Lasers in Anorectal Surgery

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ANORECTAL SURGERY

LASERS IN

ANORECTAL SURGERY Jill Canin Endres, MD, and Randolph M. Steinhagen, MD

The union of laser technology and therapeutic endoscopy has added a new domain to the treatment of surgical disease. While touted as the solution to many surgical problems by its enthusiasts, the laser has been viewed by its critics as a solution looking for a problem. Initially applied to gastrointestinal disease in the mid-1970s,31, 34, 115 laser energy was first used to treat skin disorders in the early 1960s.54 Laser technology has since been applied in many fields of general surgery as well as in the surgical subspecialties.2, 45, 64, 66, 92, 110, 120 Gastrointestinal applications have expanded from the endoscopic treatment of acute hemorrhage/' 103 the ablation of tumors/8,49, 128 and vascular malformations,23,84, 102 to the recanalization of intraluminal obstruction36, 49, 104, 105 and the treatment of numerous conditions of the anorectumY' 76, 94, 113, 117, 125 Those who favor using the laser proclaim it as having many benefits over conventional surgery. It can be applied without contact, it can reach sites remote from the surgeon's hands, penetration depth is said to be predictable, high doses of light energy can be applied without scar formation, wound healing is thought to be more rapid, and postoperative pain is said to be diminished. 3D, 41, 71, 81, 117, 118 Less well publicized are the drawbacks of this technology. It is expensive, deep tissue injury may be difficult to control, and achieving hemostasis may be arduousY, 93, 96,106 More significantly, many of the claimed benefits have not been proven. Lacking evidence sufficient to withstand the critical evaluation of other profeSSionals, proponents have often resorted to marketing aimed directly at uneducated consumers. This focused marketing campaign From the Department of Surgery, Mount Sinai Medical Center, New York, New York

SURGICAL CLINICS OF NORTH AMERICA VOLUME 74 • NUMBER 6 • DECEMBER 1994

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has increased the public demand for the use of a technology that has not been demonstrated as superior or even as equal to conventional methods. LASER TECHNOLOGY

LASER, the acronym for Light Amplification by Stimulated Emission of Radiation, describes how laser light is generated. Molecules are stimulated to an excited state by the absorption of applied energy, such as electricity. This energy is then emitted in the form of light, or photons, when the excited molecules return to their more stable lower energy level. The light produced increases in intensity by the trapping and reflecting capability of mirrors within the laser. One of the mirrors acts as only a partial reflector, allowing light to be deflected and exit to the outside, thereby producing the laser beam. 55 The medium containing the excitable molecules and facilitating this process may be composed of gas, liquid, or solid. Gas is used in CO2 and argon laser systems; crystal in the solid state Nd:YAG (neodymium:yttrium aluminum garnet) laser; and liquid in the dye lasers used in photodynamic therapy. Laser light has three distinctive properties. Light of multiple wavelengths has been converted to that of a single wavelength (monochromatic), whose waves coincide in direction and timing (collimated and coherent), allowing predictable single wavelength-tissue interactions and great accuracy.83 The wavelength of light produced is a function of the medium used in the laser generator" (Table 1). The unique characteristic of monochromicity (single wavelength light) is exploited for the selective ablation of tissues of a particular color or water content. Water primarily absorbs the long wavelength light produced by the CO2 laser, whereas hemoglobin absorbs visible light at low wavelengths such as that produced by the argon laser.83 Both laser and tissue characteristics contribute to the effect of laser light on a particular tissue. Laser properties that contribute to the ultimate tissue effect, besides the wavelength, include the power of the light source, whether the beam is applied in short or continued pulses, the size of the spot (as determined by the diameter of the fiber and the distance from the tissue), and the power density.44, 83, 115 In addition to color and water content, tissue characteristics such as thermal conductivity, density, structure, and perfusion play significant Table 1. CHARACTERISTICS OF WIDELY USED LASERS Type

Wavelength ( ....m)

Penetration Depth (mm)

