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- [00:00]
A
Welcome back, friends. You are listening to the Juice Box Podcast. Hey, everybody, it's Scott. I am here to let you know that today's episode is a little different than normal. I'm having a conversation in this one with Aaron Shiloh. He is a doctor who just performed a procedure for me. We'll tell you all about it in a second. It's one of those things that I hope you don't need, but if you do, you're gonna really, really be happy that you've heard about this. Dr. Shiloh doesn't just do what he did for me, does a couple of other things. We'll talk about those as well. So if you're a woman experiencing fibroids, if you have varicose veins, he does a lot of cool stuff besides what he did for me. It's actually very interesting how he takes his talents and his skill and applies it to places that you might not normally think about anyway. I don't want to ruin the fun for you until you jump in and hear the whole story, but I appreciate you being here and listening to this. I hope this isn't something you need, but if it is, pay attention because Dr. Shiloh really saved my ass, and he might be able to help you, too. Nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan. This episode of the Juice Box Podcast is sponsored by USA Hemorrhoid Centers. Go to usahemorroidcenters.com to learn about the procedure that I had and much more. Don't let this be a pain in your butt any longer.
- [01:43]
B
Hello, my name is Dr. Aaron Shiloh. I am an interventional radiologist working out of USA Clinics group, performing many different types of minimally invasive treatments. I'm happy to be here today to discuss various treatments that we offer, probably with specific attention to the hemorrhoid treatments that we offer.
- [02:06]
A
Yeah, Dr. Shiloh has been my physician, is my physician currently, and we're going to talk about what I had done with him as well. So I really appreciate you doing this. This is a little bit of a left turn for the podcast about what we're talking about, but I feel like it might be really important for people to hear, so I appreciate you taking the time. Thank you very much. Sure. Why don't we start with a little bit about how you. I mean, let's go back all the way. You leave high school, go to college. What do you go for? What's the process of. Of becoming a Doctor. And how do you land where you are now?
- [02:40]
B
Sure. So, you know, I always wanted to be a doctor. And I went to PEN here in Pennsylvania and studied biology and pre medicine in the University Scholars Program. And now it's called Shrier's Honors College. From there, I was fortunate enough to attend the University of Pennsylvania Medical School. And at that time, I wanted to be a brain surgeon, interestingly enough. And I sat through a couple 12 hour brain surgeries and realized that though I loved it, it was too much for me in terms of time and procedures. So I decided I was going to go into general surgery. And when I finished my medical school training, I started into general surgery again at the University of Pennsylvania. In my surgery training, one of the places I had to go to every day, literally every day, was radiology and interventional radiology. And as someone who grew up loving video games, I got to go down to interventional radiology, otherwise known as ir, and ask them to help out with different problems that we had as general surgeons. And I literally was there every day and I was like, wow, this place is cool. They're doing some really amazing, cutting edge things through tiny little pinholes. And it felt a little bit like watching them do it, like playing a video game in the human body. And. And I was like, wow, this field is new and advancing medicine. And I thought, well, this may be what I really want to do. And so I transitioned from general surgery into wanting to pursue a career in interventional radiology. Now interventional radiology has its own residency, but back then it did not. And so I ended up having to leave the University of Pennsylvania and go to Thomas Jefferson University, also in Philadelphia, and start a radiology residency. And during my residency, I got into interventional radiology. And then, then I was selected to be the chief resident at Jefferson in intervention and radiology. I'm sorry. And then I started my interventional radiology fellowship again in Jefferson, and then, you know, finished that as well. And once I was done at jeff, I took a job with a private practice group in the Philadelphia area and quickly became the chief of interventional radiology for one of the largest private practice groups in the United States. And we were doing some really amazing things, and at one point was in charge of 15 doctors, multiple physicians, assistants, and covering about 12 hospitals.
- [05:23]
A
How long ago was that?
- [05:26]
B
That was basically from 2003 to 2017.
- [05:31]
A
Okay, so in 2003, when you say we were doing some pretty amazing things, what did that mean back then?
