TStD

Tttonwh

tItcvtp(hras

tuw

D

A

1d

he Use of Alternative Energyources and New Techniques for

he Treatment of Hemorrhoidal Diseaseennis Y. Kim, MD, and Robin P. Boushey, MD, PhD, CIP, FRCSC

With the emergence of newer surgical technologies, the management of hemorrhoidaldisease has both progressed and evolved. Although rubber band ligation (RBL), surgicalhemorrhoidectomy, and the procedure for prolapsing hemorrhoids (PPH), remain usefuland are commonplace in the treatment of hemorrhoids, newer alternative energy sourceshave provided the surgeon with a wide array of new and effective techniques for managinghemorrhoidal disease. In this paper, we shall review the basic principles underlyingelectrosurgery, as well as a variety of other newer modalities, and compare them to moretraditional techniques of hemorrhoidectomy.Semin Colon Rectal Surg 18:181-186 © 2007 Elsevier Inc. All rights reserved.

Eitcroeec

ENptdo5onEith

scc(

he management of hemorrhoidal disease has progressedwith the emergence of newer surgical technologies. Al-

hough rubber band ligation (RBL), surgical hemorrhoidec-omy, and more recently, the procedure for prolapsing hem-rrhoids (PPH), remain useful and are widely available,ewer alternative energy sources have provided the surgeonith novel therapeutic approaches for treating patients withemorrhoids.Electrosurgery has been described as high-frequency elec-

rical current passed through tissue to create a desired effect.1

n the setting of hemorrhoidal disease, this effect is to essen-ially ablate flow to the offending hemorrhoidal cushion. Thisan also be achieved in a number of different ways and witharious energy sources ranging from the application of elec-rocautery, both mono- and bipolar, to the use of infraredhotocoagulation (IRC), radiofrequency ablation therapyRFA), as well as the CO2 and Nd:YAG lasers. In addition,armonic scalpel, Ligasure, and Doppler-guided hemor-hoidal artery ligation (DGHAL) are more recent advancesdded to the armamentarium of the surgeon dealing withymptomatic hemorrhoidal disease.

It is obvious, therefore, that there are a number of alterna-ive energy sources and newer treatment options that can betilized to manage hemorrhoids. Not so obvious, however, ishether one modality is more efficacious than the others.

ivision of General Surgery, Colon and Rectal Surgery Unit, The OttawaHospital, University of Ottawa, Ottawa, Ontario, Canada.

ddress reprint requests to: Robin P. Boushey, MD, The Ottawa Hospital–General Campus, 501 Smyth Rd., CCW Rm. 1617, Ottawa, ON, Canada

eK1H 8L6. E-mail: rboushey@ottawahospital.on.ca.

043-1489/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1053/j.scrs.2007.07.008

fficacy in this context can be measured by evaluating severalntraoperative and postoperative outcomes including opera-ive time, time to recovery, pain scores, analgesic usage, andost-effectiveness.2 The aim of the present article will be toeview the application of electrosurgery in the setting of hem-rrhoidal disease and to explore the various alternative en-rgy sources and novel therapeutic interventions currentlymployed in the management of this commonly encounteredlinical entity (Table 1).

lectrosurgeryo discussion of alternative energy sources would be com-lete without a brief review and discussion of the fundamen-al principles governing electrosurgery. Electrosurgery, oriathermy, involves the application of a high-frequencyr radiofrequency (RF) wave, typically at a frequency of00,000 Hz or cycles per second, to manipulate tissues in anperator-controlled and predictable fashion using an alter-ating or direct current to directly heat the tissue itself.3,4

lectrocautery, on the other hand, denotes the heating of annstrument by a direct current, which is subsequently appliedo tissues to create a desired effect such as coagulation oremostasis.In order for a current to flow, a complete circuit is neces-

ary. The concepts of current and circuit go hand in hand. Aurrent will only flow if a complete circuit is in place and thisircuit typically consists of (1) an electrosurgical generatorESU); (2) an active electrode; and (3) a passive or receptive

lectrode. Ohm’s Law states that a current is directly propor-

181

tpiaAtaoeesla

atnweathlicedtl

atuldw

Wcd

saieo

ipCfohMatvI

tctohsGbstocn

T

O

O

R

PI

R

N

H

L

D Offi

182 D.Y. Kim and R.P. Boushey

ional to the voltage or electrical energy applied and inverselyroportional to the resistance encountered. Electrical energy

s converted into thermal energy as a current passes throughresistor, or tissues, and this causes the temperature to rise.5

variety of differing tissue effects can be realized at differentemperatures: 40 to 60°C (coagulation); 100°C (vaporizationnd dessication); 200 to 400°C (carbonization). The amountf energy used is proportional or equal to the electrical powermployed. Whereas power may be defined as the amount ofnergy per unit time or rate of heat production, current den-ity denotes the amount of current per unit area. That is, thearger the contact point, the more energy must be used tochieve the desired effect (Table 1).6