Argon Nd:YAG CO2

0.51 1.06 10.60

1 4 0.1

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roles in determining laser tissue interactions. 44, so, 83 These tissue and laser characteristics determine how much of the light energy penetrates and how much is absorbed or scattered. This translates into variable tissue heating in a concentric fashion, with inflammation and edema at different depths or distances. 83

CLINICAL APPLICATIONS

CO2 laser light is well absorbed by tissues with a high water content and therefore results in minimal depth of penetration. In contrast to Nd:YAG and argon, CO2 laser energy cannot be transmitted by a fiberoptic system and therefore cannot be used endoscopically. Its use is limited to lesions within direct vision. 83,97 The efficiency of the beam is also greatly reduced once the field is occluded by even small amounts' of blood.71,97 Consequently, the CO2 laser is poor at coagulating and is used primarily for tissue vaporization. 106 The argon laser light is primarily absorbed by pigmented tissues such as those containing hemoglobin or melanin. It has virtually been replaced by the Nd:YAG laser as a coagulator owing to the greater power and the deeper penetration of the latter.33 Although it is widely applied in ophthalmology, gastrointestinal applications are confined to superficiallesions. 83 The Nd:YAG laser light is poorly absorbed by both water and pigmented tissue and therefore can penetrate deeply into tissues before being completely absorbed. Unlike the CO2 laser, the Nd:YAG laser is an excellent coagulator and has been used extensively in the treatment of hemorrhage.9, 71,95,103 At high power it has been widely applied in the ablation of tumors and as an alternative to the scalpel for tissue excision. The penetrating power of the Nd:YAG laser is four times greater than that of the argon laser and 40 times greater than that of the CO2 laser. This increased power delivery not only makes it an effective therapeutic tool but also increases the chance of perforation.83 It was originally designed as a noncontact system using a flexible quartz fiber that delivers energy at a distance of 0.5 to 1.5 cm from the tissue. Major disadvantages of the noncontact system are backscatter, unpredictable tissue penetration, and the ease with which the fiber tip can be damaged when coming into contact with blood, feces, or tissue.91, 106 Synthetic sapphire contact probes were introduced for use with the Nd:YAG laser and obviate these problems to some degree. Similar to a "hot" scalpel, contact probes are thought to improve the ability to vaporize endoscopically and to cut tumors more efficiently at lower energy levels with more precise energy delivery. 106, 107 Different geometric probes are used depending on the application desired. Contact lasers produce their effect on tissues by simple contact, as opposed to the application of pressure required by conventional or "cold" scalpels. Recently developed pulsed lasers, such as the THC:YAG, Er:YAG, and Ho:YAG, may be superior to the continuous lasers owing to their

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shorter wavelength and duation of energy exposure. The improved heat dissipation, better absorption, and finer control over penetration depth may result in a lesser risk of perforation. 8,63 Coagulation, cutting, and vaporization, all photothermal applications of laser energy, occur depending on the degree of tissue heating obtained. Tissue vaporization is used for small tumors, hemorrhoids, and condylomata. High energy is applied for short periods of time, resulting in rapid heating with a visible effect. This is similar to electrocoagulation in that tissue necrosis occurs and there is no specimen for histologic examination. Tissue cutting results from using the laser as an expensive knife or cutting cautery to perform local excision. This has been used in the treatment of hemorrhoids, fissures, and fistulae in addition to a host of tumors treated endoscopically or by open techniques. Nonthermallaser-tissue interactions of interest to the anorectal surgeon include the photochemical and cytotoxic effects of laser light as used in photodynamic therapy. OCCUPATIONAL HAZARDS

