Banding Bulletin – February 2012

Banding Bulletin – February 2012

We hope that this month’s edition of the Banding Bulletin finds you well! In this installment, I would like to present a case which helps illustrate a few of our suggested treatment protocols. We are always grateful for your calls and follow-ups, and if there are any clinical scenarios that you would like us to cover in future editions, please let ME know!

Andy and I continue to stay busy as we did more training sessions in January than in any other month in the company’s history. If you would like potential training dates or have any questions about our training, technology or treatment protocols, please let me know. In the meantime, please watch our new 3 minute video to learn more about how you and your patients will benefit from adding the CRH O’Regan SystemTM to your practice.

Case Study

Mr. X is an otherwise healthy 48 year-old male, who presented with a recurrent history of rectal bleeding, and no other real GI complaints or family history of colorectal neoplasia. His initial presentation with bleeding resulted in a colonoscopy 4 years earlier, with no gross pathology (other than hemorrhoids) noted. Since it had been over 4 years since his last colonoscopy, another study was obtained — again noting no gross pathology other than his hemorrhoids. Anoscopy confirmed typical grade II disease in all three locations, and he was banded using the CRH O’Regan SystemTM in the LL, RA and RP regions at two week intervals. The patient had no difficulties with any of the treatments and he is significantly better; however, he still has a bit of bleeding on defecation, particularly when he is constipated, and a bit of discomfort passing a bowel movement (BM).

This case brings up a number of issues that may well pertain to a significant number of your patients, so I’d like to run through our recommendations and the reasons behind them. Our recommendation is to do the following:

• Perform an anorectal exam, looking for evidence of spasm as well as any evidence of a small or partially-healed anal fissure. In our experience, we have found these fissures are very commonly overlooked or under-treated. To accurately diagnose these, it is important to digitally examine the anus, as well as the rectum, being particularly careful in the posterior midline (where 90% of these reside — the rest in the anterior midline), where you may feel a ridge, a scar, or a “rough” area surrounded by smooth anoderm. These patients often have partially healed fissures that will break open after a hard or large BM. This is a CLINICAL diagnosis, as we feel many more fissures than we see, and aggressive medical management will help a tremendous number of these patients moving forward! The patient does not always suffer from the sensation of “passing razor blades” when affected by a fissure — many have symptoms which are much milder than that!
• Perform an anoscopic exam. If a residual area of hemorrhoidal tissue remains, a 4th banding is required. Typically, you are not going to “re-band” a previously treated area, but there may be a bit of residual disease between two previously treated areas — that additional band typically does the trick!

Remember that 10-15% of your patients will resolve with fewer than 3 bandings, and 15 – 20% will require more than 3 bandings. The data from our clinics demonstrates the average patient will require approximately 3.1 banding sessions in order to take care of their hemorrhoidal complaints.

The importance of increased dietary fiber and fluid, along with minimizing time spent on the commode and the avoidance of straining should be stressed, as well as the use of a topical fissure treatment regimen (we use 0.125% NTG ointment TID-QID for up to 3 months).

The final point to keep in mind is that so many hemorrhoid patients have been “brushed aside” by their health-care providers, and are told to “live with them” when having issues. This is why so many patients are so grateful after being treated with the CRH O’Regan SystemTM. A very large number of these patients have been suffering with these issues for YEARS! We should also keep in mind that if this patient’s hemorrhoids were treated after his first colonoscopy, he may well have not shown up 4 years later with bleeding after his initial, otherwise clean endoscopic exam. Treating these patients when indicated is safe, as well as both clinically and cost effective!

Thanks for your interest in the treatment of perianal disease and if you have any questions or would like to schedule training session, please let me know. All of my contact information is below.

Best Regards,

Mitch

Mitchel Guttenplan, MD, FACS

Medical Director

CRH Medical Corporation

T: 800.660.2153 x1022 | C: 770.363.0125 | F: 770.475.9953