Banding Bulletin – September 2021

Banding Bulletin – September 2021

We hope that this edition of the “Banding Bulletin” finds you well!  This go-around, we are going to address a couple of FAQ’s that we routinely receive, announce some new support resources available to you and your practice as well as to update you on CRH Anesthesia’s progress.

FAQ’s: Post-banding Pain.

By far, the most frequent question that we receive involves patients with hemorrhoid symptoms that are also taking one of the many anticoagulants that are out there.  We’ve dealt with this in previous Bulletins, and will link to that discussion HERE.

The second most common topic includes discussions regarding the management, and more importantly, how to avoid post-banding complications.  Broadly described, the potential complications of band ligation include post-banding pain, post-banding bleeding, urinary symptoms, and the extremely rare case of infection.  All of these combined, should occur in less than 1% of your patients.  The most frequently occurring of those would be post-banding pain (again, less than 1% incidence).  This can occur almost immediately after the banding, or several days down the road.

Assuming that the patient is a good candidate for banding today, the most common reasons for immediate post-banding pain are:

• I banded too “low”
• I banded too “much” tissue
• I banded too many columns

If the patient is tender to examination (most commonly from a coexistent fissure), then, in our opinion, the patient isn’t suitable for banding today.  We look at the DRE as a good “stress test” prior to banding.  If the patient is really tender from the DRE, then you KNOW that they won’t be happy after being banded.  These patients should have the cause of their pain (again, most commonly a fissure) addressed, and in a few days to a couple of weeks, that patient will likely be ready to go.  If the patient does well with the DRE, and if it is a first visit, then the next “stress test” is the anoscopic exam.  If both of these are tolerated, and if the banding is indicated, we move on from there.

When banding the patient, following the suggested technique should make sure that the band is placed nice and “high”, and the post banding DRE should make certain that you haven’t banded too “much” tissue (additionally, it can certainly free some of that tissue up if warranted), and by limiting your banding to a single column per session, the risk of post banding pain should be minimal.  To further limit the occurrence, there are a few “tips and tricks” that we’ve identified over the years, which are easily incorporated into your practice:

• The “spiel”.  Most patients expect this procedure to be painful, and frankly, if they leave your office with just a “little pain”, they are going to be feeling much worse later on.  Spend a couple of minutes making certain that the patient understands that they should experience absolutely zero pain, and zero “pinching” after the banding.  Some mild pressure, or a feeling of needing to defecate is common, but pain/pinching is not.
• Wait a few minutes before discharging the patient.  It takes some patients (especially after the first banding) a few minutes to get a sense of what is going on after the banding.  If the patient hustles out of your office, don’t be surprised if they’re halfway home in the car, and need to turn around and come back to the office for an adjusting DRE! 
• Make sure that whoever signs your patient out in the office knows to make doubly sure that the patient is in no pain.  If the patient looks uncomfortable, then they should place the patient back in an exam room for DRE and manipulation of the banded tissue.
• Have some NTG or Ca-channel blocker ointment in the office.  Every now and again, the patient will have significant spasm of the internal sphincter or puborectalis after a banding, and we’ve had great success in relieving some of this with a DRE and a dab of NTG ointment (“off-label alert”!!).  In our practice, we had gotten to the point of using a dab routinely when doing our initial DRE, which seemed to help patients tolerate everything much better (again, “off-label”!!)
• Aggressively treat even minor fissures and patients with “tight” canals concurrently with the banding.  We’ve found that this tactic keeps the phone from ringing with issues from these patients (still “off-label”!).

We learned with time and experience, that if we were wondering whether or not we should adjust a deployed band – we should adjust it.  And, if we wondered whether or not a topical would be helpful – we should prescribe it (yes, still “off-label”).  These tips went a long way towards having the overwhelming majority of patients happy and healthy after their bandings.

I should mention here that we have a resource online titled “Information Sheet for Cross-covering Physicians”.  This has information describing how to deal with the vast majority of patient phone calls and we recommend giving everyone that might connect with your patients access to this resource in order to help address their questions.  The form also has our contact information, should the on-call person want to speak with someone for more information.

We will deal in more detail with management issues in future Bulletins, but if you need questions answered about this or any other topic now, please contact ME.

Additional Educational Support Offered:

Next month, the ACG is meeting in Las Vegas, and it will be both an in-person as well as a virtual presentation.  The ACG is typically the venue where we are best able to catch up with our banding Partners as well as with folks interested in being trained.  Not knowing how many folks will be attending in person, we want to make sure that we try to connect with as many of you as we can.  With that in mind, we are offering quick “Zoom” sessions with any of you that have any questions, would like to provide any feedback, are interested in bringing these procedures into your practice, etc.

If a conversation with Andy Gorchynsky or myself would be helpful in any way, please let ME know and we will set up a time to speak.  Thus far, some of the conversations have been as quick as 5 minutes, and in others, we’ve basically reviewed all of the material from our original didactic – whatever we can do to help!

CRH BandLeader

In our last newsletter, we introduced BandLeader – a new turn-key program developed to allow you to help more patients without increasing strain on your practice and staff. If you would like to learn more about this program you can do so here or by talking to us about how BandLeader could work for your practice.

CRH Anesthesia Management:

CRH Anesthesia has been very busy and continues to grow.  As of our last transaction (our 37th), CRH is now providing anesthesia services in77 ASC’s around the country!  We are continuing to expand, and would love to talk to you if:

• You currently have an in-house anesthesia program, and would like the program to grow as well as to realize some or all of the equity that you’ve built into that program.
• You currently out-source your anesthesia services, and would like to bring those services “in-house”.
• You currently are utilizing conscious sedation, and would like to build a deep-sedation program.

If you fall into any of these categories and would like to learn more about the benefits that CRH Anesthesia can provide to you, please let ME know, and I’ll ask the appropriate person from the CRHAM team get back to you.

Thanks, as always, for reading this edition of the Banding Bulletin, and for your continued support.  Please let us know if we can help in any way, stay safe, and we’ll hope to catch up with you soon.