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Banding Bulletin – October 2022

Banding Bulletin – October 2022

We hope that this edition of the “Banding Bulletin” finds you well! The folks at the home office told me that they wanted to publish this Bulletin in honor of October 19th, which is “National Hemorrhoid Day.” At first I called “BS” on that, but after looking online, it seems as if this is a thing . . . .so there you go! I don’t know if there is a specific gift that is appropriate for this occasion, and Hallmark didn’t provide any help at all, so I hope that this bulletin will suffice!

In this edition, we’ll invite you to visit with us at the upcoming ACG in Charlotte, talk a bit about contraindications to band ligation of hemorrhoids, as well as highlight our CRH Anesthesia team!

Join Us At The 2022 ACG in Charlotte:

In just a few days, the CRH team will be heading to Charlotte for the ACG Annual Meeting and we hope to see you there! Please come visit us at Booth 1019 as we’ll address questions, introduce our training, support and marketing services to any that are interested, and see how we can best support you and your practice in the weeks and months ahead. Our Anesthesia Team will also be at the booth if you’re interested in learning more about our flexible anesthesia partnerships. The Exhibition Center will be open Sun – Tue, Oct 23-25, and the CRH O’Regan System will be demonstrated during the Hands-On sessions on Monday (2:05pm-4:40pm) and Tuesday (1:45pm-4:20pm).

If you’ll be in Charlotte this weekend, we’d love you to stop by our Cocktail Reception on Saturday, Oct 22 from 5:30-7:30pm. We will be at the JW Marriott Charlotte – 600 South College Street – Floor 3/Room 303. RSVP here

Contraindications To Band Ligation of Hemorrhoids:

In the past couple of months, the most frequently asked questions surrounded one of the various contraindications to banding, so we thought that a summary here might help.  I’ll try to give some background behind each and will actually ask for some help from you to help better define one of them!

  • Pregnancy: Pregnancy has long been considered a contraindication to band ligation, but I have to be transparent in saying that, until today, I haven’t found anything in the literature regarding this one way or another. Previously, we haven’t seen anything that specifically states that it is dangerous to band during pregnancy, but we haven’t seen anything to show that it is safe, either. The concern is not over the possibility of teratogenesis, but rather of precipitating premature labor. Today, I came across a report out of Greece, just published in the Annals of Gastroenterology, that described 45 pregnant women in the banding group, with no pregnancy-related complications found. Obviously, this is a single report with a fairly small sample size, but it is nice to get at least a little help when it comes to this clinical question.
  • Portal Hypertension: This one has been around forever as well, but in recent years, it has become somewhat controversial. There are some who have looked at banding patients with cirrhosis and portal hypertension, and have determined that the incidence of significant post-banding bleeding was no higher in portal hypertensives. The concern persists, however that IF a patient with portal hypertension DOES have a post-banding bleed, it can be a catastrophic bleed.  For this reason, we still recommend caution in this patient population.
  • Proctitis: Band ligation obviously causes strangulation and sloughing of the banded tissue. This leaves an ulcer with resultant submucosal inflammation and fibrosis, which re-creates the fixation of the hemorrhoidal cushion that was lost, leading to the patient’s hemorrhoidal symptoms. Proper healing of the ulcer and resolution of the inflammatory process requires relatively healthy tissue to be present. For this reason, any sort of proctitis would be a contraindication to banding. Examples would include ischemic, post-radiation or IBD-related proctitis. The scariest scenario (to me at least!) would be a patient with pre-existing Crohn’s disease with colorectal involvement. Now, the literature does support the safe banding of a patient with ulcerative colitis which is quiescent, but no such assurances exist for folks with active disease.

Anticoagulants and RBL:

Then, there’s the most commonly asked question that we get . . . . what about patients that are taking one of the various anticoagulants? Unfortunately, there is more than a little controversy here as well, and not very much help in the literature, at least when it comes to the newest generation of anticoagulants. There have been many pieces written in regard to RBL and warfarin or clopidogrel, some with varying conclusions, but I’ve not found anything dealing with the Elliquis’s and Pradaxa’s of the world. In fact, we’d love to be able to provide some data here, and will be asking for help below.

If patients are to have a significant post-banding bleed, it is most likely to occur when the post-banding eschar separates from the underlying tissue (10-14 days), with a lesser “peak” incidence when the banded tissue sloughs (3-5 days). A significant bleed at the time of the banding would be VERY rare. So, IF anticoagulants are to be held for this procedure, we are not trying to protect the time of the banding (as opposed to what is done if something like a polypectomy is to be performed), but rather those 2 later time periods. It is for this reason that, a number of years ago, Nelson’s group recommended to stop the Coumadin or Plavix on the day of the procedure, keeping them off of the Coumadin for 7 days and Plavix for 10 days (this was all before the newer drugs were introduced). Frankly, holding anticoagulants for 7-10 days scares the hell out of us! Our feeling was always that we could easily stop bleeding, but we couldn’t stop an MI or a stroke! 

When looking at the literature at the time, there were many that declared RBL on either of these meds to be “contraindications” but most had very small sample sizes behind their conclusions. There are only 2 reports of any size that I’m aware of . . . . 1 report of 150+ bandings on Coumadin with only 1 post-banding bleed – that bleed coming from a coexistent fissure rather than from the banding site – and another with 84 patients, half taking Plavix and half not . . . .with bleed rates the same in both groups.

Considering everything above, we cannot make recommendations from CRH, but we can tell you how we handled these patients in our clinics. We would first contact whomever was responsible for the patient’s anticoagulation, as we sometimes received the message that the patient no longer needed to be on those meds! We would tell the patient to stop taking the meds and band away! If we were told that the patient DID need the medications (and again, we’re talking about Coumadin and Plavix here), we would adjust our symptomatic threshold for treatment, only considering patients with more significant symptoms, and we would certainly inform the patient of the potentially elevated risk of a bleed, and what might be needed if such a bleed occurred. If the patient was symptomatic enough and understands the potential of an increased risk, we’d move forward. Using this approach, I personally have had only 1 patient with an issue, (taking Plavix) bleeding twice after banding, not from the previous banding site but rather from a column that had yet to be banded!

Now, For The “New Stuff” – Can You Help Us?

There is nothing that we’ve found in the literature to help us with patients taking a DOAC, so we really aren’t any help here.  We do know that some folks are performing procedures on these patients out there but don’t have any data to look at.  If any of you are willing to share data, we’d love to do a risk analysis in regard to banding patients on these medications.  If you have the ability to glean this information from your records, and if you would be willing to share it with us, we’d love to be able to provide an answer to this very important question.  Please just ping ME, and we will make whatever arrangements would be necessary to proceed!

CRH Anesthesia Continues To Grow!

CRH Anesthesia is excited to announce its latest acquisition, our first in Arizona! This brings the number of ASC’s that CRH serves up to 98, in 18 states. If you are thinking about realizing some or all of the equity that you’ve built into your current anesthesia service, or if you currently outsource your anesthesia and would like to bring it “in house”, or if you are thinking about building a deep sedation program, please let ME know! We’ll connect you with our CRHAM team and see how we can help!

Last Line of Defense – Cybersecurity Protection

SecureSolutions Now is a managed cybersecurity service designed to provide clinics with the essential tools necessary to protect critical systems and patient information.

Read a recent blog post about anti-virus software HERE and learn more about how SecureSolutions Now can help you avoid a breach HERE.

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Thank you for checking out this edition of the bulletin. Please let us know if any clinical or operational questions come up – we look forward to hearing from you!  And, of course, most importantly, Happy Hemorrhoid Day!!

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