We hope that the “pre-DDW” edition of the Banding Bulletin finds you well! This month, we will re-visit the topic that we are most frequently asked about — anticoagulants and band ligation of hemorrhoids. We will also extend an invitation to visit with us in Washington for DDW.
We receive questions regarding the use of these drugs in patients who would benefit from rubber band ligation (RBL) of their hemorrhoids on an almost daily basis. Unfortunately, the situation is not much different from what was reported last year, as there are a number of suggestions out there without a whole lot of data to back any of them up! I will try to summarize things below, and then (for what it’s worth!), relay our own practices.
At one point, we only had warfarin to worry about, and despite the lack of sufficient supporting data, most authors considered its use to be at least a relative contraindication to RBL(*). Later, clopidogrel came onto the scene, and so it was considered by many to be a contraindication as well — and again, without much supporting data! The studies that I’ve found have all been retrospective in nature, with very small sample sizes, and often with results that did not reach clinical significance. The cautions (some will say contraindications) surrounding RBL in patients on these medications do however need to be considered from both a medicolegal as well as a clinical perspective. This all being said, many of the recommendations out there are puzzling given the following information.
• RBL has been shown to cause bleeding immediately, in several days when the tissue sloughs, and at 10 days – 2 weeks when the eschar separates from the ulcer bed(*). To date, we are unaware of an immediate bleeder using the CRH technology(*), likely because of the gentle suction generated by the device as opposed to the more conventional grasping devices used in the past. Why would we stop anticoagulants days ahead of the procedure, starting them soon thereafter if patients as a rule do not bleed at the time of the procedure?
• Dr. Cleator has banded 151 times with patients on warfarin, and there was only 1 post-procedural bleed — and that was not actually from the banding site, but rather from a coexistent fissure that needed to be cauterized.(*)
• Patients are on their anticoagulants for a reason! Depending upon the reason for the anticoagulation, there may well be a significant risk to the patient if these medications are held. If it is difficult to prove a significantly increased risk of bleeding by banding patients on these meds, it would be equally difficult to explain any complication that would be the result of holding these meds!
• There really is NO good data that I’ve been able to find surrounding the newest generation of medications, and so I really can’t comment in regard to this subset of patients.
Nelson’s group (*) gives what I see as being the most reasonable protocol for holding patients’ meds if that is your practice, as they hold the medications beginning on the day of the procedure, so they are not being held for an extremely long period of time, AND the patients are actually protected at a time when they are more likely to bleed!
Because of the controversy surrounding this topic and the lack of significant randomized controlled studies being performed, CRH as a company is certainly not able to make any recommendations (other than to issue the required cautions), but I can pass along Andy’s, Jarrod’s, and my practice, along what I’ve heard from a number of partners in the field.
I have heard everything from practices where they simply won’t band people on anticoagulants – period, to practices that do not stop the medications on anyone! In our own practices, we would ask the physician in charge of the patient’s anticoagulation if the meds could be safely held. If we were told “yes”, then we’d hold the patient’s meds beginning on the day of the ligation, following Nelson’s recommendations. If they told us that it was unsafe to discontinue these meds, then I would “adjust my threshold” for treatment. If they had milder symptoms, then I would consider amping up the conservative treatments available until the time came when we could temporarily hold their meds. If they had significant symptoms (which can be made worse by those same anticoagulants), then we would do a “risk/benefit” analysis and if there were compelling enough reasons to treat, we’d certainly do so after thoroughly discussing these risks with the patient.
(*) References available on request.
DDW Begins this Weekend!
For those of you traveling to D.C. for the DDW this week, CRH will be represented in full force at the conference, as we’ll be available during the “hands-on” hemorrhoid treatment sessions on Saturday, and then in the Exhibition Hall at booth # 1026 from Sunday through Tuesday. If you are in the area, please drop by and say “hello” – we’d love to hear how everyone is doing and address any clinical questions you have.
Alternatively, if you are interested in introducing the CRH O’Regan System into your practice or would like to learn more about our anesthesia services, please come by as well and we’ll make sure you have all the information you need.
We will also be able to schedule a visit to your practice for a new training session, an “advanced session”, or simply to work with your practice in order to see if we can provide any clinical or operational support.
Safe travels and we hope to see you in Washington!
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953