In chronic grade 2 disease LHP can be a treatment of choice, and it is very effective for long-term results and also, sclerotherapy and rubber band ligation are the other alternatives as a treatment method. However, the problem is in grade 3 disease, in this group, laser treatment is not preferred because it requires more shots and gives much energy to put out the package, on the other hand, if you don’t apply enough shots, the treatment is not effective. You can use open surgery to all packages, however, this also increases postoperative pain, recovery time and could be cause anal stenosis. Then, do we have to use a single method in patients with multiple hemorrhoid packages with both grade 2 and 3 diseases?
The most important outcome in the surgical treatment of hemorrhoid disease is less pain after surgery and rapid return to daily life, and low recurrence rates.
Patients with symptomatic grade 3 and 4 hemorrhoid diseases, Milligan - Morgan (open) or Ferguson (closed) hemorrhoidectomy techniques are still considered as the gold standard, mainly in patients with fourth-degree hemorrhoids [6]. The recurrence rate is low in these techniques however, discomfort and postoperative pain decrease the quality of life of the patients after surgery and returning the routine daily work is getting longer [7, 8]. Additionally, potential morbidity including anal canal stenosis and iatrogenic incontinence should not be forgotten [9, 10]. On the other hand, in some conditions, patients with severe pain, long standing swelling and bleeding with grade 2 disease when the surgery is indicated, these techniques are unnecessarily extended and the other methods should be preferred [11]. When you compare the postoperative early and mid-term pain levels of the patients, also the results of this study showed that patients treated with Ferguson technique had the most severe pain scores after surgery in all time periods (postoperative 6th, 12th, 24th hour, and 1st-week) than the other techniques (LHP and combined method).
Laser hemorrhoidopexy is a new method recently used in the treatment of hemorrhoid disease and is a revolutionary approach in the treatment of hemorrhoids [12, 13]. Laser hemorrhoidopexy does not cause any changes in the anatomy of the anal canal and improves the symptoms by not disrupting the physiological functions of the hemorrhoidal plexus in the anus [12]. In addition, LHP has lesser postoperative pain than the other conventional methods [13]. Several prospective randomized studies were comparing LHP procedure with other techniques found that postoperative pain was lower in the LHP group than in all other procedures [13, 14]. Postoperative comfort is the most important point in the choice of surgical modality for patients [15]. For that reason, most patients want to get LHP for their disease. However, the recurrence rate after LHP in the long term period, is more than the conventional surgery [16]. While offering the method to the patient, according to the symptoms severity and grade of hemorrhoid disease, this point should be discussed with patient carefully. According to the results of the randomized controlled study conducted in 2020, the rates of needing treatment due to recurrent symptoms in hemorrhoid disease and the rates of recurrent prolapse are higher in LHP, though the total mean time without complaints after surgery is shorter in LHP than open techniques [17]. In this study, the postoperative pain scores of all time periods (postoperative 6th, 12th, 24th hour, and 1st-week) in LHP group were lesser than the other techniques (FH and FH + LHP) statistically. However, in two patients postoperative thrombosis were detected in LHP group and also in a follow up period in two patients recurrent disease were detected at postoperative 6 and 13 mounts.
Postoperative pain is important factor for early return to normal daily life and work. The relationship between LHP and postoperative pain has been investigated in many studies [1, 2, 18]. In a prospective study conducted by Brusciano et al [18], On 50 patients with stage 2–3 hemorrhoids treated with a laser; postoperative pain and the time to return to daily activity were evaluated. All patients returned to their daily activities after 2 days. The postoperative pain score (at 12, 18, and 24 hours postoperatively), assessed by the visual analog scale, was quite low (mean value 2). Similarly, in this study, the postoperative pain score of the patients (at postoperative 6, 12, and 24 hours) in the LHP group was lower (mean value of 1.1-1.2-0.3 respectively), and all our patients returned to their daily activities after 1 day after LHP. In the FH group, the postoperative hospital stay was longer and the return to normal daily life was also longer than the other groups. There was one bleeding on the 6th day and there was one urinary retention occured in the FH group, a foley catheter was applied and was removed after 24 hours.
Nonetheless, not all patients are suitable for laser treatment only. In a group of patients, there are many hemorrhoid packages and some of them are large and prolapsed while others may be small and limited in the anal canal. In these patients, to perform conventional methods to all packages will be resulted in much pain and long time discomfort after surgery. The comfort of the patients will be so harmful. However, if you want to apply laser to all packages, in big packs (grade 3 and 4), it is not preferred because the number of laser shots and given energy will be high in large packs, so that, will require more energy, if it exceeds the upper energy limit, it may cause tissue damage. As a result, laser treatment alone may not be sufficient in large packs and can cause higher postoperative edema and necrosis after surgery [19]. For that reason, we thought to use the combined method in patients who have more than 2 packs and not all of them are suitable for laser. In our knowledge, there is no study found in the literature that use the combination of LHP and FH.
In this study, we performed combined method to patients with grade 2–3 hemorrhoid disease with more packages of both small and large ones including. The reason for choosing the combined method was that when we applied the Ferguson only to all packages, the postoperative pain was more and the complication rate was more also. However, since we performed the LHP alone, we will not provide a complete cure in patients with large packages, so that we have started to use this combined method in this group of patients.
The strength of this study is that, it is the first study in the literature that was comparing the results of conventional method, laser and combined method. The weakness of this study is, it was conducted in a single center, the patient’s number is low in each group and the symptoms were measured according to the information received from the patients.
As a conclusion, combined method of FH and LHP can be safely preferred for patients with multiple hemorrhoid packages with both grade 2 and 3 symptomatic disease. Thus, postoperative pain becomes less and recurrence rate remains low.