- [05:37]
B
So there was a lot of things that we were Doing that are things you don't know about. It was actually fascinating. I was watching the pit recently, and they actually referenced interventional radiology. And we're always, like, in the shadows. No one ever talks about us. But, you know, things like patients coming in with a bleed from their colon or from their gut, and we can go in through a tiny hole in an artery and find the source of bleeding and put a little metal plug in there and stop the bleeding, known as a GI bleed. That's basic biopsies. Things like many people need a thyroid biopsy or a lung biopsy or kidney or liver biopsy, using CAT scans and ultrasounds and X rays to perform procedures on people. One of the things that I was actually most skilled at and became the leader for my group is using my techniques to do minimally invasive cancer treatments, like ablations of liver tumors, lung tumors, kidney tumors. So instead of taking out kidney cancer, for example, you can put a needle in the tumor, hook it up to a machine and turn it on, and watch the kidney cancer completely disappear from there. We had this other really neat thing where if people have metastatic disease to the liver or col. Or liver cancer from cirrhosis, you can embolize the liver using different techniques, sometimes particles, sometimes chemotherapeutic agents. And the thing that I really ended up pushing forward, at least in the community around Philadelphia, was radioactive bead embolization. So you can actually put in small glass particles that contain. Or that can be made of resin as well, but small particles that contain a radioactive substance called Yttrium 90, and that you can then impregnate tumors with radioactive beads, and they will then radiate tumors from the inside out. So at that time, it was being done in only a handful of places around the United States when I first started, and I brought that to the local Philadelphia area, and over the years, did hundreds and hundreds of treatments on many, many patients.
- [07:41]
A
So then how do you. Well, I guess we should list first. What are all the procedures that you do right now in your clinic that
- [07:49]
B
works with sort of the transitioning? So then around 2000, actually around 2014, I opened up my own vein practice. In addition to doing this other job, I was also one day a week running my own practice treating patients with varicose veins, doing superficial vein treatments, again using ablation and minimally invasive treatments. And around 2018, I was offered an opportunity to go to the outpatient world and move my vein practice to someone's office and start doing some of the treatments that I do in the hospital in an outpatient office setting. Unfortunately, that didn't work out for various reasons that are not relevant to this discussion at the moment. But we basically proved that you can do the same procedures that were done once in the hospital that were super complicated, could be done in an outpatient office setting. So then I eventually joined my current company, USA Clinics Group, around 2020. So now five years. And at this group, we do treatments for varicose veins, for women's fibroids, an embolization procedure where you kill the fibroids with small particles, like I was describing, in the liver. And then we started doing a new treatment called hemorrhoid artery embolization. And also we do treatments. I do treatments for patients with knee pain and osteoarthritis called the genicular artery embolization. I embolize people's prostates if they get enlarged, a very common problem, bph, and then also some arterial disease, peripheral arterial disease. So if you have a narrowing in an artery in your leg, you can open it up with balloons and stents. So basically now I do vein treatments, treatments for fibroids, treatments for hemorrhoids, treatments for knee pain, prostatic enlargement, and. And peripheral arterial disease.
- [09:40]
A
So you're basically either capping something, cleaning, clearing something, or delivering something. The technology is that right?
- [09:50]
B
That's about right. I mean, you know, in vein disease, mainly, we're closing problematic veins. In arterial disease, we're opening up arteries that are not. The blood isn't flowing through them. And then in our embolization procedures, like the hemorrhoid embolization, fibroid embolization, genicular artery embolization, prostate embolization, anything that's an embolization is a procedure where either particles, small particles, or metal plugs called coils are delivered via a small catheter to the area of interest to block the flow to that structure.
- [10:25]
A
When we're talking about a fibroid. So if a female develops a fibroid, they used to just. They just take them out usually, right? So they. Now you're going to go in there and do what to it? Like, does it come out? Does it get shrunk? Does it. You know, what's the recovery time like? I'm interested in that procedure specifically.
- [10:43]
B
So that's a wonderful question. I could talk about fibroids for an hour as well. But the fibroid embolization is not a new technique that started in 1995 in Los Angeles, and I personally been performing them since 1998. So a couple Thousand in my. You know, in my belt. So to your point, most women with fibroids are treated, unfortunately, still to this day in the United States by hysterectomy. There are 400,000 hysterectomies done in the United States every single year. The vast majority of them are on patients with benign fibroid disease. Some of them are for cancer, and those, of course, need to come out. But for fibroid disease, you absolutely don't need to have your uterus removed. The equivalent is, to me, is that historically, you know, years and years ago, if you had heart disease, what would happen? You'd have your chest opened up. You'd have triple quadruple bypass. We probably both know plenty of people who had open heart surgery. We all now know that the standard of care is a minimally invasive approach. So most patients now can be treated through a catheterization of an artery and opening up the artery in the heart. So in heart disease, we've moved to a less invasive treatment option. In a fibroid embolization, we catheterize an artery either in the wrist or the leg. Like the hemorrhoid embolization.
