The importance of surgeon experience for assessment of the outcomes of minimally invasive treatment for chronic haemorrhoids

Introduction. The impact of surgeon experience, changing during a study, on the characteristics of transmucosal laser vaporization and dearterialization of hemorrhoidal arteries has not been sufficiently studied.

Aim. To determine the impact of the surgeon experience on the objectivity of the assessment of outcomes of treatment using hemorrhoidal dearterialization and hemorrhoidal laser ablation techniques in patients with chronic grade 2–3 haemorrhoids.

Materials and methods. Ninety-five patients underwent transmucosal laser thermal ablation, and 132 underwent dearterialization. All operations were performed by the same surgeon. The following properties for the treatment techniques were assessed: operation duration, pain intensity and duration, and postoperative haemorrhages. The learning curve was studied by grouping patients into quartiles.

Results. The attainment of mastery in laser vaporization required 23 operations, and that in dearterization required 33 operations. The characteristics of the treatment techniques that were studied with and without regard to the surgeon experience differed from each other according to all indications. The trend of their changes had the same pattern: all patients operated during the experience consolidation phase had better outcomes. The statistical significance remained after comparison of operation duration and assessment of pain syndrome, but ceased to be found after assessment of the number of complications.

Discussion. The outcomes of treatment of chronic grade 2–3 haemorrhoids using hemorrhoidal dearterialization and laser thermal ablation techniques, which were measured by analysed characteristics, depend on the surgeon experience, and are more objective in patients who were operated during the surgeon experience consolidation.

Conclusions. When assessing the outcomes of treatment of chronic haemorrhoids to establish the statistical significance of the analysis performed, it is important to take into account the surgeon experience in mastering these treatments.

1. Titov AYu, Kostevich IV. Submucosal laser ablation of internal hemorrhoids. Pirogov Russian Journal of Surgery. 2020;(3):89–96. (In Russ.) https://doi.org/10.17116/hirurgia202003189.

2. Cherepenin MYu, Gorskiy VA, Armashov VP. Results of treatment of hemorrhoids by submucosal w-laser destruction of hemorroidal piles. Koloproktologia. 2020;19(2):104–111. (In Russ.) https://doi.org/10.33878/2073-7556-2020-19-2-104-111.

3. Abritsova MV. Possibilities of minimally invasive treatments of hemorrhoidal disease. Ambulatornaya Khirurgiya. 2018;(3–4):77–82. (In Russ.) https://doi.org/10.21518/1995-1477-2018-3-4-77-82.

4. Symeonidis D, Spyridakis M, Zacharoulis D, Tzovaras G, Samara AA, Valaroutsos A et al. Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study. BMC Surg. 2022;22(1):416. https://doi.org/10.1186/s12893-022-01861-z.

5. Zagriadskii EA, Tolstyh VS. Doppler-guided hemorrhoidal dearterialization. Technical evolution and results of treatment (review). Koloproktologia. 2021;20(1):87–98. (In Russ.) https://doi.org/10.33878/2073-7556-2021-20-1-87-98.

6. Naderan M, Shoar S, Nazari M, Elsayed A, Mahmoodzadeh H, Khorgami Z. A randomized controlled trial comparing laser intra-hemorrhoidal coagulation and Milligan-Morgan hemorrhoidectomy. J Invest Surg. 2017;30(5):325–331. https://doi.org/10.1080/08941939.2016.1248304.

7. Matveev IA, Matveev AI, Dgebuadze VT, Povarnin NN, Zobov SN, Morozova LA, Kurakina KE. Desarterization of hemorrhoidal arteries in outpatient treatment of chronic hemorrhoids. Ambulatornaya Khirurgiya. 2023;20(2):249–257. (In Russ.) https://doi.org/10.21518/akh2023-022.

8. Matveev IA, Gibert BK, Matveev AI, Borodin NA, Morozova LA, Povarnin NN. Transmucosal laser ablation for combined hemorrhoids of 2–3 stages. Koloproktologia. 2023;22(2):86–91. (In Russ.) https://doi.org/10.33878/2073-7556-2023-22-2-86-91.