Electrosurgery modalities can be delivered in two waysnd with varying effects contingent on the output settings ofhe ESU. Monopolar cautery involves the application of alter-ating radiofrequency energy thorough an active electrode,hich then traverses through tissues to reach a receptive

lectrode. The receptive electrode, usually a dispersive padttached to the patient, then provides a path of least resis-ance back to electrosurgical generator. Energy delivery andeat generation is limited to the active electrode. With bipo-

ar cautery, the active and return electrodes are in close prox-mity or adjacent to one another, usually in the form of for-eps. Tissue is grasped between the two electrodes, andnergy flows from one electrode to the other with minimalispersion. Bipolar cautery, it is argued, is more efficient inerms of its ability to coapt smaller vessels with minimalateral or depth of spread.7

The mode or output settings of the electrosurgical gener-tor modulate the waveform delivered, thereby altering theissue effects. Waveforms can be delivered in either a contin-ous or an interrupted fashion to produce cutting or coagu-

ation, respectively. Furthermore, by adding off time to theuty cycle, a pure cut can be transformed into a blended cut,

able 1 Summary of Various Treatment Modalities

Grade ofHemorrhoid

Cost andAvailability

R hemorrhoidectomy,no diathermy

III, IV Inexpensive, widelavailable

R hemorrhoidectomy,diathermy

III, IV Inexpensive, widelavailable

BL I, II Inexpensive, widelavailable

PH II-IV ExpensiveRC I, II Expensive

FA I, IV Expensive

d:YAG I, IV Expensive

armonic scalpel III, IV Expensive

igasure III, IV Expensive

GHAL I-IV Expensive

hich not only allows for cutting but coagulation as well. d

hereas cutting involves a lower voltage, higher wattageurrent, coagulation involves a high-voltage, short-durationischarge of current.3

Having briefly outlined some of the principles of electro-urgery, with an emphasis on the differences between mono-nd bipolar cautery and the various modes of energy delivery,t now seems appropriate to briefly discuss the application oflectrosurgery, as it compares with other modalities, to hem-rrhoidal disease.Diathermy coagulation, both bipolar and monopolar, is an

nexpensive, widely available modality which has been em-loyed in the surgical arena since its inception by Bovie andushing in the 1920s, two individuals often regarded as the

athers of modern electrosurgery. In comparison to bothpen and closed hemorrhoidectomy, diathermy coagulationas been found to be equivalent to the scissor dissectionilligan-Morgan operation in terms of postoperative pain

nd analgesia use.8 Other studies have suggested that dia-hermy coagulation may require increased analgesic usageersus conventional scissor excision in patients with GradesII and IV hemorrhoidal disease.9,10

PPH is a relatively newer method of treating hemorrhoidshat involves the application of a circular stapler to remove aircumferential portion of rectal mucosa proximal to the den-ate line as a means of ligating the feeding venules to theffending hemorrhoidal plexus and fixing redundant mucosaigher in the anal canal.11 Two randomized, prospectivetudies exploring the outcomes in patients with prolapsing,rade IV hemorrhoids demonstrated that PPH may, in fact,e associated with an increased number of new and recurrentymptoms and may not be as effective as diathermy coagula-ion as a definitive cure for patients with fourth-degree hem-rrhoids.12 Diathermy hemorrhoidectomy has also beenompared with both the Ligasure and harmonic scalpel, twoewer surgical instruments which will be discussed in further

Setting BenefitsAlleviation of

Symptoms

tpatient Curative Yes

tpatient Curative Yes

ce Curative Yes

tpatient Decreased pain and LOS Yesce (multipleessions)

Decreased pain Increasedrecurrence

ce ?tpatient

Decreased pain and LOS ? Increasedrecurrence

tpatient CurativeDecreased pain

Yes

tpatient Curative, can treatadvanced disease

Yes

tpatient Curative, can treatadvanced disease

Yes

ce outpatient Curative Yes

y Ou

y Ou

y Offi

OuOffi

sOffiOuOu

Ou

Ou

etail later.

