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Banding Bulletin – May 2013

Banding Bulletin – May 2013

We hope that this month’s edition of the “Banding Bulletin” finds you well! As you can see, we’ve updated the look of the bulletin to reflect the design of our revamped marketing materials – we hope you like it! This month, we will present a case which brings up a few frequently asked questions, as well as to announce an expansion of our educational and support services.

Case Study

Mrs. X is a 68 year old woman, presenting with a several year history of multiple anorectal complaints, including external swelling, itching, bleeding, prolapse and “incontinence”. She had a long history of chronic constipation, which has improved since she started taking supplemental fiber. It was necessary for her to manually reduce her prolapsing hemorrhoids after defecation. With the exception of some mild hypertension and osteoarthritis, she is in good health. She had a negative colonoscopy (other than finding a few scattered diverticulae and internal hemorrhoids) 3 months prior to her presentation.

Physical exam was remarkable only for the findings on her anorectal exam. She was noted to have external skin tags, a monilial-appearing rash, and on Valsalva, she demonstrated some mild prolapse of the right anterior (RA) and left lateral (LL) internal hemorrhoids. Digital exam revealed fairly good sphincter tone, and the prolapsing tissue was very easily reduced. No masses or tenderness were appreciated, and the stool was positive for a bit of bright red blood. Anoscopy revealed Grade III hemorrhoids in the RA and LL positions, and Grade II hemorrhoids in the Right Posterior (RP) position.

In 2 week intervals, the LL, RA and RP hemorrhoidal columns were ligated using the CRH O’Regan System. The patient was given instructions regarding “Kegel” exercises. The fungal rash was treated with a topical anti fungal cream, and after the third banding, virtually all of the pre-treatment symptoms had cleared except for a bit of swelling/mild prolapse anteriorly. A 4th band was applied, and the patient’s symptoms – including the fecal soiling – resolved completely! There are several points illustrated by this case:


  • Some patients will need more than 3 bandings (15% or so), and patients with significant leakage or severe Grade III disease tend to be among those patients. Extra bandings, when performed, are typically NOT a re-banding of a previously treated site, but more often are placed “between” two previous banding sites, to address some additional prolapsing tissue or a “minor pile”.
  • “External” symptoms are often successfully treated by banding the patient “internally”. This is in large part due to the fact that many/most of these “external” symptoms are truly the result of the internal hemorrhoids. In our clinic, 90% of these patients were successfully treated without ever addressing the external skin tags!
  • Patients’ histories are often misleading in these situations, including many complaints of “incontinence”. If the patient did not demonstrate good sphincter tone on anorectal exam, then attention would be given to the evaluation and treatment of true incontinence. In this case, however, the situation was due to the patient’s prolapsing hemorrhoid tissue, interrupting a good tight anal closure, allowing for fecal seepage. In this latter situation, addressing the prolapsing hemorrhoidal tissue will often improve or “cure” the leakage.
  • While statistically, Grade III hemorrhoids tend to be a bit more difficult to control using rubber band ligation (RBL), the fact that the morbidity is SO much less than it is after surgery, it is VERY reasonable to treat these patients with RBL. Consider the resistant cases for more invasive care if required.

This is obviously a summary of the major points of the case — if there are any specific questions that I can get into a bit more deeply for you, please let me know and I’ll be happy to provide any additional information you might need!

Additional educational resources for your practice!

In addition to our longstanding offer to provide no-cost physician-to-physician training and refreshers at your practice, CRH is happy to announce that these resources are in the process of being expanded! The first in a series of didactic presentations was posted on our WEBSITE in an attempt to respond to some of the more frequently asked questions that we receive, and there are more of these to come. ANDY and I would continue to invite you to contact us directly by cell phone or email if any questions pop up as well — we are always happy to support you in a “24/7” fashion.

We have received some very positive (and appreciated!) feedback from some of our Partners who have had their “mid-levels” along with their MA’s and office/ASC staffs attend our presentations. Those participants found value in learning about anorectal disorders, becoming more familiar with the procedures that their patients would be experiencing, and being able to address a number of their patients’ questions and concerns. For those of you that have NOT had this sort of an experience for their staff, we are happy to head back your way in order to work with them, and help to bring them “up to speed”. We’ve received particularly strong feedback from those midlevels attending the sessions, as their ability to evaluate, treat and refer patients appropriately has improved. If this is something that you would like to take advantage of, please contact ME and I will provide you with our availability!

We’re going to Disney World!

Actually we’re not — but we WILL be in Orlando this weekend for DDW, and in the Exhibition Hall from Sunday through Tuesday at BOOTH 1566! We will be demonstrating the use of the CRH O’Regan System® and have all of our support materials, videos etc. Please come by the booth and say “hello”! Andy Gorchynsky and I will be there along with a number of other CRH personnel, and we each are looking forward to seeing everyone there and answering any questions you might have.

Thanks again for your continued interest, and we hope to see you soon. Have a great weekend, and if you are heading to Orlando — safe travels!


Mitchel Guttenplan, MD, FACS
Medical Director
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953

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