We’ve put together these clinical pearls to share our experience offering the CRH O’Regan System with all participating physicians. Select a quick link, or scroll to read all pearls:
- Use the 0.125% Nitroglycerin ointment* liberally, particularly with patients with anal sphincter spasm, pelvic floor spasm, and while the patient is recovering from their thrombosed external hemorrhoids in addition to their anal fissures. Caution the patient to lie down when applying the ointment, and to avoid taking erectile dysfunction medications such as Cialis, Viagra and Levitra while they are taking these nitrates. A pea-sized amount of the medication should be placed just inside the anal verge, so that the medication is able to contact the area of the internal sphincter. If the patient is hesitant to use their gloved finger to administer the ointment, then a bit of the medication may be placed on a suppository and then inserted — using the suppository as an “applicator” of sorts. For a patient with a severely tender fissure, we have seen positive results by using a short course (10 days or 2 weeks maximum) of a steroid-containing suppository — the suppository will help treat the fissure’s inflammation and helping with the associated symptoms.
- NITROGLYCERIN IS YOUR FRIEND*! One of the most frequently overlooked issues is that of a coexistent fissure in your symptomatic patients. YOU DO NOT NEED TO SEE A FISSURE IN ORDER TO KNOW THAT IT EXISTS! If the patient is tender in the midline (usually posteriorly), and if the patient does not have a fistula or an abscess, then for all practical purposes, THEY HAVE A FISSURE! If you feel an area of thickening, a “ridge”, a “seam,” or any other evidence of prior or concurrent inflammation in the midline – THEY HAVE A FISSURE! Failure to address this will severely impact your success rate in treating these patients. Dr. Cleator goes as far as to give NTG to virtually all of his patients, as he notices that there is less pain experienced by the patients, and he feels that the resultant ulcers heal a bit quicker with routine use.
- TRY TO ESTABLISH A RELATIONSHIP WITH A COMPOUNDING PHARMACY NEAR YOU! We have several that we deal with that are aware of the meds that we will be prescribing, and because they are able to mix up the NTG in bulk, it results in a significant cost savings to the patients.
* “off-label” usage. Reference: Guttenplan, Mitchel. Anorectal Topicals – White Paper. January 2015
Thrombosed external hemorrhoids
- These typically only need an I&D if they present within the first 24-48 hours of the onset of symptoms. After 48 hours (some authors use 72 hours as their cut-off) the clot begins to organize, and is more difficult to enucleate. There is literature to suggest that an incision and drainage of a more chronic thrombosed external hemorrhoid may actually DELAY the patient’s recovery! For this reason, we treat these more chronic patients with topicals (NTG for the associated spasm* and a topical anesthetic for pain relief).
- Placement of typical hemorrhoids: With the patient in the left lateral decubitus position, the Left Lateral hemorrhoid will be at 6:00 (as you are looking at the patient in the LL decubitus position), the Right Anterior hemorrhoid at 2:00, and the Right Posterior hemorrhoid at 10:00.
- “Blind” placement of the band: This is truly not “blind,” as you have already seen and palpated the hemorrhoids. Use an examining finger to help introduce the bander, so that the forward edge of the bander does not catch any of the soft tissues, which would cause discomfort to the patient. Advance the bander further in than it will ultimately need it to be, and pass it along the direction of the rectal lumen (usually parallel to the patient’s spine). Draw the ligator back to the point where the band will be deployed, and only then “point” the ligator towards the hemorrhoid column in question. This point can be estimated by utilizing the ridge on the “band pusher” as if it is at the anal verge, then you should be in a satisfactory position, proximal to the dentate line. The ability to sense that the tip of the bander is at the “L-angle” of the rectum will help to confirm the placement of the bander.
- Do NOT “push” the ligator up towards the pile in question, as if to “reach out” to the tissue, as this often makes it more difficult to obtain a satisfactory amount of tissue. Simply aiming the device in the correct direction will allow that tissue which is most prominent and already filling the lumen to be captured by the syringe. LET THE LIGATOR DO ALL OF THE WORK FOR YOU – the more effort that you put into obtaining tissue, the less successful you will be!! If you do not obtain tissue on this first positioning of the ligator (evidenced by the syringe plunger retracting when letting go of it after aspirating), do not push on the ligator, but rather just increase the angle at which you are holding the device.
After deploying the band
- After deploying the band, a digital exam is performed to make certain of four things:
- You have banded a sufficient amount of tissue
- There is no muscular entrapment
- The diameter of the neck of the “pseudopolyp” that was created is fairly narrow, minimizing the size of the resultant ulcer, and minimizing the chance of post banding bleeds.
- The patient does not have a pain or “pinching” sensation.
- Manipulation of the banded pile: We recommend that you manipulate the banded pile routinely after deploying the band in order to assure that the banded tissue is free from the muscularis. The pile should slide and move much like the skin on the dorsum of the hand, rather than like the skin on the palm of the hand. Care should also be taken to make certain that there is no entrapment of surrounding mucosa away from the pile. A sense that the band has a fairly narrow diameter, and that the “neck” of the pile makes the tissue feel as if it is a small pedunculated polyp will help to minimize the risks of pain or bleeding. IF THE PATIENT HAS PAIN AFTER BANDING then a more “vigorous” manipulation is required, and using the finger to “pull” the base of the banded tissue from the right, the left, and from the proximal side of the pile, as well as “pushing” the pile from below will typically free up the necessary tissue and relieve the discomfort. If the patient is still uncomfortable, the examining finger should be used to “roll” the band a bit. If the band was placed too “low,” and below the dentate line, then do not try to “adjust” the band, rather pop it off, using two fingertips if necessary.
- Have your patient wait around a few minutes after a banding, just to make certain that they don’t feel a pain or “pinch.” If there is a pinching sensation, then you must adjust the band, or pop it off if necessary. Otherwise that pinch will become more severe. If the patient leaves without that “pinch,” then less than 1% of your patients should experience significant pain.
Best practices to avoid complications
- If the patient has a fissure (usually posterior – or at the 9:00 position as the patient is lying down in LL Decub), stay away from that hemorrhoid until the fissure is significantly healed, even if the RP hemorrhoid is the most severe one. Start elsewhere (RA or LL), and come back to the RP in a subsequent visit. The same holds true for the patient with a thrombosed external hemorrhoid. Stay away from the corresponding internal hemorrhoid until the external component improves. If the patient is really miserable with symptoms from either a fissure or thrombosis, then begin medical management of these problems and defer banding for a week or two.
- Band one column of hemorrhoids at a sitting in an effort to minimize complications. Avoid banding anyone on Coumadin or Plavix. Also avoid pregnant women and patients with signs of portal hypertension or any active proctitis (including Crohn’s, radiation, ischemic, etc.).
- Realize that many people will have cutaneous yeast infections in response to the mucoid deposition on the perianal skin from their internal hemorrhoids, and the constant wiping and trauma to the skin that occurs…use antifungal creams liberally (I use Lotrisone cream with an added corticosteroid). If this is not successful, then I will utilize a 2 or 3 day course of Diflucan. Patients should avoid using soaps, scrubs, special wipes, etc. in the perianal area, as these tend to worsen the condition.
- TAKE ADVANTAGE OF THE SUPPORT OFFERED BY CRH! Feel free to utilize our 24/7 professional support along with the marketing, operational, billing and coding support that is available to you from CRH. We are also happy to plan for a refresher training session for you after you’ve had some experience with the Technology. Most that arrange for these follow-up session report that there was a significant benefit realized. This is all provided at no cost to you, so please take full advantage of it.