Keywords CO2 Lasers - laser surgery - colorectal surgery - anus diseases - anal fissure - hemorrhoidal disease
Introduction
The use of different types of laser in surgical procedures is well established in several areas of medicine, with Obstetrics and Gynecology standing out, to treat vulvovaginal atrophy,[1 ]
[2 ] outpatient aesthetic surgeries such as nymphoplasty[3 ]
[4 ] and genitourinary symptoms of post-menopause.[2 ]
[4 ]
[5 ]
[6 ] Additionally, lasers have been gaining space and recognition in other fields, such as coloproctology, where they can be safe and feasible if correctly used in anorectal procedures, such as hemorrhoidectomy, anal fissure correction, skin tag resection, pilonidal cyst and HPV treatmen[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
Several studies show that the use of laser has entailed a considerable decrease in the time for the patients to resume their basic day-to-day activities, a decreased rate of postoperative infections, less postoperative pain and lower use of painkillers, in comparison with widely used traditional surgical techniques.
Furthermore, in 2017 Dessily et. al described outpatient laser treatment, with loco-regional anesthesia and promising results, with a low rate of recurrence (2.9%) and considerably shorter recovery time.[8 ]
However, even though there already is evidence of the benefits of the use of laser in coloproctology,[7 ]
[8 ]
[9 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[20 ] anal skin tag is a condition seldom explored in literature with regard to new techniques.
This is a prevalent condition among the population and even though it is often not given the due attention by the doctors themselves, it may generate great harm to the patient's quality of life, either due to aesthetic or functional reasons (hygiene difficulties, discomfort during physical activities, itchiness, among others).
As it is a benign condition, characterized by an excess of skin in the anal area, this procedure can be performed in an outpatient manner, with no need for admission, which decreases the expenses for the patient and generates greater comfort, not requiring hospital admission procedures.
Thus, due to the scarcity of papers concerning the use of CO2 laser for anal skin tag with local anesthesia, the purpose of this work is to demonstrate that it is possible to carry out anal skin tag resection as an outpatient procedure, with combined anesthesia, which presents an excellent degree of patient satisfaction, low pain in the postoperative period, rapid recovery in the postoperative period and a low level of late and early complications.
Objectives
Primary Objective
To assess the degree of postoperative satisfaction, pain, and healing in patients that have undergone outpatient clinic anal skin tag resection with CO2 laser and topical and injectable local anesthesia.
Secondary Objective
Demographic evaluation of the sample, as well as intraoperative parameters (need for stitches) and acute and chronic complications in the postoperative period (bleeding, residual skin tag, residual fissure, and need for reintervention).
Methods
Longitudinal prospective studies. The patients evaluated were operated on by a single doctor as an outpatient procedure, at a private clinic in São Paulo, with topical and injectable local anesthesia and CO2 laser with a preestablished surgical technique. Patients were followed to assess the degree of satisfaction, pain and postoperative healing.
Population
This study evaluated patients operated on at a private clinic in the central region of São Paulo, from December 2021 to November 2023. Patients with anal skin tags were selected, who underwent an outpatient surgical procedure with CO2 laser.
Demographic data (age, sex), reason for the surgery (aesthetic or functional), primary disease, intraoperative details (need for stitching), pain during the postoperative period, need for use of opioids during the postoperative period or intramuscular corticoid during the postoperative period, time of healing of the surgical wound, local complications, complications with or without the need for acute or late reintervention and degree of satisfaction of the patients in relation to the main complaint were assessed.
All data were collected and recorded in an anonymous database (RedCap).
Exclusion Criteria
Patients who underwent the procedure jointly with the application of botulinum toxin or diode laser were excluded.
Surgical Technique
As it is an outpatient surgery, the first phase of the procedure consisted of topic anesthesia with lidocaine 23% and tetracaine 7% cream 1 hour prior to the positioning of the patient, with subsequent injectable anesthesia with lidocaine 2% with a vasoconstrictor.
All procedures were performed in lithotomy, under an aseptic technique, without systemic sedation.
The second phase of the procedure consisted of the resection of the skin tag, after delimiting the area to be resected.
The decision regarding the need for stitches during the intraoperative period varied according to the bleeding and the resected area, with the thread used being absorbable (poliglecaprone 25 or polyglactin 910).
Definitions
A successful surgery was defined as that which was performed at the clinic, in an outpatient manner, with no difficulties with the anesthesia or the resection of the skin tag.
Morbidity includes all acute (impossibility of topic anesthesia and bleeding) and chronic (anal fissure, chronic pain, residual skin tag with need for reintervention) postoperative complications within 48 hours.
The assessment of the patients' pain scale was done based on the Visual Analogue Scale ([Fig. 1 ]) and all patients were actively asked about the use of medication during the follow-up appointments.
Fig. 1 Visual Analogue Scale for Pain.