Drawbacks of laser technology are numerous, particularly in light of the paucity of scientific evidence of its superiority. In addition to the lack of tissue for histologic study after ablation by laser energy, the high cost of equipment, special training, and increased operative time often make the use of this technology prohibitive. Lasers expose patients, physicians, and staff to serious risks. Misdirected laser beams can burn skin and hair, cause permanent eye injury, and ignite operating room contents.lO, 17,40,58 In a recent study at our institution, Brodman and colleagues reviewed their laser surgeries used for obtaining laser operating privileges. 17 Despite extensive training before operating the laser, significant morbidity to the patient or operating personnel occurred in 9% of cases owing to laser-related burns. Most concerning is the evidence supporting the potential for infectious particle transmission from the laser plume to the operator. Intact human papilloma virus (HPV) DNA,3,47, 53,109 HIV proviral DNA,5 and viable bacteriophages82 have been identified in the laser plume. Furthermore, a case of a laser surgeon contracting laryngeal papillomatosis has been reported. 57 With the increasing number of HIV-infected patients being treated for condyloma 24 and the malignant potential of HPV subtypes that preferentially infect the anogenital region,114, 126 the need for awareness of the potential infectivity of the plume and available means of protection are even more pronounced. Smoke evacuators, special goggles, filters, and masks, as well as fire-resistant gowns must be made available to all personnel involved in laser surgery.17, 57, 109, 130 HEMORRHOIDS It is estimated that at least 10 million people per year seek medical attention for symptomatic hemorrhoids. 65 Most patients can be treated

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conservatively13, 26, 119 or by one of many nonoperative therapies such as rubber band ligation, injection sclerotherapy, and infrared coagulation. 13, 26, 69, 70, 89 Surgical excision, required in less than 10% of symptomatic hemorrhoidal disease,13, 26 is usually reserved for patients who have failed alternative therapies; have associated fissures, tags, and hypertrophied anal papillae; or who have severely prolapsed hemorrhoids with a significant external component.113 In recent years, lasers have also been used in the treatment of symptomatic hemorrhoids of all stages.62, 90, 93, 96, 113,116, 129, 132 Enthusiasts claim that, compared with traditional procedures, this technique results in less pain, fewer complications, and an earlier return to workY, 62, 90, 106, 117, 129, 132 CO2 Laser. The absorption of this laser light by tissue with a high water content causes superficial burns. Because of its limited penetration, it is thought to be precise and minimally injurious to adjacent tissues. 62 A significant disadvantage is that this same property limits its usefulness ' for coagulation and hemostasis. The largest series of hemorrhoidectomy using a CO2 laser was reported by Iwagaki from Japan. 62 Laser hemorrhoidectomies were performed on 1816 consecutive patients with second-, third-, and fourthdegree hemorrhoids. After the pile was mobilized by incising the skin around the hemorrhoid with the laser, the base was ligated by rubber banding, and finally electrocautery was used for hemostasis at the completion of the procedure. Use of this multimodality approach resulted in a low overall complication rate. Of concern, however, was a 3.4% rate of stenosis, approximately one third of which required operative intervention. Stenosis following laser hemorrhoidectomy is caused by the same factors as after conventional surgery: excessive excision or destruction of anoderm. Higher stenosis rates following laser hemorrhoidectomy may be indicative of the fact that in clinical application, the extent of tissue destruction may not be as precise as has been claimed. Wang et aI, in Taiwan, randomized 88 patients to laser photocoagulation or hemorrhoidectomy using a Ferguson closed technique. 129 In the laser group a CO2 laser was used to excise the external component, in addition to a Nd:YAG laser being used to "photoradiate" the internal component. Results were favorable in the laser patients, with lesser narcotic requirements (11% versus 56%), a lower incidence of urinary retention (7% vs 39%), and a shorter postoperative stay. Overall complications were similar and low in both groups, but prolonged wound healing was noted in the laser-treated group. This study is frequently cited as an important demonstration of laser effectiveness, yet it compares a nonexcisional modality to an excisional one and is therefore of limited value. In essence, the Nd:YAG laser was used in a manner similar to infrared coagulation, but at a far greater cost. Leff prospectively followed 226 of his patients who underwent three-quadrant hemorrhoidectomy for third- and fourth-degree hemorrhoids,?7 It is not clear how patients were chosen to receive each treatment, but 170 were treated by excision with a CO2 laser and 56 with a

