Banding Bulletin – January 2018
Suggested New Year’s Resolutions
“I’m going to identify more fissures!” The most common reason patients do not respond to a round of band ligations seems to be the presence of a coexistent anal fissure. The literature tells us that 20% of hemorrhoid patients also have fissures (we think that this is actually a low number) and for these patients, if you don’t treat both issues, the patient won’t respond as you’d like. Things to keep in mind when looking for fissures:
- Internal hemorrhoids generally don’t cause pain, so if pain is involved, the most common reason is a coexistent fissure.
- You won’t see most fissures as they are typically either partially healed or the remaining fissure is within the anal canal, and so not visible either by endoscopy or visual exam.
- The diagnosis should be a clinical one, so any tenderness in the posterior or anterior midline (where fissures usually occur), any palpable scarring in those places, the presence of a sentinel tag, or the presence of a “fissure face” (the characteristic reaction of a patient as your finger crosses the area of a fissure) indicates the likely presence of a fissure (assuming the absence of an abscess or a fistula).
- Patients complaining of their hemorrhoid “flare-ups” quite often are referring to their fissures, which “flare up” when they’ve had a few constipated BMs, etc.
“I’m going to do an anorectal examination on my patients BEFORE they get their propofol at the time of colonoscopy!” The anorectal examination is so helpful in the evaluation of patients with any anorectal complaint, and frankly, the flexible scope has been shown to be notoriously poor in identifying issues near the anal verge, so a digital exam can pay huge benefits. However, once the patient has been sedated, sphincter tone is altered and patient feedback is lost, so the value of that exam plummets. This is why, so often, we see patients back in the office for banding and only then discover that they are too tender to treat because of their fissure, fistula, etc. Taking advantage of the “sneak peek” that you get at your patients in the endo suite will allow you to more efficiently and effectively care for your patients, and will avoid the frustration of bringing patients in for the first banding visit only to find out that you need to “cool off” their fissure before treating their hemorrhoids.
“I’m going to work on my ‘spiel’.” First off, I learned something, as I thought it was spelled “schpiel”, but there you go! Many patients present with incorrect pre-conceptions; making certain that their expectations are within reason is one step to ensure you have a satisfied patient at the end of the day. The points we most likely need to polish up on include:
- External tags and external hemorrhoids – many to most patients come in with the expectations that banding will get rid of their tags, etc. Whenever we see someone with external disease, we make sure to communicate that banding will take care of their “external symptoms” about 90% of the time, but the tags and external hemorrhoids will remain (although the perception is that the external hemorrhoids “shrink” a bit, most likely because they tend to not swell as much after internal banding is performed). If the patient is coming in with the idea that this is a cosmetic procedure, then everyone will be disappointed!
- The vast majority of folks will need 3 bandings. Too often we hear “we’ll band one and see how you do.” With that approach, you’ll see a tremendous “failure rate” as the average number of bands in our practice was just a smidge over 3 per patient. We have learned to tell folks that they should expect to have 3 bandings; although there are a few folks that can get by with fewer than 3 and some folks that need more than 3.
- Grade III patients and patients with “leakage”. These patients are the ones most likely to need more than 3 bands, and every now and again, you’ll run into a grade III patient that is not taken care of by banding. We tell our grade III patients that banding does a great job on most folks, but if anyone is going to need more than 3 bandings, or if anyone is going to fail a banding, it is a grade III patient. We let them know that, as opposed to grade II patients, grade III disease is more reliably treated surgically, but as we know how miserable a surgical approach is and that the vast majority of grade IIIs do well with banding, we like to try banding first. If the patient does not respond to banding, we haven’t burned any bridges in regard to surgery. If they would prefer to start off with a surgical approach, then a trip to the surgeon would be your next step.
- “You should have absolutely no pain or ‘pinching’ after being banded. If you do, the pain or pinching will worsen without intervention, so please tell me now as I can fix things by adjusting the band in the office”. Tell this to all of your patients, and don’t let them leave the office until you know that they are comfortable. This will keep the phone from ringing, and make sure that everyone is happy!
“I’m going to re-evaluate our office’s or our ASC’s anesthesia setup!” CRH Anesthesia has had an incredible year and we’re now servicing 35 ASCs in 7 states, along with participating in an anesthesia development program in an 8th state, providing more than 235,000 anesthetics per year alongside our GI Partners! We’d love the opportunity to speak with you if you:
- Currently have your own anesthesia program, and would like to ascertain its value as well as learn how CRH’s anesthesia team can optimize its performance, as well as to learn how you can monetize some or all of the equity that you’ve built in the program.
- Currently have a 3rd party providing anesthesia services, and you’d like to bring those services “in-house”, or
- Currently are using conscious sedation, and would like to build a propofol-based anesthesia service at your Center.
CARTER BLANTON is the Director of Business Development for CRH Anesthesia, and if you are interested, either of us would love the opportunity to speak with you!
Wishing Everyone a Happy 2018!