Banding Bulletin – July 2023

Banding Bulletin – July 2023

Thanks for checking out this edition of the Banding Bulletin! In keeping with the format of our last mailing, I’m going to include a few “one-off” cases, just as reminders that every now and again, a red herring shows up in your office! I am also sharing information about anticoagulants and banding, trying to enlist your help, and an update concerning CRH Anesthesia.

“One-Off” Cases

Patient #1: A man in his mid-forties presented complaining of a long history of intermittent hemorrhoid-type symptoms (mostly bleeding and itching), telling us that his hemorrhoids would periodically “flare up,” increasing in irritation. After a few days of discomfort, he would start bleeding and these symptoms would respond after using one of the OTC hemorrhoid creams. He had a colonoscopy which showed evidence of internal and external hemorrhoids during a partially deflated retroflexed view, and not much else, other than what turned out to be a small hyperplastic polyp. External examination didn’t show much either, other than a few non-descript skin tags, and for lack of a better descriptor, a small (2-3mm max.) reddish “dot” to the left of the anal canal, about 3cm from the verge. Palpation around this dot revealed some subcutaneous thickening just deep to the skin finding, and that thickening was felt to be tracking posteriorly in the perianal area. A DRE revealed a small, inflamed area in the posterior midline 2-3 cm from the anal verge. Anoscopy showed that this area (again, just a few millimeters in diameter) was a bit inflamed and confirmed the presence of grade II hemorrhoids but was otherwise pretty unremarkable. He was sent for a surgical consultation.

This patient had a fistula-in-ano. When we saw him in the clinic, he did not have the typical open draining sinus tract that you would expect to see. Both the internal and external orifices were partially healed over and so the expected draining sinus tract was not visible. You wouldn’t necessarily expect to see this colonoscopically as, in retroflexion, the scope was sitting in the anal canal, blocking its visibility, and even on straight withdrawal, even if the changes were more obvious, they may well be missed as it is not a side-viewing scope. In our experience, when we hear of a patient complaining of “hemorrhoids flaring up,” the vast majority of the time they are actually referring to a symptomatic fissure which was almost completely healed, but after a few bad bowel movements, their symptoms return. Every now and again, however, it is a fistula-in-ano that causes these symptoms, and we should always be on the lookout for them!  A history consistent with that of a previous perianal abscess should make us even more suspicious that we’re dealing with a fistula! These folks should always be scoped in order to look for evidence of Crohn’s, cancer, etc., and then the patients should be considered for surgical referral if indicated.

Patient #2: A man in his 50s was being treated for symptomatic, grade III hemorrhoids. Two days after his second banding, he experienced some bleeding, describing a “gush” of blood in the toilet on defecation. He was otherwise feeling well without any symptoms consistent with hemodynamic instability. He was asked to come into the office and had normal vital signs, and a digital examination showed a minimal amount of dark blood. Labs were drawn including coags and a CBC, and just to make certain that everything was stable, they took the patient to the endo suite for a flexible sigmoidoscopy.

Discussion:

The patient was hemodynamically stable, and their bloodwork was normal. Flexible sigmoidoscopy revealed a dry band present where he was banded a few days prior. There was now a non-bleeding ulcer noted at the site of the first banding, which looked to be the culprit. The ulcer was only a few millimeters in diameter and there was no obvious vessel noted. A clip was placed over the ulcer and the patient was later discharged home without any further clinical issues.

This case raises a few points that we’d like to address, hopefully clarifying a few things and making life easier for everyone:

1. Some bleeding is fairly common after band ligation of a hemorrhoid. Significant bleeding is quite rare.
2. It doesn’t take much blood in the toilet to turn the water red and scare the hell out of the patient.
3. Significant bleeding, if it does happen, virtually never happens immediately after a banding. Instead, it generally occurs in the same time frame as a post-polypectomy bleed (2 weeks, +/- a few days).
4. We recommend always doing a post-banding DRE to make certain that the base of the banded tissue is narrow, rather than broadly-based. Just as the likelihood of a broader-based polypectomy to bleed is greater than if the polyp has a narrow stalk, a broader-based rubber band is more likely to lead to a larger ulcer (and higher likelihood of bleeding) than a more narrow-based band. For this reason, if the post-banding DRE reveals a “thicker base,” manipulation of the banded tissue, to free things up a bit, will narrow the base and increase the safety profile of that band.
5. Patients should be told that some minor bleeding may occur. If you are notified that there is some bleeding, and if it is minor in nature, reassurance is generally all that is needed. If it is more than just a bit of spotting that is noted, we recommend holding off on topical medications (if prescribed) for two days, laying down and keeping their feet up on pillows for 30 minutes or so, which usually does the trick. On the CRH website, the additional suggestion of putting an ice pack under their bottom has been made, but frankly, I’m not sure if the efficacy of this technique is more in the ice pack, or the fact that by holding the ice pack in place, the patient cannot be on the toilet, straining to see if they’re still bleeding, wiping, etc.!
6. If the very unusual situation of a post-banding bleed that really needs intervention should occur (I’m not sure that the case presented needed anything based on the description from the flex sig), there are several ways to approach it. As a surgeon, I’m most comfortable using a slotted anoscope, and so if the issue was a bleeding ulcer, I would cauterize it with a silver nitrate stick. If, on the other hand, an arteriolar “pumper” was noted, then I would band it under direct vision across that same anoscope. I would assume that GIs would be much more comfortable with a flexible scope, so that ulcer would generally best be treated with whatever sort of cautery you like to use, and a “pumper” would be treated with a clip. I should add that personally, I’ve never had to put a suture in anything here. Either scenario was easily taken care of as described.

Anticoagulants and Banding – asking for your help!

By far, the most frequently asked questions that we receive involve the scenario of the patient with symptomatic hemorrhoids on one or more anticoagulants. While there is some information in the literature about Coumadin and Plavix, I’m aware of nothing that deals with the newer medications that are currently in use. We know there are some of you out there who are banding patients on these medications. If you are one of them and would be willing to share data with us regarding these patients, we’d love the opportunity to compile this data and hopefully come up with some answers for this very common question. Just prior to the outbreak of COVID, we had a few practices willing to provide their information, but as expected, the pandemic put an end to all of it. So, if you are treating these patients and would be willing to share your data with us, please contact ME at your convenience.

Training and Support Available to Your Practice!

CRH continues to offer clinical training and support to practices across the country!  Whether it be an “on-site” visit for a “refresher” session for previously trained providers; or a new associate or APP that is interested in bringing these procedures to your practice; or even a quick “Zoom” session for a Q and A or to provide additional didactic material, we are here to help!  We also have the availability to provide virtual front or back-office “in-service” training, provide marketing help as well as billing and coding support!   

If any of the above appeals to you, please simply ping ME, and we’ll work to get you on our calendar.

CRH Anesthesia Still on the Move!

CRH Anesthesia continues to grow, currently serving 120 ASCs in 18 states, performing approximately 700,000 procedures per year, and is continuing to expand it’s footprint.  So, if you are in the process of developing an ASC, are interested in building a deep sedation program, or if you currently are outsourcing your anesthesia service and would like to bring it in-house, please let ME know and we will get you the information that you need!

Thanks again to each of you for opening this Banding Bulletin.  Please let me know if there is anything that we can do for you and your practice, and we’ll be checking in again soon.