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standard closed surgical technique. He reported no difference in wound healing, complication rates, or the need to refill narcotic prescriptions. Nd:YAG Noncontact Laser. This laser, although providing better coagulation, is not precise as a cutting device.ll6 Tissue penetration is much deeper than with the CO2 laser, and thus more complications are likely. The laser energy is applied directly over target tissue and care is taken to leave normal areas of tissue between the lasered sites. 106 Nd:YAG Contact Laser. The Nd:YAG contact tip has been reported to provide more cutting precision while maintaining the coagulating properties of this laser system. 27 First- and second-degree hemorrhoids are "coapted" by using a flat contact probe. Low-power laser energy is applied until the tissue blanches. Sankar treated large second-, third-, and fourth-degree hemorrhoids by contact laser excision using a modified Parks submucosal hemorrhoidectomy.106 "Coaptation" of these larger hemorrhoids was avoided because of concern about excess edema formation. Submucosal hemorrhoidectomy using the contact Nd:YAG laser is accomplished by incising the mucosa overlying the hemorrhoid with a small tipped laser scalpel at low power. The hemorrhoidal tissue is separated from the underlying muscle and the pedicle ligated with absorbable suture. The tip of the pedicle is lased, as are the bleeding points. The mucosa is approximated as in a conventional closed procedure. IOB Sankar treated 36 patients with this technique. 106 Ninety-seven percent had pain requiring only acetaminophen. There was no urinary retention, hemorrhage, incontinence, or recurrence at 2.5 years. Wound healing without fibrosis occurred at 15 days to 3 months. Until Senagore at the Ferguson Clinic prospectively studied 86 patients randomized to laser or conventional scalpel hemorrhoidectomy,113 no published study adequately compared these two groups. Patients all underwent Ferguson closed hemorrhoidectomy for thirdand fourth-degree combined internal! external hemorrhoids requiring a three-quadrant hemorrhoidectomy. Fifty-one patients were treated with a contact Nd:YAG laser and 36 by scalpel. No differences in blood loss, operative time, or time until return to work were noted. Additionally, postoperative pain scores, as collected by a blinded coordinator, as well as analgesia use, were not significantly different. There was a significant increase in wound inflammation and dehiscence at 7 days postoperatively in the laser group. Use of the Nd:YAG laser added $480 to the cost of each procedure. At 6 weeks, wounds in both groups had healed equally well. Nicholson et al also reported a small, prospectively randomized series comparing excisional hemorrhoidectomy to Nd:YAG contact laser hemorrhoidectomy.93 The authors found no differences except for less early edema and significantly increased costs in the laser group. No study satisfactorily supports the claims put forth by enthusiasts of laser hemorrhoidectomy. Marketing techniques, however, have done an outstanding job of reaching a lay public eager to find a painless cure for their hemorrhoids. In many series, complications such as delayed

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bleeding, stenosis, and intersphincteric abscess are often remarked upon but not well quantitated. 9o, 106, 116 Complications are, of course, to be expected in any invasive treatment of hemorrhoidal disease, but the cost, safety, and efficacy of these modalities need to be adequately' compared in large, prospectively randomized studies. As clearly stated in the recent ASCRS Practice Parameters, the indications for treatment of hemorrhoids by newer techniques should follow the indications established for treatment by conventional means. ll9

CONDYLOMATA ACUMINATA

The rising incidence of condylomata acuminata presents a real challenge for urologists, gynecologists, and anorectal surgeons alike. 4, ll, 110 Anogenital warts, caused by the sexually transmitted HPV virus, have, such a variable clinical presentation and course between individuals of different gender, sexual preference, and immunologic status, that treatment outcomes are inconstant. Sexual transmissibility, troublesome symptoms, cosmesis, and potential for malignant transformation make this common disease a true public health concern.lI, 114, 126 Treatment is focused on destroying the clinical manifestation of the infection, the verrucae, by any of several techniques. Unfortunately, this does not ensure the patient a permanent cure.127 Recurrence rates of 10% to 65% are reported with topical application of podophyllin, caustic agents, and cytostatics25, 56, 99, 122, 127 as well as with immunotherapy, interferon injections, and cryotherapy.25, 42,51 Surgical excision and electrocautery fulguration remain the primary surgical options for the treatment of recurrent or recalcitrant condylomata.25, 127 The limiting factor of this approach has been the pain associated with these techniques. Laser vaporization of anal warts has been praised for causing less pain, bleeding, and scarring than traditional methods of treatment. It is also purported to promote faster healing in a more efficient manner. 4, 22, 46, 100, liB While the success in using the laser to treat condylomata in gynecologic and urologic sites has been well reported,4, 22, lOa, 121 the results of laser ablation of perianal and intra-anal papillomas are less well described. Additionally, condylomata in and around the anus are more difficult to eradicate than condylomata in other locations.u The CO2 laser is the one most frequently used for the treatment of anogenital condylomata. Warts are vaporized at settings of 15 to 20 watts in the continuous wave mode and the smoke (or plume) is suctioned by a vacuum system attached to a filter. HPV DNA has been identified in this plume3, 47, 53, 109 and has been linked to papilloma virus respiratory infections in operating room personnel who may inhale vaporized particles. 57 In addition to precautions mentioned previously, laser filters should be changed frequently to ensure a high suction rate. 53 The Nd:YAG laser, if used at low powers to avoid tissue damage, may be associated with a higher cure rate and a lower recurrence rate because of its greater depth of penetration. lOB

