMC4623721.
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