We hope that this edition of the “Banding Bulletin” finds you well! This month we’ll discuss tips and tricks to avoid complications when banding, in an effort to achieve optimal clinical results, debunk some common myths about cybersecurity, and include some updates about CRH Anesthesia!
Let’s begin with the basics. There are 2 main things that you should avoid in order to ensure you have a happy patient. Avoid banding the wrong patient, and avoid banding the right patient at the wrong time!
The Wrong Patient: Contraindications to banding include: pregnancy, portal hypertension and proctitis. We would also include patients with other structural issues in the anal canal – since these are typically due to some previous surgical misadventure, trauma or infection. There are also patients that simply aren’t candidates for an awake, outpatient procedure regardless of how minimal an intervention.
The Right Patient at the Wrong Time: If a patient has some coexistent problem that causes significant pain, even with a DRE, they are in no shape to be banded at this time. Statistically, the most common problem you’ll encounter is an anal fissure. The literature will tell you that 20% of hemorrhoid patients also have fissures . . . . and, in my opinion, this is a low estimate. Then, there are fissures, and there are fissures! If you notice an old scar from a fissure, but the patient is not particularly uncomfortable at the time of DRE, they will likely do well with a banding. If, however, the patient cannot tolerate a DRE, or they can but are unable to tolerate the anoscopic exam that follows, they most often have a fissure! These should be treated and allowed to “cool off” for a couple of weeks prior to banding. If, on their return, they are still tender, then we need to get more aggressive and move onto “plan B” in treating the fissure or whatever other issue is being addressed. If not, we would complete the exam, and if tolerated and in need of it, we’d begin the banding process. We would keep the patient on whatever topical that you’ve prescribed (and I’m a “nitro-guy”), and avoid the hemorrhoid closest to the fissure when starting to band. Please reach out to ME directly if there are any questions about these sorts of scenarios.
The most common mistakes when banding are:
This is why folks with the most success keep their bands up really high, don’t grab a deep or broad chunk of tissue in the band (and if they do, they free up the band to correct things), and band a single column per session.
Fortunately, complications when using the CRH O’Regan System, accompanied by the recommended treatment protocols, are very uncommon. Dr. Cleator’s extensive report demonstrated a roughly 1% complication rate, which is far lower than any report I’ve seen through the years. The potential complications include significant pain, significant bleeding, urinary issues and the very rare instance of infection. Occasionally, you may also see a vasovagal response.. Let’s take a closer look at these below.
Pain: Pain has historically been the most frequent issue with band ligation, with some reports showing 20-50% of banding patients experiencing significant to severe pain. This should be almost entirely eliminated with the CRH O’Regan System along with proper technique and associated treatment protocols as required.
Bleeding: A little post banding bleeding is very common, but bleeding severe enough to require intervention is quite uncommon. Our numbers are approximately 1:7000-8000. Keeping the diameter of the deployed band in the narrow range seems to be the key in preventing these issues. Using the analogy of a polyp, after the band has been placed, we want there to be at least a big enough “head” to make sure that the band doesn’t fall right off, and we want the “stalk” nice and narrow. A narrow “stalk” leads to a smaller post-banding ulcer, which leads to a much lower bleed rate. Bleeding most commonly occurs within 10-14 days, with a much lesser peak in the 3-5 day range. Should a bleed occur, they are almost universally easy to control with a clip (if there’s a “pumper”) or cautery (for an ulcer).
Urinary Symptoms: A bit of urinary hesitancy is encountered every now and again, and is usually relieved by topicals and/or a warm sitz bath. True urinary retention is exceedingly rare. I’ve only heard of 2 cases of urinary retention from all of the single bandings done thus far using the CRH O’Regan System, and both were in men with significant pre-existing prostate disease. In 1 of the cases, the feedback from the treating Urologist was that he didn’t know how the patient was able to pee the day before the banding, much less after, because of the severity of his BPH!
Vasovagal Response: This is nothing unique to these procedures. I had a young patient faint on me while obtaining an informed consent for an upcoming hernia operation from the other side of the exam room, so, it is certainly possible to experience this in a clinical encounter as well.
Infection: Fortunately, this is incredibly rare. In fact, I’m not sure that anyone has ever provided the statistical risk of pelvic infection after banding. Any of the reports I’ve seen were case presentations with literature review as opposed to someone saying that “X%” of banding patients will have this issue. There are several purported mechanisms for something like this to happen, and the easiest way for you to keep these risks as tiny as they are, is to be aggressive when manipulating the band with your post-procedural examination. Keeping the resultant ulcer small as well as being certain that you have a superficial “bite” of tissue with the band will do much of the work for you here as well.
The next question that is most frequently asked is “what do we do if someone calls with any of these complaints, or if the call comes in and my partner who doesn’t band is on call?” We have this resource specifically for that reason, which can be found HERE. Andy Gorchynsky and I are always available to address questions should they pop up as well, and our contact information is at the bottom of that sheet.
The healthcare industry is increasingly vulnerable to cyber threats and, somehow, it’s still easy to overlook the severity. SecureSolutions Now is a managed cybersecurity service designed to provide clinics with the essential tools necessary to protect critical systems and patient information.
Check out a recent blog post about common misconceptions physicians have around cybersecurity HERE and learn more about how SecureSolutions Now can help you avoid a breach HERE.
CRH Anesthesia continues to grow, as we now provide anesthesia services to 91 ASC’s in 17 states! If you currently have an anesthesia service and are considering realizing some or all of the equity that you’ve built up over time, if you currently outsource your anesthesia and would like to bring it “in-house”, or if you currently don’t offer deep sedation but would like to, please let ME know. I’ll have someone from CRHAM contact you right away!
Does your practice currently have cybersecurity insurance coverage? Please click the link below to submit your answer. We appreciate your input!
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Thanks so much for checking out this bulletin. As always, let us know if any clinical or operational questions pop up, if you think that a “refresher” would be helpful to you, if you have other providers in the practice that would like to be trained, etc. Just say the word and we’d love to get you on our calendars!