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As with all techniques, recurrence rates are difficult to ascertain owing to the differences in patient population, potential for reinfection, inability to treat subclinical disease, and variability in recurrence time. Most reports, however, are uncontrolled, and little if any information can be gleaned from them. Cure rates of 52% to 100% have been shown in many noncontrolled trials of laser therapy for anogenital condylomata with variable follow-up intervals. 4, 46, 56, 112 A small, randomized trial prospectively comparing CO2 ablation with conventional surgical treatment of refractory anogenital condylomata was undertaken by Duus and colleagues in Copenhagen.32 Fortythree patients were followed for 6 months after treatment. Conventional surgical treatment included excision alone or with electrocautery. No difference in cure rate, median time of recurrence, pain scores, or healing times were noted. Scar formation was seen in 28% of the laser group and in 9% of the surgery group, but this was not found to be a significant difference. Despite purported advantages of the laser causing less pain than other modalities, published studies of pain assessment after laser treatment of anal papillomas are sporadic. Sixty-eight percent of 52 patients treated with CO2 laser under general anesthesia for anogenital condylomata reported no postoperative discomfort. 75 The 5 patients with anal involvement only were not evaluated separately, but 16 of the 27 patients with anal condylomata reported temporary pain at defecation. Billingham and Lewis studied 38 patients with extensive condylomata of the anusY Lesions were treated with electrocautery if they were located to the right of the anus, whereas those to the left were treated with a CO2 laser. More patients reported greater pain on the laser side than on the electrocautery side, but many felt no difference. All patients had recurrences at some point in the follow-up. Recurrence was more likely to be extensive on the laser side and to occur earlier. The authors speculated that the poorer results obtained with the laser may have been due to difficulty in predicting adequate depth of tissue destruction with the laser and undertreatment of the laser side. In our own experience, we have treated 55 patients with anal condylomata in the last 3 years. Twenty-seven were treated with the CO2 laser and 28 with fulguration and/or excision. Patient selection was based on patient preference or the availability of the laser. We have not found any differences in postoperative pain, wound healing, or recurrence rates. It is suspected that subclinical infection is responsible for the failure to cure many patients with anogenital condyloma.48, 126 The CO2 laser has been used to treat epithelial surfaces contiguous with overt wart disease. Theorizing that this nearby tissue harbors virus, Baggish treated the clinically uninvolved surrounding mucosa and skin with a brush technique using a defocused beam. 4 This resulted in coagulation of the epithelial surface only and left the dermis intact. Compared with an earlier series treated with wart vaporization only, the group treated

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with the brush technique had an improved primary cure rate (91% versus 65.8%). Many patients are treated with laser therapy only after other modalities have failed. 4, 32, 46,112 In these select patients in whom high failure rates are likely, multimodality therapy may be considered. Seventy-five patients with recalcitrant anogenital condylomata were treated with CO2 laser vaporization by Vance and Davis.124 They found that the addition of intralesional interferon injections to laser vaporization reduced the recurrence rate from 38% to 18% at 13 weeks. Laser vaporization provides another modality of treatment of anal condyloma acuminatum. However, no real evidence exists that this technique is superior to conventional modalities. If a CO2 laser is already available, application to recalcitrant anogenital warts may be considered. When taking into account the considerable expense of the equipment, the potential risk to operating room personnel, and the absence of evidence that laser vaporization presents a tangible benefit, the purchase of equipment solely for the treatment of anal condylomata appears unwarranted. MALIGNANT TUMORS

