Láser en medicina

El láser es un instrumento más en el arsenal tecnológico de la medicina moderna. La palabra láser se compone de las primeras letras en inglés de “Amplificación de la luz por emisión estimulada de radiación” (Light Amplified of Stimulated Emisión by Radiation) y sus inventores ganaron el Premio Nobel de Física en 1964 (Townes de Estados Unidos, Básov y Prójorov de la Unión Soviética). Fue Maiman en 1964 quien construyó el primer láser de Rubí y los oftalmólogos los primeros en usarlo en fotocoagular retina. Hay diversos tipos de láser (de estado sólido como el Alexandrita y Nd-Yag),  de colorantes, de gas (como el CO2) y la longitud de onda determina los efectos sobre el tejido de absorción y profundidad del láser.

Son los oftalmólogos los principales usuarios de esta tecnología en conjunto con los dermatólogos, cirujanos plásticos y cirujanos vasculares. Los otorrinolaringólogos, ginecólogos, cirujanos de quemados, proctólogos, urólogos, gastroenterólogos también usan ciertos tipos de   láser en sus procedimientos. Las aplicaciones médicas están determinadas para cada tipo de láser en función a la longitud de onda que tiene diversos efectos sobre el tejido.

 

Los oftalmólogos usan tres tipos de láser:

  • Láser de argón (488-514 nm) para fotocoagular retina (retinopatía diabética, edema macular, lesiones periféricas de la retina, tumores vasculares)  que se utiliza acoplado a una lámpara de hendidura o bio-microscopio. Alternativamente se usa un Nd-Yag doblado que es lo usual hoy.
  • Láser Nd-Yag Q-Switch (1064 nm) también va acoplado a una lámpara de hendidura y es un láser de corte para tratar capsuloptomía posterior que es una patología de relativa frecuencia después de la catarata
  • Láser Excimer (193 nm) para tratar miopía, hipermetropía y astigmatismo y se usa en conjunto con un microscopio mediante la técnica Lasik o PRK.

Últimamente los oftalmólogos están usando un nuevo  laser femtosegundos (1053 nm) que da luz en pico muy cortos y se está usando en cirugía catarata y cirugía refractiva.

 

Los dermatólogos y cirujanos plásticos son otros usuarios de láser en diversas aplicaciones:

  • Láser fraccionado de CO2 (10.6 nm) que es un bisturí quirúrgico que se usa acoplado a un escáner de barrido (rectángulo, triángulo, cuadrado, rombo) que permite dividir el laser en pequeños rayos con un efecto más acotado en el tejido. Se usa en cicatrices, rejuvenecimiento, arrugas, líneas de expresión, manchas, cicatrices de acné, minimizar poros y en general en mejorar envejecimiento de la piel. También se usa en implante capilar.
  • Láser Diodo (808 nm) que se usa en depilación por su longitud de penetración en el tejido obteniendo mejores resultados que el IPL. En razón a las diversos tipos de piel se combina su uso con el láser Alexandrita (755nm) y Nd-Yag (1064nm) para folículos más profundos. Los tratamientos, dependiendo de las características de cada piel, se hacen en cuatro, seis u ocho sesiones.
  • Laser Q-Switch Nd-Yag (532/1064 nm) son laser que actúan con una energía alta y densidad corta duración (Q-Swith) que permite tratar lesiones dérmicas y epidérmicas como tatuajes, lentigo solar, manchas, lesiones pigmentadas, melasma, rejuvenecimiento.  Es un avance de la tecnología en tratar lesiones de piel.
  • Laser fraccionado no ablativo (1540 nm) tiene la característica de penetrar profundamente la piel a través de diversos rayos o haces (fraccionar)  y es muy exitoso en e el tratamiento de cicatrices de acné, estrías y rejuvenecimiento cutáneo. Estos láser no ablativos actúan sobre la capa intermedia de la piel sin dañar la superficie (epidermis).
  • Láser  Erbium fraccionado ablativo (2940 nm) es un láser que por su longitud de onda produce una menor necrosis del  tejido y una recuperación más rápida que el CO2. Se usa en arrugas, rejuvenecimiento, en aplicaciones de juvenecimiento vaginal e incontinencia urinaria.

 

Los otorrinolaringólogos  usan dos tipos de láser: el CO2 fraccionado (10.6 nm) y el Diodo (810 nm). El médico ORL usa el láser de CO2 acoplado a los microscopios quirúrgicos y endoscopios para tratar lesiones de laringe como nódulos, quistes, pólipos, resección de tumores, cirugía de cornetes, cirugía de ronquido, cáncer de laringe.

 

Los cirujanos vasculares usan el láser Nd-Yag (1064 nm),  IPL para lesiones vasculares superficiales y láser endovenoso para el tratamiento de várices. La aplicaciones vasculares superficiales como rosácea, manchas. Para el tratamiento de arañas vasculares la principal característica que deben tener estos equipos es su penetración en la piel de mínimo 2 mm para tener resultados efectivos por lo que necesitan equipos de alta potencia en períodos cortos. El láser endovenoso se usa mediante fibra para tratar várices profundas.

 

Los ginecólogos usan el láser de CO2 (10,6 nm) en tratar rejuvenecimiento vaginal e incontinencia urinaria, cáncer cervicouterino. Los equipos de CO2 vienen con adaptadores especiales para tratar la vulva y por intermedio del colposcopío se tratan patologías de cuello.

 

Los urólogos y gastroenterólogos usan el láser Holmiun-Yag (2150 nm) en tratar patología benigna de próstata, tumores, procedimientos en gastroenterología entre otros.

 

Resumen

Hay muchos tipos de láser con diversos efectos en el tejido y que determina su uso en cada procedimiento médico. Los oftalmólogos son los principales y más antiguos usuarios de esta tecnología en fotocoagular retina con el argón y/o Nd-Yag doblado, en tratar la capsuloptomía posterior con el Nd-Yag y cirugía refractiva con el Excimer. Últimamente apareció un laser femtosegundo para tratar catarata y cirugía refractiva. Los otorrinolaringólogos los usan fundamentalmente el láser en tratar lesiones de laringe. En el campo de la estética, dermatología y cirugía plástica es otro campo médico donde se está usando crecientemente esta tecnología pero su aplicación más eficiente son los laser Q-Swith y fraccionados. El otro láser usado en diversos campos médicos es el Erbium con aplicaciones acotadas. El mercado ofrece mucha tecnología, no siempre exitosa en relación a los procedimientos tradicionales, donde es sustantivo el consejo médico. La relación costo/efectividad es importante de evaluar donde la tecnología se va decantando en aplicaciones específicas con buenos resultados en los pacientes.

 

Ing. Jaime Calderón Riveros

 

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