We hope that December’s edition of the “Banding Bulletin” finds you well! This month, we’ll have a case presentation and look forward to the New Year!
Mr. X is a 57 year old male with a long history of hemorrhoidal symptoms (itching, bleeding, mild prolapse) presenting for treatment. He has had an otherwise unremarkable colonoscopy within the past couple of months, and has no other GI symptoms nor any significant past medical or surgical history. Anoscopy revealed large, grade II hemorrhoids, the largest being in the left lateral position, and this was banded at his first session without incident. Presenting 2 weeks later for his next treatment, the right anterior hemorrhoid was banded without issue, and the patient went home.
The next morning, the patient called the office complaining of perianal pain. He did not have any fever, chills or urinary symptoms. He was asked to come back to the office, and a digital examination was repeated, demonstrating only what was felt to be a fairly typical “polyp” of banded tissue, along with some sphincteric “tightness”. A small amount of dilute topical nitroglycerin ointment was inserted, and the band was manipulated to free up a bit of the distal-most banded tissue, after which the patient almost immediately noted symptomatic improvement. The patient was prescribed NTG moving forward, and advised to purchase an OTC 5% lidocaine cream if there was any residual discomfort. The patient later completed his course of treatment with excellent results and no further issues.
Significant pain after banding is one of the few potential complications of RBL. Fortunately, using the CRH O’Regan System, this happens less than 1% of the time. Causes of pain may include having too much tissue in the band, tissue which is too close to the dentate line, a coexistent fissure, or spasm secondary to the banding. I treat spasm with the “off-label” use of a dilute topical nitroglycerin ointment, applied into the anal canal 3 times daily, along with sitz baths as needed.
The key to avoiding these problems is to make certain that the patient understands that they should experience NO pain and NO “pinching” after the band has been placed, and to give them a few minutes after banding to make certain that they only feel a bit of pressure, fullness or mild tenesmus.
We tell our patients that even a “little pain” or a “little pinch” will get worse without adjusting the band. If the patient does leave your office too soon, and finds later on that they are uncomfortable we’ve found that manipulation of the band the next day can still be helpful. However, when you get much further out than 36-48 hours, this maneuver is not helpful, and giving them the topical NTG +/- topical lidocaine is the best approach.
We also avoid banding patients that have significant pain on initial digital exam (typically due to a fissure), “cooling off” the fissure for a couple of weeks with appropriate treatment before beginning to band the patient.
CRH on the Road
We will be attending our last 2 conferences of the year in December — the Regional ACG meeting in Nashville on the weekend of 12/4, and the NYSGE in New York City starting 12/17. If you will be attending either of these meetings, please stop by and say “hello”! We’d love to hear how things are going, and if there is anything that we can help with, or if you have any questions, we will be there to help!
CRH is looking forward to some exciting news in the New Year. Suffice it to say that we’ve been listening to your comments and suggestions, and we look forward to being able to use the words “new and improved” sometime in 2016!!
We also have been thrilled from the response to our periodic webinars for both trained and untrained physicians, and we look forward to more of these throughout the year. Our next set of webinars for our trained Partners will be on December 8th. We deal with FAQ’s during these webinars, but if you have a question, please don’t wait for those sessions and feel free to contact Andy Gorchynsky or ME directly. We are available “24/7” if we can provide support of any kind.
As the year comes to a close, everyone at CRH would like to wish you and yours the happiest of Holidays, and a safe, happy and healthy New Year! We are grateful for the relationships that we have built with our Partners over the past 7-8 years, and look forward to working with more of you in the future!
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953