In the United States and Europe, lasers have been used in the treatment of colorectal cancers primarily for palliation of patients deemed inoperable or to be poor surgical risks, and for recanalization of obstructing tumors prior to formal bowel preparation and primary resection (Table 2). Local palliative treatments such as radiation, electrocautery, and cryosurgery have been explored for decades in an attempt to improve quality of life in patients with advanced disease or concomitant medical Table 2. INDICATIONS FOR LASER TREATMENT OF COLORECTAL CANCER Patient factors Advanced age Systemic disease Patient refuses extensive surgery and/or colostomy Tumor factors Locoregionally advanced Widespread metastases Temporizing measure for symptom control Recent myocardial infarction or cerebrovascular accident Neoadjuvant therapy Palliation of end-stage disease Tenesmus Bleeding Pain Obstructon Mucus discharge Preresectional recanalization ?Adenoma and small malignancies

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illness. They have been met with variable success and considerable complication rates. 24,43, 52 Since the early 1980s many reports have described the application of laser photoablation for the treatment of neoplasms of the colon and rectum. I9-21, 28, 29, 72, 81, 86, 101, 111, 125, 128, 131 Laser therapy is considered by its proponents to be advantageous because it provides palliation as good as, if not better than, other local techniques. It may be performed in an outpatient setting or during a short hospital stay, and it is reported to be associated with a lower complication rate and an improved quality of life. Additionally, it may be applied to lesions above the peritoneal reflection. Disadvantages include the high cost of the equipment, the potential complications in both very distal anorectal tumors and more proximal intraperitoneal lesions, and the lack of advantage over less costly traditional methods of fulguration within the rectum.

Technique

Laser photoablation can be used to produce coagulation necrosis of the tumor with a delayed slough and/or vaporization with immediate destruction. 19, 78, 81, 125 The laser most commonly used today in the treatment of colorectal lesions is the noncontact Nd:YAGI4, 15, 78 with a tissue penetration of up to 4 mm. Maximal power outputs in the range of 80 to 110 watts are used at different pulse intervals depending on the desired effecU5, 19, 123 For flat lesions at risk for perforation and for cancers close to the anal canal, which may be painful to ablate, using very short pulses125 or an argon laser20 is recommended. In larger tumors, a "scanning" or "painting" technique has been described using a longer exposure time at a lower power. 123 The invisible infrared beam is transmitted through a thin flexible glass or quartz fiber that is ensheathed in a Teflon catheter which can be passed down the instrument channel of a standard flexible sigmoidoscope or colonoscope.74, 125, 128 A visible laser light source is used to aid in the aiming of the invisible beam, and the fiber tip is maintained at a distance of 5 to 10 mm from the tissue during the treatmenF8,125 To avoid perforation, tumors that cause significant luminal narrowing are best vaporized beginning at their superior margin and working distally.19 Tissue edema in treated areas can make forward visualization difficulF8, 123 Guide wires and dilators may be used when very narrow tumors do not allow passage of the endoscope.78, 125 A significant disadvantage of Nd:YAG vaporization is the difficulty in predicting the amount of delayed necrosis by the macroscopic appearance of the tissue during the procedure. Some laser endoscopists advocate using the Nd:YAG for coagulation only and await the delayed sloughing between treatments. 20,81 Laser treatment of bleeding and obstructing tumors is continued until the bleeding has stopped or sufficient tumor mass has been vaporized. 125 This may be accomplished in a single session or may require repeated treatments, especially to maintain

