Laser in Proctology: Science, Myths, and Marketing

“One must attend in medical practice not primarily to plausible theories, but to experience combined with reason.” – Hippocrates

Benign proctological conditions are prevalent in clinical practice, causing significant discomfort to patients, both due to symptoms and the anxiety related to surgical treatment. Managing these conditions is often challenging, as various techniques can be applied to treat the same pathology, depending on the characteristics of the disease, the preferences of the patients, and the experience of the surgeon. In this context, the growing interest in minimally invasive approaches and new technologies aimed at reducing surgical trauma is understandable. Among these innovations, the application of laser in proctology has gained attention recently.[1]

The term “laser” is an acronym for “Light Amplification by Stimulated Emission of Radiation”, which describes a highly concentrated beam of light as an electromagnetic wave. Although this technology remains relevant today, the use of laser in surgery is not new; its first applications in coloproctology date back to the 1970s.[2] Initially, the laser was used for coagulating bleeding and vaporizing tumors, in addition to treating orificial conditions such as hemorrhoids, fistulas, fissures, and condylomas. Technically, the laser can function as a method of fulguration, coagulation, vaporization, cutting, or photodynamic therapy, depending on the modality, which varies according to the wavelength and depth of tissue penetration. The most commonly used types of laser include CO₂, Nd:YAG, diode, and argon.[3]

Currently, the use of laser in coloproctology is mainly focused on treating orificial pathologies, such as anal fistulas (FiLaC: Fistula Laser Closure), pilonidal cysts (SiLaT: Sinus Laser Therapy; EPSiT: Endoscopic Pilonidal Sinus Treatment), anal fissures (LaFiP: Laser Fissuroplasty), and hemorrhoidal disease (LHP: Laser Hemorroidoplasty). Additionally, laser has been explored for aesthetic purposes, such as anal bleaching. However, the scientific evidence supporting these approaches is still limited, and the results are inconsistent, making it difficult to assess their practical effectiveness. This variability can be attributed to factors such as case selection, the complexity of clinical presentations, variation in follow-up times, and a lack of standardization in laser application.[4]

There are still many aspects to be discussed regarding the use of this technology, including technical standardization and its combination with other procedures during the same surgery. In hemorrhoidal disease, for example, there is debate about the need to associate mucopexy with laser treatment. In fistulas, controversies arise regarding the preoperative use of seton, curettage of the tract, and closure of the internal opening. In pilonidal cysts, the necessity of debridement and removal of debris is debated. In the treatment of anal fissures, discussions involve the combined use of botulinum toxin, lateral internal sphincterotomy, and the approach to hypertrophic papillae and skin tags. When the laser is combined with other techniques, it becomes challenging to isolate and accurately assess its true efficacy.

While the pursuit of minimally invasive techniques that reduce surgical trauma is desirable, it is essential that new approaches are rigorously evaluated and compared with established procedures. The indiscriminate use of emerging technologies, often driven by commercial interests, can expose patients to unnecessary risks and increase skepticism regarding the actual efficacy of the methods. Although new technologies are often received with enthusiasm and high expectations, clinical experience and long-term results do not always demonstrate significant superiority over conventional techniques.

Thus, despite the promising potential of laser in coloproctology, its adoption must be guided by a commitment to evidence-based practice, ensuring that the benefits translate into better clinical outcomes for patients. The introduction of new technologies should be governed by ethical and professional responsibility, avoiding the promotion of innovations as miraculous solutions without adequate scientific backing. Currently, the laser is not considered the standard treatment for any orificial pathology, which is only mentioned sparingly in European and North American guidelines, where it is regarded as an alternative option for selected cases.

The enthusiasm for laser use must be supported by robust studies investigating its efficacy, safety, and cost-effectiveness in both the short and long term. Only with solid evidence will it be possible to define the definitive role of this technology in the therapeutic arsenal of the colorectal surgeon. In light of current evidence, the routine use of laser as a first-line therapy still lacks sufficient support in scientific literature.

Authors' Contributions

Both authors contributed equally to the writing of this editorial.

Publikationsverlauf

Eingereicht: 24. Oktober 2024

Angenommen: 25. November 2024

Artikel online veröffentlicht:
18. Dezember 2024

• References

• 1 Solari S, Martellucci J, Annicchiarico A, Scheiterle M, Bergamini C, Prosperi P. Laser technology in proctological diseases: is it really the wave of the future?. Updates Surg 2023; 75 (07) 1759-1772
• 2 Safatle NF, Safatle ADM, Kazmirik M. O uso do laser na colo-proctologia. Rev Bras Colo-Proct. 1988; 8 (01) 23-29
• 3 Sankar MY, Joffe SN. Laser surgery in colonic and anorectal lesions. Surg Clin North Am 1988; 68 (06) 1447-1469
• 4 Ambe PC. Laser interventions in coloproctology. A plea for standardized treatment protocols. Tech Coloproctol 2023; 27 (10) 953-955