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Banding Bulletin – April 2017

Banding Bulletin – April 2017

We hope that this edition of the Banding Bulletin finds you well!  This month, we’ll touch on how to manage patients who don’t see full symptomatic relief after banding all 3 hemorrhoids, discuss our smartphone app and provide a quick update on CRH Anesthesia Management!

How to approach patients with persistent symptoms

When we head back to practices for “refresher” sessions, we sometimes see patients who haven’t fully responded to a round of banding.  Based on our observations, we have a few recommendations on how to best care for these more difficult patients, as the most common reasons for an incomplete clinical response in these patients (in order of decreasing frequency) seems to be:

  • A missed anal fissure:  The literature states that 20% of hemorrhoid patients also have fissures which, in our experience, seems to be a VERY conservative estimate!  Some important considerations when it comes to fissures include:
    • You will not see the majority of fissures as many/most are partially healed, with portions of the fissure re-epithelialized.
    • Most fissure patients do not “jump off the table” on exam – again, the majority of fissures are partially healed, and so often only have subtle symptoms.
    • The diagnosis of an anal fissure is a CLINICAL one!  If the patient has any tenderness in the midline (posterior more frequent than anterior) without evidence of abscess or fistula, or if you can palpate any scarring in the midline just inside the introitus, then the patient likely has a fissure.  A good digital anorectal examination is all that is needed to make this diagnosis.
  • The need for an additional band:  In our clinics, the average number of bands required per patient was 3.08.  Approximately 10 to 15% of folks did not need all 3 columns banded to completely relieve their symptoms and 15-20% required more than 3 bands.  Patients more likely to require more than 3 bands include those with Grade III disease as well as those complaining of “leakage”.

We would typically wait at least 4-6 weeks after the 3rd banding session before considering the placement of additional bands, as it seems that the scarring process that occurs after a banding takes some time to demonstrate its full effect, and if you act more quickly than that, you may be treating someone that, if left alone, would’ve done just fine.  At this follow-up visit,  anoscopy will guide you as to where to place that additional band.

  • Truly symptomatic external disease:  The vast majority of patients complaining of “external symptoms” are helped by banding their internal hemorrhoids.  In our experience, a full 90% of these patients are helped by band ligation using the CRH O’Regan System and the remaining 10% need tag excision or a similar intervention to complete their care.  It is especially important to set proper expectations for patients complaining of external symptoms.  We should communicate that “while we see success in relieving symptoms in patients with external tags and hemorrhoids, after treatment, your tags and external hemorrhoids will still be there, but 90% of the time, the symptoms are relieved.  If you fall into the 10% with continued symptoms, then we’ll have to have those tags removed…”

Please let us know if you have some of these more “stubborn” clinical situations, as we are always happy to head your way to assist you with them.  Our hope would be to help with their evaluation and in planning for appropriate care.  Please notify your Account Manager or ME and we can go from there!

CRH Anesthesia Management News!

Last month, CRH Anesthesia Management was proud to announce our latest two agreements, acquiring a 60% interest in a GI Anesthesia Service in Florida, and helping to develop a new Anesthesia Program in Washington State.  These developments expand our footprint into 8 states!

If you have a current anesthesia service and would like to monetize some of the equity you’ve built in the service, or if you currently do not have an anesthesia program and would like to develop one, we’d love the opportunity to speak with you!  If you are interested, please contact Carter Blanton, our VP of Business Development for our Anesthesia Team, or ME, and we can start the process!

The CRH O’Regan System App

CRH has developed a great resource in order to help you to care for your patients – the CRH O’Regan System App for both IOS and Android devices!  The app includes links to our support materials, videos, tips and tricks, etc.  The App is free and available for download onto your smart phone or tablet.

Thanks so much for having a look at this Bulletin.  Please let me know if you have any questions that you’d like us to address in future issues and also if we can help you or your practice in any way!  If you are reading this and are not currently trained, let ME know and we’ll provide you with additional information.


Mitchel Guttenplan, MD, FACS
Medical Director
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953

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