ITwhtsbbe

lsspaotttrloa

uTqadfs

fiaitRcipemvt

RThtlocata

bp

gattcmhhcbt1vipcrfm

Moontl

tqttsPvrqowptit

LNAGmfiIc

New techniques for the treatment of hemorrhoidal disease 183

nfrared Photocoagulationhe use of IRC in the management of hemorrhoidal diseaseas first described by Neiger in 1978.13 Since then, thereave been multiple papers comparing the application of IRCo other modalities, particularly RBL, in the management ofymptomatic early-grade hemorrhoids. The treatment ofleeding and prolapsing internal hemorrhoids using IRC haseen demonstrated to be technically simple, therapeuticallyffective, and complication free.14-16

IRC utilizes infrared light, which typically starts at a wave-ength of 700 and 800 nm, to penetrate tissues. This light isubsequently converted to heat, ultimately causing tissue de-truction and eventually fibrosis. The use of a 1.5-secondulse generates a tissue temperature of 100°C, which results in3-mm depth of coagulated protein.17 However, varying the

ptical wavelength of the coagulator or the contact time varieshe depth of penetration into the tissues. Three sites of coagula-ion are recommended in a triangular configuration proximal tohe hemorrhoidal plexus. Although larger, prolapsing hemor-hoids may not respond as well to this technique, photocoagu-ation provides a safe, rapid, and noninvasive alternative to otherutpatient procedures. However, its use may be limited by thevailability and expense of the equipment.

The first randomized trial comparing infrared photocoag-lation to RBL hemorrhoidectomy was performed in 1983 byempleton and colleagues.18 As has been shown in subse-uent trials, both methods are equally effective in the man-gement of Grade I and 2 hemorrhoids.19-21 The same findingoes not hold when applied to the treatment third- andourth-degree hemorrhoids, where RBL has been demon-trated to be more effective.20

In 2002, Johanson and Rimm performed a meta-analysis ofve prospective trials involving 747 patients with first-degreend second-degree hemorrhoids, and a minimum follow-upnterval of 12 months, to assess the efficacy and complica-ions of infrared coagulation, injection sclerotherapy, andBL.21 The treatment response for patients receiving infraredoagulation and RBL were equivalent at 1 year, with patientsn the band ligation group experiencing significantly moreost treatment pain (19.9% versus 3.5%; P � 0.02). How-ver, treatment with infrared coagulation was associated withore treatment sessions for recurrence of symptoms (15.5%

ersus 5.3%). Both modalities were found to be equivalent inhe treatment of first- and second-degree hemorrhoids.21

adiofrequency Ablationhe first in vivo application of RFA was performed by McGa-an and Rossi in 1990. 22 Although initially designed for thereatment of hepatocellular carcinoma (HCC) and metastaticiver lesions, RFA has since been utilized in the managementf a variety of clinical scenarios ranging from the treatment ofhronic pain to the ablation of aberrant conduction pathwayss in Wolff–Parkinson–White syndrome.22 Its overall effect iso cause cell death by coagulative necrosis. Its application to

norectal disease, particularly hemorrhoids, is fairly recent r

ut has been shown to be an effective treatment strategy inatients with hemorrhoids of varying stages.23-25

RFA has been described as a “refined” type of electrosur-ery that uses a wave of electrons at a frequency between 2nd 4 MHz to incise, excise, ablate, or coagulate the targetedissue.26 The Ellman dual-frequency 4-MHz (Ellman Interna-ional Inc., Oceanside, NY) is one of the more common ma-hines currently employed. A needle electrode, most com-only 16 gauge, acts as the active electrode delivering aigh-frequency, low-voltage current, which causes frictionaleating of tissues through ionic agitation, and, subsequently,ell death at temperatures between 60 and 100°C. RFA maye performed on an outpatient basis under conscious seda-ion with the typical ablation session lasting approximately0 to 20 minutes. RFA can be used to treat hemorrhoids in aariety of ways. More explicitly, it has been used in isolation,n conjunction with submucosal hemorrhoidectomy, or withlication and fixation. Furthermore, while RFA has beenompared with a variety of other modalities to treat hemor-hoids including RBL, PPH, and DGHAL,27 there are only aew randomized, prospective studies comparing it to otherodalities.In 2003, Gupta compared in situ RFA versus Milligan–organ hemorrhoidectomy in patients with Grade III hem-

rrhoids.28 RFA was associated with significantly less post-perative pain, shorter hospital stay, and earlier return toormal activity. Similar results were obtained in a compara-ive study performed by the same author over a 2-year fol-ow-up period.29

