CRH Anesthesia Interview in Becker’s ASC Review
2017 has been a tremendous year for CRH Anesthesia! We have now completed a total of 15 acquisitions, providing service in 35 ASCs in 7 states, and have launched a MAC development program in an 8th state! CMS recently issued its final rule on 2018 reimbursement, bringing to light some of the potential challenges of running a GI Anesthesia Program. This is where CRH’s expertise really comes into play, helping you to maximize the value and success of your program.
Jay Kreger, President of CRH Anesthesia, addresses some of these points in a recent interview published in Becker’s ASC Review. Read the interview HERE.
Case Presentation
At a recent training session, a 45 year old woman presented with complaints of “hemorrhoids” with periodic mild bleeding, more frequent itching, and more severe issues when her hemorrhoids “flare up” every couple of months. The patient had no pertinent past medical or surgical history, was on no meds, and had no known allergies. Her bowel habits were described as “pretty normal” except during “flare-ups”, when she would typically experience a bout of constipation or diarrhea. Further questioning revealed that during these “flare-ups”, the patient experienced more pain than usual, along with bleeding and itching. Colonoscopic examination performed 2 months earlier only revealed hemorrhoidal changes.
Based on the patient’s story, we anticipated finding an anal fissure, as in our experience, this is the most common diagnosis in patients complaining of flare-ups. On careful visual examination, however, a 2-3mm reddish “spot” was seen 3cm antero-lateral to the anal verge on the patient’s left. Palpation of the area demonstrated a bit of induration deep to the “spot” and some additional subcutaneous induration was noted from that spot heading back towards the introitus. Digital exam did not reveal evidence of a fissure, but a point of induration was noted approximately 2cm from the anal verge at the same radian as was the area of induration. Anoscopy revealed grade II hemorrhoidal changes and the area of induration was not well-defined visually.
So, this patient had a fistula in ano, which was quiescent at the time of examination. Because of this, there was no open sinus tract noted, nor were there signs of abscess or other acute inflammation. The fistula was closed at the time, but because the entire tract was never obliterated, it was only a matter of time before it would get inflamed and open and drain again. This process is what the patient assumed was her hemorrhoids “flaring up”. As there was no evidence of Crohn’s, cancer, etc. on recent colonoscopy, a surgical referral was initiated.
When a fistula-in-ano is noted, we should make certain that neither IBD nor CA is present, and keep in mind that often endoscopic examination is not very helpful in identifying the internal fistula tract. When searching for the internal orifice of the fistula, “Goodsall’s Rule” states that a fistula with an opening anteriorly within 4cm of the anal verge typically communicates directly with the anal canal along the same radian, while more remote fistulas anteriorly as well as posterior fistulas typically communicate at the posterior midline. Of course, there are exceptions to this rule, and “all bets are off” when dealing with IBD!
We’d love to visit with you!
If you’ve never been trained in the use of the CRH O’Regan System, our team is standing by to provide you with any information you might need, and to schedule a training session at your office! One of our surgeons will provide didactic information followed by a banding session where you will start treating patients that you’ve gathered for that day. Our Clinical Support Specialists will follow up for another session, and then we are available to support you in any way that we can.
For those Partners currently utilizing our technology, we are also anxious to visit with you in order to address any questions you might have, to help in the evaluation and treatment of any of your “stubborn” clinical cases, to provide refresher sessions, etc. Please let ME know and we’ll get you on our calendar!
Happy Holidays and Happy New Year!
It’s hard to believe that it is December already! All of us at CRH would like to thank you for your support and kindness, and to wish you and yours the happiest of Holiday seasons, and a healthy, happy and prosperous New Year! We look forward to catching up with everyone in 2018!
