Emergency treatment of bleeding hemorrhoids in a patient taking aspirin and clopidogrel using a 1470 nm diode laser and the ELITE minimal invasive technique

Abstract

INTRODUCTION

The most characteristic proctological disease in the Western World is hemorrhoidal disease (HD), and it is common that its symptoms can overlap with other anorectal diseases such as abscesses, fissure, polyps, neoplasms and inflammatory bowel disease [1]. Prevailing presentation includes anal pain, irritation and/or soiling, sensation of a prolapsing lesion and most frequently rectal bleeding, which can be elicited by hard stool during defecation [2]. The risk of bleeding is substantially increased if the patient is regularly taking blood thinners as it happened with our case. As [3] support there are many methods, invasive and less invasive, and all of them have their advantages and disadvantages. However, the use of the most recent 1470 nm diode laser with the dedicated hemorrhoid probe offers more advantages to the patient with minimal pain, rapid healing process and low recurrence rate. In the majority of the cases, HD Grades II/III are treated on an outpatient basis [4] unless any other clinical findings or risk factors dictate otherwise.

CASE REPORT

A 74-year-old, smoker, male patient came urgently on the 30 December 2018 to the Accident and Emergency Department of our clinic, reporting heavy rectal bleeding and intense pain during defecation for 2 days; however, there were no clinical signs of anemia. Past medical history included coronary artery disease (CAD) and angioplasty with the placement of three stents 6 years ago. As a result, he was on anticoagulation protocol with 75 mg clopidogrel and 75 mg aspirin. There were no other medications and no known drug allergies. Furthermore, the patient has never had any similar symptoms and neither has ever suffered from hemorrhoids in the past. Initial physical examination showed HD Grade III, with three nodules protruding outside the anal canal and required manual reduction; the two nodules at 3 and 7 o’clock, respectively, were thrombosed and bleeding, while there was also a smaller one at 11 o’clock. Once the pre-operative testing protocol was ready, a colonoscopy was performed to exclude any other additional anorectal diseases or possible differential diagnoses for bleeding, and the findings were normal. Due to the urgent character of the case and taking into consideration the blood thinners the patient was on, the surgeon decided, after having the informed consent of the patient, to proceed with the expert laser intrahemorrhoidal therapy (ELITE) minimal invasive technique for the hemorrhoids with the use of a 1470 nm diode laser in order to limit the potential complications including any post-operative (post-op) bleeding.

An urgent bowel preparation took place with a cleansing enema, and surgery took place under local anesthesia in the peri-anal region along with sedation. For prevention of an infection, a dose of IV antibiotics (metronidazole 500 mg) was administered to the patient during the procedure and it was repeated every 8 h until the patient’s discharge. The ELITE was initiated with the use of a 1470 nm laser unit. A designated optic fiber with a specific conical glass tip (hemorrhoid probe) helped with the treatment of each hemorrhoidal nodule. The laser unit was set at 7.0 W/3 s and single pulse, and each nodule received the dedicated energy homogenously in pulses for better control during the thermal seal-off of the hemorrhoidal nodules. Total operating time was 31 min. and the energy delivered to the area was 1270 J, without the need for any sutures.

Right after the end of the procedure, the patient got admitted for a precautionary overnight stay due to the possible, yet minor, risk of bleeding due to his CAD and medications.

Eighteen hours after the surgery, the pain experienced by the patient was a Level 4 on Visual Analog Pain Scale (VAPS), compared to a pre-operatively 10/10. Clinical post-op examination showed normal findings with extended tissue ecchymosis due to the large amount of energy given. The patient was discharged the day after the surgery and returned to daily activities after 5 days; he was prescribed only with paracetamol 500 mg as needed for analgesia in the possibility of pain during the next 48 h. First bowel movement occurred 30 h after the surgery without bleeding, with a slight discomfort, yet without any difficulty. During the follow-up visit that took place a week later, the reported pain dropped to 2/10 (VAPS), without any discomfort. On the second follow-up, 15-days post-op, physical examination confirmed that the hemorrhoidal piles have been substantially shrunk and the healing process was normal. Next follow-up visits took place on the 6th, 12th and 18th months after surgery, with the latter being in June 2020; there have never been any complications, any bleeding from the points of entry of the optic fiber, and of course, no signs of recurrence of the hemorrhoidal nodules.

DISCUSSION

The use of diode laser in the treatment of HD has been widely used during the past few years. De Nardi et al. [5] argued in their research that mean bleeding and pain scores have been significantly reduced after 3, 12 and 24 months post-op in patients with HD Grades II and III. Treatment of thrombosed external hemorrhoids depends on the timing the patient is looking for help [2]. According to Naderan et al. [7], when comparing 980 nm diode laser to a classic Milligan-Morgan hemorrhoidectomy, the post-op pain as well as intra-operative bleeding are reduced, and the administration of analgesics are enough for any post-op pain. In our case, with the use of 1470 nm, we have a very localized heat generation offering a safer and more precise application due to the fact that this wavelength is highly absorbed by water compared to previous wavelengths, such as 980 nm, which were equally absorbed by hemoglobin and water. Brusciano et al. [6] highlight this fact, emphasizing that 1470 nm diode laser results in negligible post-op discomfort and its use could be considered as a painless, minimally invasive technique for HD. The management of HD with a diode laser has a variety of advantages against other more invasive treatments when performed by a skilled surgeon: decreased operating time, minor post-op pain and discomfort, no application of sutures, quick healing times, low recurrence rates [3] and good patients’ acceptance [8]. In a similar scenario, if a patient came in with thrombosed and bleeding HD Grade IV along with rectal prolapse, ‘ceteris paribus’, the minimal invasive technique and the use of the 1470 nm diode laser would not have been enough per se; in that case, a combination of surgical procedures, such as Milligan-Morgan along with the ELITE treatment, can have very promising results as it was proven through our daily practice in the past decade in the treatment of difficult and/or severely neglected cases. Consequently, the experienced general surgeon can evaluate each case and reach to a shared decision, with the patient taking into consideration the clinical picture of the latter and the advances a 1470 nm diode laser has to offer in the treatment of HD.

FUNDING

We would like to emphasize that this case report has not accepted any funding of any kind and its sole purpose is to enhance the knowledge in the field of the applications of the diode laser in everyday proctology.

CONFLICT OF INTEREST STATEMENT

None declared.

ACKNOWLEDGEMENTS

Hereby, we would like to thank the medical staff of Euromedica General Clinic of Thessaloniki for their continuous support in the use of new technologies and applications in a variety of emergency settings.

References