I hope that this month’s edition of the Banding Bulletin finds you well! This month, we want to use a case study in order to help provide some information regarding one of the more frequently received questions from our Partners, as well as to make share some practice management tips that we learned in our own clinics. I first want to encourage you to contact Andy Gorchynsky or ME for any questions that might pop up — we are always here to help, and want to provide you with any professional support you might need!
CASE STUDY – SHOULD WE BAND SOMEONE WITH A HISTORY OF PROCTITIS?
Case presented: An otherwise healthy male in his late 40’s, with a history of mild ulcerative colitis (now quiescent) and symptomatic hemorrhoids with swelling, itching and bleeding, presents for treatment. Colonoscopy reveals no active colitis, and the rectum is completely free of any inflammatory changes. Is this a patient who is suitable for banding?
In the past month or so, we’ve had several inquiries regarding the banding of patients with a history of Crohn’s Disease, Ulcerative Colitis or proctitis of one sort or another, and so I’d like to review some of the indications and contraindications for treating your patients with symptomatic hemorrhoids. I should preface this discussion with a note that there is little to back up most of these recommendations in the literature — these recommendations have been “out there” seemingly forever, and there is not a lot of good evidence to support or refute what is listed below. We are always concerned about the medico-legal implications of anything that we do for our patients, and it is in that spirit that the information below is presented.
The relative contraindications to RBL have historically included the following:
The concern here is that banding might precipitate premature labor. I have not found anything in the literature to support or refute that concern, but from a medico legal perspective unless someone can prove it safe, our recommendation is to avoid treating pregnant patients. We typically wait until after the patient’s “postpartum check” to treat them, and care should be taken before banding patients that have had issues with a 3rd or 4th degree tear during vaginal delivery.
The concern here is that if the patient were to be banded, and that banding site were to bleed, the consequences could be severe (because of the portal hypertension as well as the commonly associated coagulopathy). It is a common misconception that portal hypertensives have more frequent symptomatic hemorrhoids than “normals”, but the literature shows that this is not the case — portal hypertensives have hemorrhoids as frequently as non-hypertensives. Treatment for these patients would include aggressive medical management for hemorrhoids as well as for portal hypertension, and Dr. Cleator notes that topical NTG in these patients can be quite helpful as well.
We will deal with this topic more completely in next month’s edition of the Banding Bulletin, but suffice it to say that there is some controversy in regard to this topic. We try to get people off of their Coumadin, Plavix, etc. — but haven’t seen much of an issue with mini-dose ASA in advance of the treatment. If, for whatever reason, you cannot take the patient off of their anticoagulation, then we will “adjust our indications” to meet the added risk of post-banding bleeding, treating only the more severely affected patients in this category. The only mention of this that I’ve found in the literature was by Dr. Cleator, who banded 61 anti coagulated patients (60 of them taking Coumadin) patients a total of 150 times, and he had only 1 significant post-banding bleed that was controlled with cautery.
Active Rectal Disease
It is our practice to NOT band anyone with any active rectal inflammation, whether it is due to Crohn’s, Ulcerative Colitis, Proctitis of any kind (infectious, ischemic, post-radiation, etc.). That concern is in risking the possibility of creating some sort of transmural process from what is essentially a mucosal banding. Symptomatic hemorrhoid patients with these coexisting conditions should be treated using conservative medical management if at all possible.
If patients have a history of having one of these issues but are without active disease, then it seems likely that we are able to band patients with symptomatic hemorrhoids. Dr. Cleator’s experience has shown that as long as the patient is quiescent, and the rectum looks and feels healthy, then we can proceed as in any other patient. Dr. Cleator is very aggressive with NTG in these patients in order to try to increase perfusion in the area, and by doing so, speeding up the healing process. I have not seen this dealt with in the literature directly, but the information provided above stems from Dr. Cleator’s extensive experience along with that of the “Centers for Colorectal Health”, and so covering tens of thousands of patients.
OPERATIONAL TIP – THE “BUTT CLINIC”!
This practice management tip is provided in the spirit of trying to help our Partners become as effective and efficient in the treatment of their hemorrhoid patients as possible. We found in our own practices that these patients and procedures typically have a different demand for time as well as a different “rhythm” when comported to your non-hemorrhoidal practice. In an effort to be as efficient as possible, offering your patients both the best care possible along with minimizing their wait in your office, we quickly learned that it is very helpful to “cluster” these patients together in your office/ASC. In my own practice, I designated a block of time for these patients, and then utilized 3 or 4 rooms concurrently — this allowed me to effectively treat 5 or 6 patients per hour.
CRH has provided “generic” versions of all of the paperwork that we utilized in our own clinics (consent forms, progress notes, patient information documentation, sample prescription forms, etc.) on our website and I’d like to encourage you to customize and utilize these documents in order to help you and your patients through the banding process. For more detailed recommendations regarding the optimal way to see these patients in your clinics, please contact ME, Andy, or practice support and we’ll be happy to fully “in-service” you and your staff!
Thanks again to each of our Partners for your continued interest and support. Please let me know if we can help with a follow-up visit to your practice, or if we can help in any way. Our aim is to help you to provide the finest care available to your patients! It was the patient response to these treatments, and the realization of just how under-served this series of problems is, that makes me as enthusiastic about the CRH O’Regan System as I am! Finally, if you are going to be in Chicago at the “HIT/GO” conference in the middle of August, please come by and say “hello” to Andy, who will be there on our behalf. We look forward to hearing from you, and hope to visit with each of you again soon!
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
T: 800.660.2153 x1022 | C: 770.363.0125 | F: 770.475.9953