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luminal patency in obstructing tumors. Patients are followed and treated electively at intervals of 6 to 8 weeks, about the time that appreciable tumor regrowth causes recurrent symptoms in most patients. IS, 20, 78 Clear contraindications have developed as experience has grown. There is no benefit in treating extraluminal lesionsY, 123, 125 Pain caused by local pelvic infiltration cannot be palliated by laser therapy.74, 88 Relative contraindications include a tumor mass in the anal canal, sphincter dysfunction secondary to tumor invasion, and malignant cachexia.88 Additionally, circumferential involvement with tumor may be associated with a higher risk of fecal soiling following treatment. Laser therapy of colorectal neoplasms is generally well tolerated. Minor discomfort may occur from gas insufflation and the local heating effect of the laser. Increased rectal discharge for 24 to 48 hours can be expected due to sloughing of necrosed tumor, Palliation

Laser photocoagulation appears effective for both hemostasis and tumor destruction in patients with rectal bleeding, discharge, tenesmus, or obstructive symptoms. 14, 39, 72,101 In a large multicenter European study, 181 patients deemed unsuitable for surgery were treated with laser therapy.86 Overall, good palliation was observed in 89%. In the subgroup of patients with obstruction, the success rate of 86% supports the use of this modality as an alternative to colostomy. The procedure-related mortality was 3.4%, which compares favorably with that experienced with emergent surgical intervention. 61, 68, 98 Although complications occurred in 11.1% of patients with hematochezia, bleeding was controlled in 90% of patients with no mortality. These results are similar to those seen in numerous smaller series that reported symptom relief in 80% to 90% of patients and mortality rates in the range of 0% to 1%.IS, 74, 81, 101 Morbidity rates ranged from 1% to 19% and included perforation, fistula, bleeding, incontinence, abscess, and stenosis. Preresection&a Laser Recanalization

Luminal recanalization using laser energy was initially performed as a palliative measure in patients with end-stage disease. 60 This prompted some investigators to apply this technique to the resectable patient with a high-grade obstruction, thus allowing orthograde bowel preparation, full colonoscopy, and subsequent one-stage resections,35,38, 71, 72 Eckhauser performed preresectional laser recanalization on 11 patients and found a significantly reduced length of stay and overall cost compared with age-matched controls treated with diversion. 38 Later success with 33 patients, only 5 of whose lesions were in the rectum, resulted in a 9% morbidity rate with only 1 perforation. 37 There were no procedure-related deaths.

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Laser recanalization may also playa role in patients with obstructing distal sigmoid or rectal cancer who may benefit from neoadjuvant therapy protocols. Daneker demonstrated that luminal patency can be established and maintained during the la-week period needed to administer and recover from neoadjuvant therapy.28

ADENOMAS AND EARLY CANCERS

Laser treatment of colorectal neoplasms with curative intent is reported sporadically.97 Endorectal ultrasonography may be used to assist in the identification of early rectal cancers. This technique, however, has limited accuracy, particularly in the identification of lymph node metastases. 1. 73 Photoablation of villous adenomas often requires a number of treatments, and recurrence has been reported in 10% to 23% of cases. I8. 80. 87 Treatment of recurrent lesions is often more difficult and less effective. 85 The success rate is between 72% and 92%16. 18. 79. 80. 87 and has been correlated with tumor size, extent of circumferential involvement, and location of the adenoma. I8. 87 Pretreatment biopsy is recommended to identify those patients with an invasive component. However, in two large series, initially undetected cancers were subsequently identified in 5.7% to 9.1% of patients. 18. 87 The major drawback in using laser vaporization for definitive treatment of premalignant or malignant lesions is that it leaves no tissue for histologic examination. Benign tumors should be removed by polypectomy whenever possible to ensure adequate histologic review. However, laser photoablation may be appropriate in selected patients. For the treatment of small cancers, tumors otherwise treated with fulguration or local excision are likely treated equally well with laser ablation. This technique is especially well applied in selected patients who are unfit for radical surgery or refuse operative intervention.