9. Каторкин СЕ, Корымасов ЕА, Сотников ВМ, Андреев НС, Кривощеков ЕН, Романов ВЕ. Современные принципы лечения геморроя. Самара: СамГМУ; 2021. 198 с.

10. Нечай ИА, Мальцев НП, Каримзода ЗК, Ветошкин ВА. Отдаленные результаты операций HAL-RAR и LHP – чему отдать предпочтение? В: Материалы Всероссийской научно-практической конференции с международным участием «Съезд колопроктологов России», Москва, 6–8 октября 2022 г. М.; 72 с. Режим доступа: https://akr-online.ru/upload/iblock/ab3/Тезисы.pdf.

11. Valsamis EM, Chouari T, O’Dowd-Booth C, Rogers B, Ricketts D. Learning curves in surgery: variables, analysis and applications. Postgrad Med J. 2018;94(1115):525–530. https://doi.org/10.1136/postgradmedj-2018-135880.

12. Khan N, Abboudi H, Khan MS, Dasgupta P, Ahmed K. Measuring the surgical “learning curve”: methods, variables and competency. BJU Int. 2014;113(3):504–508. https://doi.org/10.1111/bju.12197.

13. Tyutyunnik PS, Khatkov IE, Tsvirkun VV, Izrailov RE, Khisamov АА. Optimal model oflearning curve through the example oflaparoscopic pancreatoduodenectomy. Endoscopic Surgery. 2015;21(5):45–49. (In Russ.) https://doi.org/10.17116/endoskop201521545-49.

14. Burt BM, ElBardissi AW, Huckman RS, Cohn LH, Cevasco MW, Rawn JD et al. Influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery. J Thorac Cardiovasc Surg. 2015;150(5):1061–1067. https://doi.org/10.1016/j.jtcvs.2015.07.068.

15. Harrysson IJ, Cook J, Sirimanna P, Feldman LS, Darzi A, Aggarwal R. Systematic review oflearning curves for minimally invasive abdominal surgery: a review of the methodology of data collection, depiction of outcomes, and statistical analysis. Ann Surg. 2014;260(1):37–45. https://doi.org/10.1097/SLA.0000000000000596.

16. Ambe PC. Laser interventions in coloproctology. A plea for standardized treatment protocols. Tech Coloproctol. 2023;27(10):953–955. https://doi.org/10.1007/s10151-023-02859-2.

17. Festen S, van Hoogstraten MJ, van Geloven AA, Gerhards MF. Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results. Int J Colorectal Dis. 2009;24(12):1401–1405. https://doi.org/10.1007/s00384-009-0803-2.

18. Dursun A, Tuncer GK, Tuncer K, Karaali C, Erdoğan G, Emiroglu M. Effectiveness oflaser hemorrhoidoplasty in the treatment of hemorrhoidal disease. Cir Cir. 2023;91(2):179–185. https://doi.org/10.24875/CIRU.22000287.

19. Liu S, Qiu M, Jiang DZ, Zheng XM, Zhang W, Shen HL, Shan CX. The learning curve for endoscopic thyroidectomy: a single surgeon’s experience. Surg Endosc. 2009;23(8):1802–1806. https://doi.org/10.1007/s00464-009-0332-7.

20. Samy AK, Ridgway D, Orabi A, Suppiah A. Minimally invasive, video-assisted thyroidectomy: first experience from the United Kingdom. Ann R Coll Surg Engl. 2010;92(5):379–384. https://doi.org/10.1308/003588410X12628812459977.

21. Kwak HY, Kim SH, Chae BJ, Song BJ, Jung SS, Bae JS. Learning curve for gasless endoscopic thyroidectomy using the trans-axillary approach: CUSUM analysis of a single surgeon’s experience. Int J Surg. 2014;12(12):1273–1277. https://doi.org/10.1016/j.ijsu.2014.10.028.