LHP (Laser hemorrhoido-plasty)

V. Nutz, Köln

Riga, 12. 3 .2011

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  

Ceralas E Laser 980nm

HeLP™ : Hemorrhoid Laser Procedure LHP : Laser hemorrhoidoplasty

HeLP™ : Hemorrhoid Laser Procedures LHP™ : Laserhämorrhoidoplastie

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) ‏

Patienten

Documentation

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) ‏