In two randomized studies by Filingeri, the results ob-ained using submucosal hemorrhoidectomy with radiofre-uency ablation were compared with those of the conven-ional Parks’ operation and diathermy hemorrhoidectomy. Inhe first study, 102 patients were randomized to undergo aubmucosal hemorrhoidectomy (n � 51) or the conventionalarks’ hemorrhoidectomy (n � 51). The second study in-olved a much smaller number of patients with 15 patientseceiving submucosal hemorrhoidectomy with radiofre-uency ablation and 16 patients undergoing diathermy hem-rrhoidectomy. Performing submucosal hemorrhoidectomyith radiofrequency ablation, although not a commonlyracticed treatment modality, improved the results obtained,hereby simplifying the surgical procedure, reducing operat-ng time, postoperative pain, and bleeding, and shorteninghe hospital length of stay.30,31

asers [CO2 andeodymium:Yttrium-luminum-Garnet (Nd:YAG)]

as, liquid, and solid state lasers have been employed in theanagement of a variety of gastrointestinal disorders ranging

rom the treatment of malignancies to gastrointestinal bleed-ng, as well as the management of hemorrhoidal disease.32-38

nitially introduced in the 1970s, laser therapy has been andontinues to be an alternative energy source with a wide

ange of clinical applications outside of gastroenterology,

pshw

ititvbtb

mlaCfaptlrgo

ailhtatdp

UTOscttii(pp

qveratw

gwaP

csbrOratpGdotl

BTCaerupt

fspbiatstot

twdwclssepwtdt

184 D.Y. Kim and R.P. Boushey

articularly in the field of dermatology. The work of Ander-on and Parrish, which led to the theory of photothermolysis,as improved our overall understanding of the interactionshich take place at the laser–tissue interface.39

Photothermolysis is based on the principle that laser lights preferentially absorbed by the structure, or chromophore,argeted with minimal destruction of adjacent or surround-ng tissues. Hemoglobin, which maximally absorbs light athree different wavelengths, is the targeted structure withinessels. Other endogenous chromophores in the humanody include water and melanin. As hemoglobin is heated,he vessel through which it courses is damaged such thatlood can no longer flow through it.The two most common types of lasers in use today in theanagement of hemorrhoids are CO2 and Nd:YAG. The CO2

aser, which operates at a wavelength 10,600 nm, both cutsnd superficially ablates lesions by vaporizing tissues. TheO2 laser has been demonstrated to be an effective treatment

or hemorrhoids40-44; however, prospective, randomized tri-ls are sparse. In the one identified prospective study com-aring the immediate postoperative results of hemorrhoidec-omy by Milligan–Morgan technique using either the CO2

aser or scalpel in patients with Grades III and IV hemor-hoids, there were no statistically significant differences re-arding postoperative pain and measured consumption ofral analgesics.45

The Nd:YAG laser emits light at a wavelength of 1064 nm,nd, similar to the CO2 laser, is invisible to the naked eye. Its more capable of penetrating deeper tissues, as a result of itsower melanin coefficient, and has been compared with openemorrhoidectomy in at least three prospective, randomizedrials. In two prospective studies, the Nd:YAG laser was notssociated with a significant improvement versus conven-ional closed hemorrhoidectomy.46,47 However, one trialemonstrated that the use of the Nd:YAG laser added $480er case when compared with scalpel excision.48

ltrasonic Energy Devicehe Harmonic Scalpel (Ethicon Endosurgery, Cincinnati,H) is a fairly recent technological addition that uses ultra-

ound energy to create the desired effects of coagulation andoaptation with minimal lateral spread of energy at loweremperatures than those employed during traditional dia-hermy techniques. Although initially designed for minimallynvasive surgery (MIS), the harmonic scalpel has since beenntroduced into the arena of open surgery as well. AutoSonixUnited States Surgical, Norwalk, CT) and SonoSurg (Olym-us Surgical, Orangeburg, NY) are alternative ultrasonic scal-els currently available.Unlike traditional electrocautery that transforms high-fre-

uency electrical energy into heat, the harmonic scalpel con-erts electrical energy into mechanical energy through a pi-zoelectric crystal system which vibrates axially at a constantate of 55,000 Hz.49 Hemostasis is achieved by coaptive co-gulation at temperatures ranging from 50 to 100°C. Coap-ation refers to the fragmentation of proteins that leads to the

elding or sealing of vessels through the adherence of colla- o

en molecules.50 The harmonic scalpel has been comparedith a variety of other treatment options including both open

