Hemorrhoid disease is a common entity, with a worldwide prevalence of up to 27.9% [1] and an Australian prevalence of 38.9% [2]. It is estimated that more than 50% of the population will experience symptoms from hemorrhoids within their lifetime [3, 4].

Symptomatic hemorrhoids that have failed conservative medical management can be managed in a variety of ways, depending on their size and symptomatology. The gold standard is a traditional hemorrhoidectomy [5]; however, this is plagued with severe postoperative pain and other complications such as urinary retention, bleeding, anal stenosis, and chronic fissure [6].

Other nonexcisional treatments cause similar issues with pain and are associated with high recurrence rates. Despite the range of surgical treatments and several modifications to their technique, postoperative pain remains the key concern for both patients and clinicians in the management of symptomatic hemorrhoid disease. This often results in reluctance to undergo definitive surgical treatment or extended time off work for those that do [7].

Lasers were first described for use in hemorrhoid disease over 30 years ago [7], but only utilized recently. Although adopted widely in Europe and Asia, its use in Australia has been limited by cost and lack of experience. There are 2 main laser approaches to hemorrhoidal disease. A laser hemorrhoidoplasty (LH) involves an incision at the base of hemorrhoid, via which the hemorrhoidal tissue is coagulated using the laser probe. A hemorrhoidal laser procedure utilizes a Doppler ultrasound probe to identify the terminal branches of the superior rectal artery, which are coagulated with laser energy.

A systematic review [8] in 2021 found that laser treatment universally reported low postoperative pain scores as well as satisfactory symptom relief and recurrence rates on long-term follow-up. Nine out of 19 studies reported significantly lower pain compared with hemorrhoidectomy. Thus far, no Australian studies have been performed.

The authors present a pilot study investigating the Australian experience of LH in patients with symptomatic hemorrhoid disease that have failed conservative management. The primary outcomes are to assess severity and duration of postoperative pain using a 10-day visual analog scale, as well as time to return to normal function and work and compare this to a historical cohort of patients who underwent a traditional Milligan-Morgan hemorrhoidectomy. Secondary outcomes are to objectively assess severity of hemorrhoidal symptoms and their effect on patients’ quality of life (QoL) after 1 year and overall patient satisfaction. We hypothesize that LH involves a speedier and less painful recovery when compared to traditional hemorrhoidectomy and has comparable clinical outcomes in controlling symptoms of hemorrhoidal disease on long-term follow-up.

The study’s protocol was reviewed and approved by the Human Research Ethics Committee of Eastern Health (No. EH 2019-467) and written consent was obtained from each patient for inclusion in the study including the use of deidentified operative photography.

In our study, 30 patients underwent LH, of which 1 patient failed to complete their postoperative pain questionnaire. At the 3-month follow-up, 7 patients were lost to follow up; and at 6 months, 13 patients were lost to follow up. In our historical comparison group, 43 patients were recruited, and all patients completed their postoperative pain questionnaire. Due to posthemorrhoidectomy outcomes available in existing literature, hemorrhoidectomy patients were not followed up beyond 10 days after the procedure.

The median age in the LH group was 43.5 years (range, 32–88 years) with 23 female and 7 male patients. This group had no smokers, with 2 patients on oral anticoagulation (withheld perioperatively). This is compared to the hemorrhoidectomy group, where the median age was 42 years (range, 22–76 years) with 35 female and 8 male patients. This group included 2 smokers and did not have any patients on anticoagulation. In the LH group, 5 patients (16.7%) had a history of previous hemorrhoid procedures, which is similar to the hemorrhoidectomy group which had 6 participants (13.9%) with previous hemorrhoid interventions. The median grades of hemorrhoids were III in both groups (range, II–IV) and neither group had significant comorbidities. Baseline characteristics are further presented in Table 1.

This pilot study evaluated the outcomes of postoperative pain and return to function and work in patients with symptomatic hemorrhoids undergoing LH in an Australian population. The postoperative pain scores and recovery period were compared with a historical cohort of patients who underwent a hemorrhoidectomy by the same surgeon. This pilot trial demonstrated that LH is feasible with acceptable short-term and long-term outcomes, in particular low pain scores and decreased recovery period.

The ideal choice of treatment for hemorrhoidal disease is not straightforward. While hemorrhoid-preserving procedures are purported to reduce pain and improve recovery, there is conflicting evidence regarding their clinical efficacy and long-term outcomes. A traditional hemorrhoidectomy is considered to be the gold standard and allows complete remission of hemorrhoidal disease with recurrence estimated to be 2% to 16% for grade II to IV hemorrhoids at 1 year; however, it is fraught with a painful postoperative journey [14-16]. Therefore, we are always looking for alternatives that result in similar clinical outcomes, but with less postoperative pain.