PHOTODYNAMIC THERAPY

Photodynamic therapy is a new modality being applied in the treatment of colorectal cancer. This technology, which essentially is lightactivated chemotherapy, turns laser energy into stored chemical energy and requires photons, a photosensitive dye, and oxygen. A photon is absorbed and excites a chromophore, in this case a photosensitive dye that has been selectively taken up by the cancer cells. The photon is delivered by an appropriate wavelength light source. When oxygen is added to this system, a toxic product is produced (singlet oxygen) which is injurious to the local cellular environment. Laser treatment is applied several days after the dye is intravenously administered. The instrument frequently used is an argon-pumped dye laser. The fiber end is inserted just below the surface of the tumor, and the energy is applied at several

t

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sites. To achieve a desired level of necrosis, there must be enough oxygen, an adequate time of exposure, proper light penetration, and an adequate distribution of photosensitive dye. 63 Photodynamic therapy, which is still in the preliminary stages of clinical application, is associated with a reduced risk of perforation in experimental studies compared with conventional laser therapr and may be useful in the treatment of early or small cancers with less depth of invasion?' 67 Specific complications of light sensitivity and delayed hemorrhage suggest the need for refinement of this technology; as clinical studies are anecdotal with variable success,59, 67 utility has yet to be fully established. The unique property of tumor cells to selectively take up dye, combined with the minimally invasive nature of laser phototherapy, may result in the joining of photodynamic therapy and the armamentarium of technologies currently available to the patient with colorectal cancer. References 1. Accarpio G, Scopinaro G, Claudiani F, et al: Experience with local rectal cancer excision in light of two recent preoperative diagnostic methods. Dis Colon Rectum 30:296-298, 1987 2. Achauer BM, Vander Kam VM: Ulcerated anogenital hemangioma of infancy. Plast Reconstr Surg 87:861-866, 1991 3. Andre P, Orth G, Evenou P, et al: Risk of papillomavirus infection in carbon dioxide laser treatment of genital lesions. J Am Acad Dermatol 22:131-132, 1990 4. Baggish MS: Improved laser techniques for the elimination of genital and extragenital warts. Am J Obstet Gynecol 153:545-550, 1985 5. Baggish MS, Poiesz BJ, Joret D, et al: Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med 11:197-203, 1991 6. Barr H, Bown SC, Krasner N, et al: Photodynamic therapy for colorectal disease. Int J Colorectal Dis 4:15-19,1989 7. Barr H, Chatlani P, Tralau CJ, et al: Local eradication of rat colon cancer with photodynamic therapy: Correlation of distribution of photosensitiser with biological effects in normal and tumour tissue. Gut 32:517-523, 1991 8. Bass LS, Oz Me, Trokel SL, et al: Alternative lasers for endoscopic surgery: Comparison of pulsed thulium-holmium-chrornium:YAG with continuous-wave neodymiumYAG laser for ablation of colonic mucosa. Lasers Surg Med 11:545-549, 1991 9. Berken CA: Nd:YAG laser therapy for gastrointestinal bleeding due to radiation colitis. Am J Gastroenterol 80:730-731, 1985 10. Berninger TA, Canning CR, Gunduz K, et al: Using argon laser blue light reduces ophthalmologists' color contrast sensitivity. Arch Ophthalmol 107:1453-1458, 1989 11. Billingham RP, Lewis FG: Laser versus electrical cautery in the treatment of condylomata acuminata of the anus. Surg Gynecol Obstet 155:865-867, 1982 12. Birnbaum PL, Mercer CD: Laser fulguration for palliation of rectal tumors. Can J Surg 33:299-301, 1990 13. Bleday R, Pena JP, Rothenberger DA, et al: Symptomatic hemorrhoids: Current incidence and complications of operative therapy. Dis Colon Rectum 35:477-481, 1992 14. Bowers J: Laser therapy of colonic neoplasms. In Fleischer D, Jensen D, Bright-Asare P (eds): Therapeutic Laser Endoscopy in Gastrointestinal Disease. Boston, Martinus Nijhoff, 1983, pp 139-150 15. Bown SC, Barr H, Matthewson K, et al: Endoscopic treatment of inoperable colorectal cancers with the Nd:YAG laser. Br J Surg 73:949-952, 1986 16. Brennan FN, Laurence BH, Levitt S: Nd:YAG laser therapy for colorectal polyps. Aust NZ J Surg 61:415-418, 1991

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