I hope that this issue of the Banding Bulletin finds you well! As it has been a while since we last sent out a Bulletin, we’d like to take this opportunity to review the most frequently asked question that we receive as well as to review the results of our yearly survey.
The most frequently asked questions that we receive involve the use of anticoagulants and rubber band ligation. I’ll try to summarize the recommendations that are out there, but I’m sorry to say that there is more advice available than there are facts to back up those suggestions!!
There are any number of authors who have suggested the discontinuation of anticoagulation in conjunction with band ligation. These recommendations go back several decades, when warfarin was about the only show in town, and had little to no data behind them! As newer agents became available, these recommendations followed. . . . . again, without much in the way of data. Today, the recommendations range from it being an absolute contraindication to a relative contraindication, to an author or two that don’t recommend discontinuing the meds at all. The most confusing part about the entire topic is the fact that the majority of the post banding bleeding that does occur, happens 10 days – 2 weeks out when almost all patients are re-anticoagulated!
I will include a few links to some of the papers supporting the information given here and here, but there are a few interesting reports that bear mentioning. Dr. Cleator, reported on 151 bandings performed on patients taking warfarin who could not discontinue their anticoagulation. After only 1 of these sessions did a patient have to be treated for bleeding in the post-banding period, and in fact the patient did not bleed from the banding site, but rather from a coexistent fissure!
The ASGE came out with a position paper, discussing the use of anticoagulants in patients requiring a number of different types of procedures. Band ligation was not specifically dealt with in the paper, but polypectomy was. Given the similarity between removing a polyp, and banding a hemorrhoid where that banded tissue looks very much like a polyp, it MAY be that the information might be applicable to what we are doing during a RBL. I did say “MAY” in big bold letters!! The paper also wisely discusses the fact that there are always risks associated with the discontinuing of anticoagulation, and those risks must be evaluated when considering how to approach these patients. Nelson proposes a novel approach, where the anticoagulants are discontinued on the day of the ligation, and keeping them off for 7 days with Coumadin and 10 days with Plavix, and then restarting the meds. This is an interesting idea as it may well keep the patient a bit better protected during the time when it is more likely to bleed.
With a lack of data sufficient enough to write down recommendations in stone, the Company is NOT able to make hard and fast recommendations in regard to all of this, but I certainly can describe my own practice to you, for you to evaluate and consider. I generally contact the doc responsible for the anticoagulant in order to get an idea as to the risk of discontinuing the medication vs. continuing on it. If it is safe to do so, then I will hold the Coumadin or Plavix, and if it is not safe to discontinue the medication, I will adjust my threshold for treatment, only banding those that have more significant symptoms. Of course, this would be after thoroughly discussing the potential risks, and consenting the patient appropriately!
Announcements will be going out soon, but our next set of webinars will be held on Monday 9/8. There will be 2 sets of sessions being held — both for our currently trained Partners as well as an introductory presentation for those of you that might be considering the addition of these techniques to your practice. Stay tuned, and more detailed information will be on the way!
CRH sent out its annual survey a few weeks ago in order to find out where we stand with our current users as well as to see what we can do in order to improve. Each year, I’m consistently blown away by the number of our Partners that respond, along with the quality of the suggestions and the feedback that we receive. This year was no exception, as we had our highest response rate ever! Some of the key results we received include:
Another rewarding point for us was the fact that our most recent trainees seem to be benefitting from our recent enhancements to the training program! Our new “follow-up” visits (that take place about 3 weeks after the initial training) seems to help reinforce the suggested techniques and treatment protocols, helping to increase the comfort level of the doc as well as their practice moving forward. “Advanced” sessions are still offered at no cost to those who are interested.
To that point, if we can come back to your practice in order to help give “refresher” sessions, train new partners or friends, please contact ME and we’ll get you on our calendar!
The winner of the $500 gift card to Best Buy is Teresa DiMaria. Thanks again to all who participated in the survey!
And thanks for taking a look at this month’s Bulletin! Please let me know if I can help with anything at all, and have a great day!
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953