Ask the Expert

If you have been using GTN or diltiazem cream consistently for 6–8 weeks with proper dietary changes (high fibre, adequate water) and the fissure has not healed, it is now classified as a chronic fissure. About 10% of fissures do not respond to conservative treatment.

At this point, the tissue has likely developed fibrosis — the edges of the tear have scarred and hardened, making it physically unable to heal on its own. Continuing creams beyond this point is unlikely to help. Laser fissurectomy combined with lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic fissures. The procedure takes about 15–20 minutes, is done as a daycare procedure under local anaesthesia, and most patients experience significant pain relief from the very next bowel movement.

I would recommend seeing a qualified proctologist for a clinical examination to confirm the diagnosis and discuss your options.

Laser Haemorrhoidoplasty (LHP) has excellent long-term results. The laser shrinks the haemorrhoidal tissue by cutting off its blood supply, causing it to shrink and eventually be reabsorbed by the body. Published studies show a recurrence rate of 5–10% at 5 years, which is comparable to or better than conventional surgery.

However, piles are a lifestyle condition. If the underlying causes — chronic constipation, straining, low-fibre diet, prolonged sitting — are not addressed after surgery, new haemorrhoids can develop in different locations. That is why post-operative dietary guidance and lifestyle modification are just as important as the surgery itself.

For Grade 2 and 3 internal haemorrhoids, LHP is considered a permanent solution when combined with proper aftercare.

Both are valid treatment options, but they serve different situations. Fistulotomy is the traditional gold standard with a success rate of 90–95% for simple, low fistulas. However, it involves cutting through the sphincter muscle, which carries a risk of incontinence — particularly for complex or high fistulas.

FiLaC (Fistula-tract Laser Closure) is a sphincter-preserving technique. A radial laser fibre is passed through the fistula tract and delivers energy to close it from the inside out — without cutting any muscle. The success rate is 65–80% for complex fistulas, and importantly, the incontinence risk is essentially zero because the sphincter is never divided.

For simple, low inter-sphincteric fistulas, fistulotomy remains excellent. For complex, high, or trans-sphincteric fistulas — or for patients who want to preserve continence at all costs — FiLaC is the preferred option. The choice depends on your fistula type, which should be determined by an MRI and clinical examination.

Laser proctology is actually particularly well-suited for elderly and diabetic patients. The main advantages are: it uses local or spinal anaesthesia (no general anaesthesia risk), there is no open wound (reducing infection risk, which is elevated in diabetic patients), the procedure is short (15–30 minutes), and patients go home the same day.

For a 68-year-old diabetic patient, the key considerations are: blood sugar must be well-controlled (HbA1c below 8% ideally), any blood-thinning medications should be discussed with the surgeon, and a basic cardiac fitness assessment is advisable before any procedure under spinal anaesthesia.

In our experience, elderly patients often recover very well from laser procedures precisely because there is minimal tissue trauma compared to open surgery. I would recommend a consultation with a laser proctologist who can assess her specific condition and fitness for the procedure.

Laser piles surgery (LHP) in Pakistan typically costs between Rs. 60,000 and Rs. 150,000, depending on the city, the severity of the condition (grade), the hospital or clinic, and whether additional procedures are needed. Karachi and Lahore tend to be at the higher end, while smaller cities may charge less.

Regarding insurance: most private health insurance plans in Pakistan do cover haemorrhoid surgery as it is classified as a medically necessary procedure. However, coverage for specifically “laser” procedures varies between insurers. Some plans cover the procedure itself but may not cover the laser consumables. I recommend checking with your insurance provider for the procedure code before scheduling.

Government hospital options (such as those under the Sehat Sahulat programme) may offer conventional haemorrhoid surgery but laser procedures are generally only available in private settings at present.

Recurrent pilonidal sinus is one of the most frustrating conditions for patients because traditional excision surgery has a recurrence rate of 15–30% and involves a large wound near the tailbone that can take 6–8 weeks to heal.

SiLaC (Sinus Laser Closure) is a newer technique that uses a radial laser fibre to ablate the sinus tract from inside. The advantage is: no large wound, faster healing (1–2 weeks vs 6–8 weeks), and a recurrence rate of 10–15% in published studies. For recurrent cases, it is particularly attractive because previous surgery may have already scarred the area, making another open excision more complex.

However, SiLaC works best for sinuses with a single tract and no active abscess at the time of treatment. If there is active infection, that needs to be drained first. An MRI or ultrasound can help determine whether your specific anatomy is suitable for laser treatment.