Literature suggests that LH is more suitable for lower-grade hemorrhoids (grade II and III) with low rates of recurrence [17]. A systematic review by Longchamp et al. [17] highlights that the recurrence rate of hemorrhoids after LH ranges from 0% to 11.3% after 1 year for this cohort, and Faes et al.’s 2019 prospective study [18] in Switzerland on 50 men and women with grade II to III hemorrhoids undergoing LH estimates the 5-year recurrence to be 36% [19]. Our study highlights a similarly low rate of recurrence at 25.0% (3 of 12) for those with grade II and III hemorrhoids at 1 year. However, long-term outcomes of grade IV hemorrhoids have been understudied in literature, as LH is thought to be incomplete with severe hemorrhoid disease based on clinical experience in other countries [20]. A study by Maloku et al. [21] in 2014 highlights that LH is equally efficacious to surgical hemorrhoidectomy at a 1-month follow-up. Our study finds a 75.0% recurrence rate (3 of 4) at 1 year for those undergoing LH with grade IV disease, highlighting that LH may be less effective in severe disease. Therefore, as LH has shown to have minimal intraoperative complications, and low rates of recurrence for those with grade II and III hemorrhoids, this procedure is likely to be safe in moderate hemorrhoidal disease and this pilot study may guide larger clinical trials in Australia [22].

A randomized controlled trial of 121 patients in 2019 [20], comparing LH with suture mucopexy and excisional hemorrhoidectomy found that LH was significantly less painful than excisional hemorrhoidectomy (P< 0.001) and associated with earlier return to regular activity (15 days vs. 30 days, P< 0.001). Similar to our study, they utilized a 1,470-nm diode laser with similar amounts of energy delivered per hemorrhoid and the results of our study were comparable.

Unexpectedly, the 2-week postoperative satisfaction scores reported were higher in the hemorrhoidectomy cohort compared with the laser cohort. It may be that once the postoperative recovery period is over and the acute pain symptoms have subsided, the hemorrhoidectomy cohort are more satisfied. It is difficult to make further inferences as “satisfaction” is a subjective measure and may be related to factors other than postoperative pain.

Significant complications after LH are uncommon. The occurrence of skin tags is reported in up to 1/3 of patients after LH [17] and our cohort included 3 patients (10.0%) who required a repeat intervention for excision of residual skin tags. Skin tags may result in patients secondary to the inflammatory response from the heat energy. Such residual tags may be problematic for patients to maintain anal hygiene or for cosmesis and as such, require subsequent excision.

Although the study’s findings are favorable toward the LH cohort, several limitations must be considered. This study may be limited by the sampling error due to the low sample size (n= 30). Furthermore, low response rates at 1-year follow-up may also cause bias (n= 16). As this was the first time that LH was trialed in an Australian setting, it was treated as a “pilot study” where the procedure was able to be trialed in a small sample of patients. Given that the study has demonstrated the feasibility of the use of laser energy for hemorrhoids and safety of its use in this Australian cohort, it may serve as a stepping-stone to similar trials with larger patient populations in the future.

Furthermore, our sample of participants undergoing LH has a higher proportion of females than males in both the LH group (76.7% of females) and the comparative Milligan-Morgan hemorrhoidectomy group (81.4% of females). A New Zealand crosssectional study by Xia et al. [23] in 2020 of over 45,000 participants identifies that the incidence of hemorrhoids in women is 4% less than in men. As these proportions may therefore not be reflective of the general population, our sample may be more reflective of the local demographic of our institution and may have the potential for bias and is a limitation of the small-sampled feasibility study.

Additionally, there may be a component of response bias, whereby the reporting of patients’ pain scores in the LH group may have been more unfavorable as patients may have expected no pain after the anticipated “newer” procedure. There may also be substantial selection bias, due to the loss to follow up in the postoperative questionnaires. Furthermore, there may be some recall bias, if patients filled in the questionnaire retrospectively before their 2-week review and did not recall their pain scores accurately.

This is the first pilot study to trial laser techniques in the use of symptomatic hemorrhoidal disease in an Australian population and the results have corroborated the international experience, with decreased pain and analgesia use, earlier return to function and the workplace, and clinically efficacy on long-term follow-up. Future studies investigating LH should expand their population size, reproduce the study with randomized patient selection to compare and utilize established symptom scores to be able to objectively assess outcomes.

This pilot study demonstrates low pain scores with this revivified procedure in an Australian population, demonstrating the safety of the use of LH in symptomatic hemorrhoidal disease. LH resulted in significantly lower pain scores, defecation pain scores, and opioid analgesia use in the early postoperative period. Additionally, there was statistically significant symptom resolution and improvement in symptom-related patient QoL on long-term follow-up. Further head-to-head studies comparing LH to other hemorrhoid therapies with larger sample sizes and the utilization of objective postoperative symptoms scores are required to determine the most efficacious therapeutic approach for this common condition.