The follow-up on such patients was done 7, 15, 30, 45 and 60 days into the postoperative period, with the last one being optional, according to the patient complications and his or her complaints. At said appointments, pain, the use of opioids or intramuscular corticoids, return to work and degree of patient satisfaction were assessed, in addition to the physical coloproctological examination.
Statistical Analysis
Data were collected and recorded in an anonymous database (RedCap).
The database was analyzed with the SPSS program, with assistance from a statistician, using Student's t -test, Fisher's exact test, and Mann-Whitney test (Wilcoxon rank-sum test) (p < 0.05).
Results
40 patients were included, but one patient asked to be excluded from the study. Thus, 39 patients were evaluated, of whom 36 (92.3%) were female. The average age of said patients was 37.46 (± 10), a median of 37 ([Table 1 ]).
Table 1
Nominal variables - epidemiology
Nominal variables
N (%)
Gender
Male
3 (7.7)
Female
36 (92.3)
Age (year)
Average
37.46 ± 10
Median
37
Complaint
Aesthetic
20 (51.2)
Hygiene difficulty
9 (23.1)
Prolapse
7 (17.9)
Others
3 (7.8)
Healing Time (weeks)
Average
3.7 ± 1.8
Median
3
Postoperative Pain
Average
2.3 ± 2.7
Median
2
Use of opioids
Yes
4(10)
No
35 (90)
Complications
Yes
15 (38.5)
No
24 (61.5)
Twenty (51.2%) of them had aesthetic complaints, 9 (23.1%) hygiene difficulties and 7 prolapse (17.9%). The others had other complaints, such as bleeding or pain.
The total healing time was 3.7 (± 1.8) weeks and the patients who used injectable corticoid had a healing time 25% greater than the patients who did not use it (4.17 × 3.31), p = 0.15, as shown in [Table 2 ].
Table 2
Quantitative variables – Healing time in weeks
Variables
Healing time in weeks
p < 0.05
Use of Injectable Corticoid
0.15
Yes
4.17 ± 2
No
3.31 ± 1.6
Need for Intraoperative Stitches
0.87
Yes
3.66 ± 1.96
No
3.69 ± 1.81
Complications
0.003
Yes
4.93 ± 1.94
No
2.91 ± 1.21
The patients' average pain was 2.3 (± 2.7) and there was no correlation with the patient's sex. The average pain of the patients who required intraoperative stitches was 5.16, three times greater than the patients who did not require stitches (1.87) p = 0.006. These data can be seen in [Table 3 ].
Table 3
Quantitative Variables – Average postoperative pain
Variables
Average postoperative pain
p < 0.05
Need for Intraoperative Stitches
0.0062
Yes
5.16 ± 2.6
No
1.87 ± 1
Need for Injectable Corticoid during the Postoperative Period
0.058
Yes
3.23 ± 3.23
No
1.72 ± 2.99
Need for Opioid during the Postoperative Period
0.002
Yes
7.75 ± 2.5
No
1.87 ± 2.05
Complications
0.123
Yes
3.33 ± 3.15
No
1.79 ± 2.3
Six patients required stitches due to bleeding (5 in external hemorrhoidal and 1 on the skin) and there was no difference in the healing time of patients who did and did not require intraoperative stitches (3.66 × 3.69) p = 0.871. Of these, 4 (66.6%) required injectable corticoids in the postoperative period due to pain, and 2 due to postoperative edema. In total, 15 patients used injectable corticoid in the postoperative period, 5 (12.8%) due to postoperative pain, and 10 (25.6%) due to edema in the first postoperative follow-up appointment. The patients who used injectable corticoid had twice as much pain as those who did not (3.23 × 1.72). p = 0.058.
Two patients who required intraoperative stitches used opioids, but there was no correlation with the increase in the use of opioids due to the stitches p = 0.105. However, the average pain level of the patients who required opioids was 4 times higher than those who did not (7.75 × 1.87) p = 0.002.
Three patients used injectable corticoids and opioids in the postoperative period, 2 due to postoperative pain, and 1 due to edema in the follow-up appointment.
Regarding postoperative complications, 1 patient had an early complication with bleeding in the 1st postoperative appointment and required a reintervention at a surgical facility (2.6%), two presented with fissures (5.1%) with a healing time longer than 4 weeks, and 12 with residual skin tag (30.8%) of whom 8 had a healing time longer than 4 weeks and, out of these, three requested a reintervention for resection of the residual skin tag for aesthetic reasons, as seen from [Table 4 ]. The longer the healing time, the greater the risk of complications p = 0.003, with the average healing time of the patients with complications being 4.93 ± 1.94 and without complications 2.91 ± 1.21 weeks.
