Banding Bulletin – June 2019

Banding Bulletin – June 2019

Minimizing Risks for Your Banding Patients!

Band ligation using the CRH O’Regan System is extremely safe, with a documented complication rate of approximately 1%. Nevertheless, we would like to share some tips and tricks which help us to achieve the highest level of satisfaction for our patients. I’ll include the most frequently offered tips which will maximize your clinical outcomes while still minimizing any potential risks:

• Use the CRH O’Regan System! The CRH O’Regan System, with its patented integrated obturator and “anti-pinch” technology, offers the least traumatic approach to treating hemorrhoids. Many of your hemorrhoid patients have other anorectal issues as well, and any trauma to the area during insertion is a sure-fire way to create pain and bleeding in those patients. The CRH technology helps to avoid these issues.
• Keep the bands nice and “high”! Band ligation will cause pain in your patients if the band is too close to the “dentate line”, if too much tissue is grasped in the band, or if too many hemorrhoids are banded during a single session. Keeping the bands at least 2cm above the dentate line will minimize post banding pain.
• Keep the “neck” of the banded tissue narrow! Using the analogy of a polyp, you want the “stalk” or “neck” of the banded tissue to be narrow rather than broad. A broad stalk leaves you with a large ulcer, which is more likely to bleed than the tiny ulcer which occurs when a narrow stalk is created.
• Keep your patients in the office for 10-15 minutes after banding. It takes some patients a few minutes to know if they are feeling discomfort or a “pinching” sensation after being banded. These patients don’t need to tie up your exam rooms, but we ask them to hang out for a few minutes in the waiting room before leaving. If they feel ANY pain or “pinching”, then band manipulation is important.
• Nitro, nitro, nitro! This one is a personal recommendation, as some of the uses of topical nitroglycerine (or diltiazem, nifedipine, etc.) is “off-label”. If I sense any significant internal sphincter tightness or “spasm”, or even a HINT of a partially healed fissure is present, I get these patients on a topical medication. Treating the spasm and even the tiny little fissures (e.g. in the patients complaining of “hemorrhoid flare-ups”) alongside the hemorrhoids will give you the happiest patients.

If you have questions regarding the above (or anything else for that matter), please contact ME and we’ll get you whatever information you need!

Hemorrhoid Care in the “News”

The May edition of the American Journal of Gastroenterology included two interesting pieces regarding hemorrhoid care. Yang’s group¹ published data regarding the cost of hemorrhoid care in a select population within the US in 2014 – approximately $800 million just in the employer-insured population. The paper did not address the indirect costs of lost productivity, etc.

Cosman² included an editorial offering more color to the topic. What was particularly striking to me was the amount of money spent on medications (98% received a prescription for a topical steroid, for example), so many of which are both costly and relatively ineffective in treating the patient’s condition!

Kim’s group published data in May’s Gastrointestinal Endoscopy³ justifying the colonoscopy of patients with positive FITs even in the face of a recent endoscopic procedure (1-3 years). These pieces each provide support to the following assertions:

• We need to address patients’ hemorrhoids and other anorectal symptoms efficiently and effectively.
• Not only do these treatments offer symptomatic relief but they also limit both the need for short term endoscopic procedures as well as our liability in following these patients conservatively.
• There is a LOT of waste and inefficiency in caring for this class of patients. Proper use of the CRH O’Regan System alongside our suggested treatment algorithms is the most effective, efficient, and safe way to treat these patients.

CRH Anesthesia in 50 ASCs!

Last month, CRH was proud to announce our 22^nd anesthesia transaction (and 4^th in the state of Georgia)! CRH Anesthesia and our Partners now serve 50 ASCs in 11 states, providing anesthetic care for approximately 324,000 cases annually.

We’re continuing to grow and look to further expand our footprint, so if you have an existing anesthesia program and would like to increase its productivity as well as realize some of the equity you’ve built, we’d love to show you how we can help!

If you currently outsource your anesthesia, or are thinking about building a deep sedation program, we can help with that as well. For more information, please contact Carter Blanton, who heads up the Business Development efforts of CRH Anesthesia, or ME, and we can go from there!

Please let us know how we can help!

We would love the opportunity to work with you and to help you to provide the best possible care for your patients! If you currently are a “bander”, we always enjoy coming back to your practice for a “refresher” or “advanced” session. If you, a partner, a friend, or an Advanced Practitioner in your practice are interested in bringing these procedures “in house”, let me know and we’ll work to set up a no-cost training session for you.

Please let ME know if you have any questions or need any additional information.

Thanks to everyone for your interest, and we look forward to touching base again soon.

¹Yang et al., Burden and Cost of Outpatient Hemorrhoids in the United States Employer-Insured Population, 2014. Am J Gastroenterol. 2019;114(5):798-803
²Cosman, Bard C. Piles of Money: “Hemorrhoids” Are a Billion-Dollar Industry. Am J Gastroenterol. 2019; 114(5):716-717
³Kim et al. Yield of repeat colonoscopy in asymptomatic individuals with a positive fecal immunochemical test and recent colonoscopy. Gastrointest Endosc. 2019;89(5):1037-1043