nd closed hemorrhoidectomy; diathermy hemorrhoidectomy;PH; and Ligasure.51

The issue of postoperative pain is all important in theontext of managing hemorrhoidal disease and the harmoniccalpel has been shown to be associated with both similar andetter pain profiles postoperatively in patients with hemor-hoids of all grades, as compared with traditional surgery.52,53

ther purported advantages of the harmonic scalpel are de-ived from studies demonstrating decreased operative timend length of stay,54 and reduced blood loss comparable toraditional bipolar or scissors hemorrhoidectomy.55 In com-arison to stapled hemorrhoidopexy for the management ofrade III hemorrhoidal disease, at least one randomized trialemonstrated that patients derive greater short-term benefitsf reduced pain, shorter length of stay, and earlier resump-ion to work following PPH; however, long-term results areacking.7

ipolar Sealing Deviceshe Ligasure (Valleylab, Tyco Health Care Group, Boulder,O) is an electrothermal bipolar vessel sealer purported tochieve complete hemostasis by reforming the collagen andlastin in vessel walls to form an autologous seal. Since itsecent introduction in the late 1990s, the LigaSure has beensed by gynecologists, urologists, and general surgeons toerform a variety of procedures ranging from hysterectomyo hemorrhoidectomy.

According to the manufacturer, the Ligasure employs aeedback-controlled response system that diagnoses the tis-ue type in the jaws of the instrument and delivers the appro-riate amount of energy to effectively seal the vessel or tissueundle.56 This leads to permanent fusion of vessels up to and

ncluding 7 mm in diameter using a combination of pressurend energy to both reduce thermal spread and minimizehermal spread to approximately 2 mm with high burst pres-ures as compared with seals, clips, and ligatures.57 In effect,he Ligasure may be considered an alternative to closed hem-rrhoidectomy with the major difference being that it is su-ureless.

Similar to the harmonic scalpel, Ligasure has been showno reduce operative times versus conventional techniquesith or without diathermy.57-59 Other benefits include re-uced intraoperative blood loss and postoperative pain asell as earlier resumption of work or normal activity.60 In

omparison to PPH, both methods were found to be equiva-ent in all major aspects analyzed.61 Another study demon-trated that although it may be more painful than PPH in thehort term, it is a more radical procedure with less intraop-rative bleeding.62 When compared with the harmonic scal-el, a double-blind, randomized controlled trial in patientsith Grade III and IV hemorrhoids demonstrated that pa-

ients who underwent Ligasure hemorrhoidectomy had re-uced postoperative pain and operating times.51 It is impor-ant to bear in mind that when the Ligasure is compared with

ther modalities, it is used only for advanced hemorrhoidal

di

DHTcusAttt

iorcamdoaMdw

CDeooboogt

ttciseiotltsotn

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

New techniques for the treatment of hemorrhoidal disease 185

isease. Extended follow-up with a larger number of patientss required to confirm the long-term results of this procedure.

oppler-Guidedemorrhoidal Artery Ligation

he first description of DGHAL was in 1995 by Morinaga andolleagues.63 Since then, it has become an increasingly pop-lar technique that can be performed under both general andpinal anesthesia, or, more recently, with conscious sedation.s newer techniques for treating hemorrhoids are developed,

he emphasis has shifted away from excision procedures andhe possible resulting pain and complications to less invasive,argeted procedures.64

DGHAL uses a specially designed proctoscope with anncorporated Doppler transducer with an applied frequencyf 8.2 MHz. This is inserted and used to locate the hemor-hoidal arteries by an audible alteration in signal. Once lo-ated, the artery is then ligated with a needle holder using anbsorbable suture in a figure-of-eight fashion into the sub-ucosa through a lateral port or ligation window, therebyisrupting the arterial inflow and causing the offending hem-rrhoidal cushion to retract. Studies have demonstrated anverage of five branches of the superior rectal artery.65 Sinceorinaga’s article in 1995, there have been at least 15 articles

emonstrating that DGHAL is an effective and safe procedureith minimal complications.66

onclusionespite the availability of newer techniques, the optimal en-rgy or non-energy-dependent modality for managing hem-rrhoidal disease remains elusive. The decision to employne treatment strategy over another, however, should beased on a number of factors relating to not only the pathol-gy or grade of hemorrhoid under consideration, but also theverall cost and availability of resources and equipment, sur-eon comfort, and experience, as well as the complicationshat could possibly ensue.