Table 4
Qualitative Variables – Complications
Variables
N (%)
Complications
N (%)
Yes
15 (38)
No
24 (62)
Type of Complication
Acute
1 (7)
Chronic
14 (93)
Chronic Complications
Residual Skin Tag
12 (86)
Anal Fissure
2 (14)
Need for Reintervention
Acute
1 (25)
Chronic
3 (75)
There was no correlation between increased pain and postoperative complications (p = 0.123), with the average pain being 3.33 ± 3.15 in patients with complications and 1.79 ± 2.3 in patients without complications.
Regarding the degree of patient satisfaction, 38 (97.5%) were satisfied and 1 (2.5%) was partially satisfied, even after a reintervention to resect the residual skin tag.
Discussion
Treatments for vulvovaginal atrophy,[1 ] genitourinary symptom of post-menopause[2 ]
[4 ]
[5 ] and outpatient aesthetic surgeries such as nymphoplasty[3 ]are some examples of the use of lasers in medicine, and the benefits are established. In coloproctology, different types of lasers have been gaining space and recognition, where they can be safe and feasible if correctly used in anorectal procedures, such as hemorrhoidectomy, anal fissure correction, skin tag resection, pilonidal cyst and HPV treatment.[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
Hemorrhoidal disease is a common surgical issue that affects 39% of the world population[22 ] during people's lives and different surgical treatments[14 ]
[15 ]
[22 ]
[23 ] are available. Mostly due to postoperative pain, different modalities, such as laser, arose as alternatives, which can be performed as outpatient procedures with local anesthesia or at surgical facilities.[11 ]
[12 ]
[13 ]
[23 ]
A little explored condition in literature about new techniques is the anal skin tag. Even though it is often not given due attention by the doctors themselves, this is a condition that may generate great harm to the patient's quality of life, either due to aesthetic or functional reasons (hygiene difficulties, discomfort during physical activities, itchiness, among others).
This study demonstrated a low level of pain during the postoperative period in patients that underwent anal skin tag resection with CO2 laser and topic anesthesia, with only 10% of the patients requiring the use of opioids for pain management, with an average pain of 2.3 according to the visual analogue scale. These data match the results for hemorrhoidectomies with CO2 laser, with less pain during the postoperative period, faster healing, lower rate of stenosis, and less sphincter damage, in addition to being a less invasive procedure, which can be repeated several times.[18 ]
In this study, the worsening of the postoperative pain had a statistically significant correlation with the need for stitches. However, they were necessary in a minority of patients, either due to hemorrhoidal nipple bleeding or due to a large extent of resected skin.
Furthermore, an average healing time of 3.7 weeks was observed. Even though the time it took patients to return to work was not recorded, most of them resumed early. This observation agrees with other coloproctology studies, which demonstrate that with the use of laser, a considerable decrease in the patients' time to return to their basic daily activities was noted, which was 7 days, in addition to a decrease in the rates of postoperative infections.[11 ]
[12 ]
[13 ]
[14 ]
[16 ]
[18 ]
The association between a low level of pain and a short healing time reinforces the possibility of an early return to work in the postoperative period.
Moreover, the current study presented low rates of complication, showing that it is possible to carry out the procedure in an outpatient manner, with the topic anesthesia and safety, given that there was only 1 acute complication with the need for reintervention. The only patient that required intervention presented with hemorrhoidal thrombosis with moderate bleeding 24 hours after the procedure was performed, with the new operation being recommended to be performed at a surgical facility.
These data reinforce the safety of the use of laser, already demonstrated in other coloproctological conditions, such as in 2017, when Dessily et. al described the outpatient laser treatment of pilonidal cysts with loco-regional anesthesia and promising results, with the rate of recurrence being low (2.9%) and the recovery time considerably shorter.[8 ]
This is an important consideration, given all the difficulties scheduling procedures at surgical facilities, either due to issues with health insurance, surgical scheduling, prior surgeries running late, or even evaluating the comfort of the patient, who is quickly discharged after the procedure with no need for admission, fasting, etc.
Furthermore, about chronic complications, even though the data shows a rate of 35.9% of chronicity, with 2 anal fissures and 12 residual skin tags, only 3 patients with skin tags opted for a reintervention.
Since 97.5% of patients were satisfied and only 2.5% were partially satisfied, it can be inferred that there is probably a bias in the assessment by the coloproctologist, who overestimates the presence of residual skin tags in his or her assessment, being more perfectionist than the patients themselves.
Limitations of the Study
Even though all patients were operated on with a CO2 laser, the devices sent were defined by the company that let them. Therefore, since old devices were used in many of the procedures, it was not possible to determine the total quantity of power used.
Moreover, even though the maximum dose of injectable anesthetic was not exceeded in any of the procedures, the individually used dose was not calculated, since it was used on demand, which could interfere with the postoperative pain.
Conclusions
The anal skin tag resection with topic anesthesia and CO2 laser is an effective and safe procedure at an outpatient level, with no need for admission. Its advantages are low levels of pain during the postoperative period, rapid healing, and a low rate of serious complications, with a high degree of patient satisfaction.
Bibliographical Record