The matter is further complicated by the fact that many ofhe clinical trials mentioned in the current discussion, al-hough for the most part prospective and randomized, can beriticized for several reasons. First, the majority of these stud-es involve small sample sizes and are usually performed in aingle institution by a single surgeon. Second, although op-rative time, pain scores, and recurrence of symptoms aremportant factors to be compared, cost-effective analysis isften overlooked or not factored into the overall analysis ofhe various studies that we identified. Finally, long-term fol-ow-up of patients, particularly in those treated with one ofhe newer modalities such as the harmonic scalpel or Liga-ure, is required. With the advent of newer technologies, it isf the utmost importance that surgeons rigorously assessherapeutic efficacy and cost–benefit ratios before such tech-

ology is applied to their practice and overall patient care.

eferences1. Soderstrom R: Principles of electrosurgery as applied to gynecology, in

Rock JA, Thompson JD (eds): Te Linde’s operative gynecology (ed 8).Philadelphia, PA, Lippincott-Raven, 1997, pp 321-326

2. Madoff RD, Dykes S: What’s new in colon and rectal surgery. J Am CollSurg 198:91-104, 2004

3. Jobe BA, John GH: Minimally invasive surgery, in Brunicardi FC (ed):Schwartz’s principles of surgery (ed 8). New York, NY, McGraw-Hill,Medical Publishing Division, 2005, pp 379-401

4. Norman DA, Newton R, Nicholas GV: Direct current electrotherapy ofinternal hemorrhoids: an effective, safe, and painless outpatient ap-proach. Gastrointest Endosc 38:519-520, 1992

5. Massarweh NN: Electrosurgery: history, principles, and current andfuture uses. J Am Coll Surg 202:520-530, 2006

6. Feil W, Lippert H, Lozac’h P, et al: Atlas of surgical stapling. JohannAmbrosius Barth, Heidelberg, 2000, pp 48-58

7. Chung CC: Double-blind, randomized trial comparing Harmonic Scal-pel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scis-sors excision: ligation technique. Dis Colon Rectum 45:789-794, 2002

8. Andrews BT, Layer GT, Jackson BT, et al: Randomized trial comparingdiathermy hemorrhoidectomy with the scissor dissection Milligan-Morgan operation. Dis Colon Rectum 36:580-583, 1993

9. Bassi R, Bergami G: Surgical treatment of hemorrhoids: diathermy hem-orrhoidectomy and traditional techniques. A prospective randomizedtrial. Minerva Chir 52:387-391, 1997

0. Ibrahim S, Tsang C, Lee YL, et al: Prospective, randomized trial com-paring pain and complications between diathermy and scissors forclosed hemorrhoidectomy. Dis Colon Rectum 41:1418-1420, 1998

1. Longo A: Treatment of hemorrhoids disease by reduction of mucosaand hemorrhoidal prolapse with a circular suturing device: a new pro-cedure, in Sixth World Congress of Endoscopic Surgery, Rome, Italy,Bolonha: Monduzzi; 1998, p 777-784

2. Ortiz H, Marzo J, Armendáriz P, et al: Stapled hemorrhoidopexy vs.diathermy excision for fourth-degree hemorrhoids: a randomized, clin-ical trial and review of the literature. Dis Colon Rectum 488:9-15, 2005

3. Neiger A: Infrared-photo-coagulation for hemorrhoids treatment.Schweiz Med Wochenschr 108:500-504, 1978

4. Charua GL, Avendano EO, Hernandez CF: Infrared photocoagulationin the treatment of hemorrhoids. Rev Gastroenterol Mex 63:131-134,1998

5. Nevah EI: The outpatient management of internal hemorrhoids byinfrared photocoagulation. Rev Med Panama 18:166-170, 1993

6. Ambrose NS, Hares MM, Alexander-Williams J, et al: Prospective ran-domised comparison of photocoagulation and rubber band ligation intreatment of haemorrhoids. Br Med J (Clin Res Ed) 286:1389-1391,1983

7. Hardy A, Chan CLH, Cohen CRG: The surgical management of haem-orrhoids—a review. Dig Surg 22:26-33, 2005

8. Templeton JL, Spence RA, Kennedy TL, et al: Comparison of infraredcoagulation and rubber band ligation for first and second degree hae-morrhoids: a randomised prospective clinical trial. Br Med J (Clin ResEd) 286:1387-1389, 1983

9. Gupta PJ: Infrared coagulation versus rubber band ligation in earlystage hemorrhoids. Braz J Med Biol Res 36:1433-1439, 2003

0. Linares Santiago E, Gomez Parra M, Mendoza Olivares FJ, et al: Effec-tiveness of hemorrhoidal treatment by rubber band ligation and infra-red photocoagulation. Rev Esp Enferm Dig 93:238-247, 2001

1. Johanson JF, Rimm A: Optimal nonsurgical treatment of hemorrhoids:a comparative analysis of infrared coagulation, rubber band ligation,and injection sclerotherapy. Am J Gastroenterol 87:1600-1606, 1992

2. Nazir B, Chaturvedi AK, Rao: A Image-guided radiofrequency ablationof tumors: current status. Phys Recent Adv 13:315-322, 2003

3. Gupta PJ: Novel technique: radiofrequency coagulation—a treatmentalternative for early-stage hemorrhoids. Med Gen Ed 31:1, 2002

4. Gupta PJ: Radiofrequency ablation and placation—a new technique forprolapsing hemorrhoidal disease. Curr Surg 63:44-50, 2006

5. Gupta PJ: Ambulatory hemorrhoid therapy with radiofrequency coag-

ulation. Clinical practice paper. Rom J Gastroenterol 14:37-41, 2005

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

5

5

5

5

5

5

5

5

5

5

6

6

6

6

6

6

6

186 D.Y. Kim and R.P. Boushey

6. Fernando HC, Hoyos AD, Litle V, et al: Radiofrequency ablation: iden-tification of the ideal patient. Clin Lung Cancer 6:149-152, 2004

7. Gupta PJ: Radioablation and suture fixation of advance grades of hem-orrhoids. An effective alternative to staplers and Doppler guided liga-tion of hemorrhoids. Rev Esp Enferm Dig 98:740-746, 2006

8. Gupta PJ: Randomized trial comparing in-situ radiofrequency ablationand Milligan-Morgan hemorrhoidectomy in prolapsing hemorrhoids.J Nippon Med 70:393-400, 2003

9. Gupta PJ: A comparative study between radiofrequency ablation withplication and Milligan-Morgan hemorrhoidectomy for grade III hem-orrhoids. Tech Coloproctol 8:163-168, 2004

0. Filingeri V, Gravantel G, Baldessaril E, et al: Prospective randomizedtrial of submucosal hemorrhoidectomy with radiofrequency bistouryvs. conventional Parks’ operation. Techn Coloproctol 8:31-36, 2004

1. Filingeri V: Randomised trial comparing submucosal hemorrhoidec-tomy with radiofrequency bistoury vs. diathermic hemorrhoidectomy.Eur Rev Med Pharmacol Sci 8:79-85, 2004

2. Tasev V, Poleganova Iu, Bulanov D: [Laser use in various fields ofsurgery]. Khirurgiia (Sofiia) 56:33-35, 2000

3. Walfisch S, Ohana N, Charuzi E: [Nd:YAG laser for anorectal surgery:initial experience in Israel]. Harefuah 126:1-4, 1994

4. Wang JY: The role of lasers in hemorrhoidectomy. Dis Colon Rectum34:78-82, 1999

5. Davis RC Jr: Use of Nd:YAG laser therapy for treatment of hemorrhoidaldisease. Clin Laser Mon 10:161-162, 1992

6. Richards K: Lasers in general surgery. Nurs Clin North Am 25:667-71,1990

7. Katras T, Miranda R, Vo N, et al: Endoscopic laser surgery. A single-center comprehensive experience. Am Surg 57:134-138, 1991

8. Sankar MY, Joffe SN. Laser surgery in colonic and anorectal lesions.Surg Clin North Am 68:1447-1469, 1988

9. Schmults CD: Laser treatment of vascular lesions. Dermatol Clin 23:4,2005

0. Hodgson WJ, Morgan J: Ambulatory hemorrhoidectomy with CO2laser. Dis Colon Rectum 38:1265-1269, 1995

1. Masson JL: [Outpatient hemorrhoidectomy using the CO2 laser]. J Chir127(4):227-229, 1990

2. Iwagaki H, Higuchi Y, Fuchimoto S, et al: The laser treatment of hem-orrhoids: results of a study on 1816 patients. Jpn J Surg 19(6):658-661,1989

3. Skobelkin OK, Tolstykh PI, Derbenev VA, et al: [Carbon dioxide laserin the surgical treatment of proctologic diseases]. Vestn Khir Im I I Grek143:3-5, 1989

4. Chia YW, Darzi A, Speakman CT, et al: CO2 laser haemorrhoidec-tomy—does it alter anorectal function or decrease pain compared toconventional haemorrhoidectomy? Int J Colorectal Dis 10:22-24, 1995

5. Pandini LC: Surgical treatment of haemorrhoidal disease with CO2laser and Milligan-Morgan cold scalpel technique. Colorectal Dis8:592-595, 2006

6. Enriquez-Navascues JM, Devesa Múgica JM, Bucheli Proaño P. [Hem-orrhoidectomy: conventional or by Nd:Yag contact laser? A prospectiveand randomized study]. Revista española de enfermedades digestivas:organo oficial de la Sociedad Española de Patología Digestiva 84:235-

239, 1993

7. Wang JY, Chang-Chien CR, Chen JS, et al: The role of lasers in hemor-rhoidectomy. Dis Colon Rectum 34:78-82, 1991

8. Senagore A, Mazier WP, Luchtefeld MA, et al: Treatment of advancedhemorrhoidal disease: a prospective, randomized comparison of coldscalpel vs. contact Nd:YAG laser. Dis Colon Rectum 36:1042-1049,1993

9. Feil W, Lippert H, Lozac’h P, et al: Atlas of surgical stapling. JohannAmbrosius Barth, Heidelberg, 2000, p. 48

0. Feil W, Lippert H, Lozac’h P, et al: Atlas of surgical stapling. JohannAmbrosius Barth, Heidelberg, 2000, pp. 52-58

1. Kwok SY, Chung CC, Tsui KK, et al: A double-blind, randomized trialcomparing Ligasure and Harmonic Scalpel hemorrhoidectomy. Dis Co-lon Rectum 48:344-348, 2005

2. Tan JJ: Prospective, randomized trial comparing diathermy and Har-monic Scalpel hemorrhoidectomy. Dis Colon Rectum 44:677-679,2001

3. Khan S: Surgical treatment of hemorrhoids: prospective, randomizedtrial comparing closed excisional hemorrhoidectomy and the Har-monic Scalpel technique of excisional hemorrhoidectomy. Dis ColonRectum 44:845-849, 2001

4. Ramadan E: Harmonic scalpel hemorrhoidectomy: preliminary resultsof a new alternative method. Tech Coloproctol 6:89-92, 2002

5. Chung CC: Double-blind, randomized trial comparing Harmonic Scal-pel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scis-sors excision: ligation technique. Dis Colon Rectum 45:789-794, 2002

6. Heniford BT, Matthews BD, Sing RF, et al: Initial results with an elec-trothermal bipolar vessel sealer. Surg Endosc 15:799-801, 2001

7. Franklin EJ, Seetharam S, Lowney J, et al: Randomized, clinical trial ofLigasure vs conventional diathermy in hemorrhoidectomy. Dis ColonRectum 46:380-383, 2003

8. Chung YC: Clinical experience of sutureless closed hemorrhoidectomywith LigaSure. Dis Colon Rectum 4:87-92, 2003

9. Pattana-Arun J, Sooriprasoet N, Sahakijrungruang C, et al: Closed vsligasure hemorrhoidectomy: a prospective, randomized clinical trial.J Med Assoc Thai 89:453-458, 2006

0. Wang JY: Randomized controlled trial of LigaSure with submucosaldissection versus Ferguson hemorrhoidectomy for prolapsed hemor-rhoids. World J Surg 30:462-466, 2006

1. Kraemer M, Parulava T, Roblick M, et al: Prospective, randomizedstudy: proximate PPH stapler vs. LigaSure for hemorrhoidal surgery.Dis Colon Rectum 48:1517-1522, 2005

2. Basdanis G, Papadopoulos VN, Michalopoulos A, et al: Randomizedclinical trial of stapled hemorrhoidectomy vs open with Ligasure forprolapsed piles. Surg Endosc 19:235-239, 2005

3. Morinaga K, Hasuda K, Ikeda T: A novel therapy for internal hemor-rhoids: ligation of the hemorrhoidal artery with a newly devised instru-ment (Moricorn) in conjunction with a Doppler flowmeter. Am J Gas-troenterol 90:610-613, 1995

4. Scheyer M: Doppler-guided hemorrhoidal artery ligation. Am J Surg191:89-93, 2006

5. Aigner F: The superior rectal artery and its branching pattern withregard to its clinical influence on ligation techniques for internal hem-orrhoids. Am J Surg 187:102-108, 2004

6. Greenberg R, Karin E, Avital S, et al: First 100 cases with Doppler-guided hemorrhoidal artery ligation. Dis Colon and Rectum 49:485-

489, 2006