- [12:01]
A
Right.
- [12:02]
B
And we inject small, inert plastic beads called embospheres into the fibroids. The fibroids are benign tumors, and so they don't have to be removed, and they will shrink, just like you said, they shrink. I like to refer to it as like a grape into a raisin. So they dry up and they desiccate. So in my hands, most fibroids shrink under after the procedure by about 70 to 80%. So think of like a tennis ball going to a golf ball shrink. They don't completely disappear. On rare occasion, the fibroids come out of the body. But, you know, these are individual things that we discuss with patients when we look at their imaging, their ultrasound or MRI prior to their procedure.
- [12:44]
A
So if somebody's having, like, a blockage or a urinary issue around a fibroid, it's possible that doing this to it would shrink it enough to maybe relieve the issue they were having.
- [12:54]
B
Oh, absolutely. Most women with fibroid disease are in their mid-40s. The most common symptom women experience is heavy menstrual bleeding. Many, many women suffer from years with this problem because they don't want their uterus out, they don't want a big abdominal surgery, and they aren't offered any other options. And thus they don't know about it, and they keep suffering. I have countless women I treated one yesterday whose hemoglobin was 4, you know, normal, being 12 to 15. And she's allowed to bleed down, bleed down, bleed down, get blood transfusions, iron transfusion, et cetera, et cetera, et cetera, all because no one said, hey, maybe you want this procedure to stop this bleeding. And so inevitably, at least currently, most of the patients arrive at my door 3 through things like this, podcast, social media, et cetera. They hear about it, they find out about it, and they come to us
- [13:45]
A
directly after this embolization. Then the fibroid doesn't bleed any longer.
- [13:49]
B
Right.
- [13:50]
A
Okay. Wow, that's awesome.
- [13:52]
B
Fibroids that bleed. So in fibroid disease, there, it depends on the location of the fibroid. Fibroids are classified in basically three separate locations. Submucosal, intramural, or sub cirrhosal. And depending upon the location of the fibroids, determines the symptoms that they're having. So I always tell women that fibroid disease is like real estate. You know, the famous quote, location, location, location. So depending upon where the fibroids located will determine the symptoms, not so much how big they are. So a big fibroid on the outside of the uterus, on the front will squish the bladder and make women pee over and over and over and over again. Every 20 minutes, they feel like they have to pee. That same fibroid inside the uterus will give them heavy bleeding. That same fibroid on the backside of the uterus will push on their colon and give them constipation or low back pain. Low, down and near the cervix will give them pain during sex and on and on and on. So depending upon the location of the fibroid, you know, determines the symptoms. Many women have multiple fibroids, and thus they come in with numerous symptoms. Bleeding and pain and pressure on their bladder, et cetera, et cetera, et cetera. Some women's uteruses grow to as big as five months pregnant.
- [15:00]
A
Wow. With the five now, do you do imaging prior to the procedure or do you find them during the procedure? Let's be honest, some health issues don't make it into your family group chat conversations. But that doesn't mean they're not affecting your day to day life. This episode is sponsored by USA Hemorrhoid Centers and they're changing the game with Hemorrhoid Artery embolization, a non surgical, minimally invasive treatment that targets hemorrhoids. Without the horror stories people usually imagine. No major surgery, no long downtime, just a smarter outpatient option. They've got multiple locations across the US and they accept most insurance plans. So help might be more accessible than you think. If this is something you've been avoiding dealing with, consider this your sign. And take it from me, as I know firsthand how life changing this procedure and company is. Check them out@usahemoroidcenters.com no.
- [15:58]
B
Most women, when they come in, either have had an ultrasound beforehand or we do one on site. And then as needed, we order MRIs to better evaluate the fibroids that used to be the standard of care. We found that it doesn't change our management all that much. So there are occasions where I get MRIs and they give beautiful pictures and they really help me see. But when we do the fibroid embolization, we target the entire uterus. So if you have one fibroid or you have 25 fibroids, it's irrelevant. They all get treated at once.
- [16:28]
A
Yeah. And I guess the million dollar question here, is it covered by insurance?
- [16:32]
B
Absolutely. This procedure has been validated. Unfortunately, you know, some procedures like we're going to discuss are validated, but just quote unquote, not enough for certain insurers to cover them. How they make this decision is not something I'm can really sort out. But my gut is that it's a financial decision more than anything else. And the type of studies that are being asked for required are nearly impossible to get enough data on. But UFC, since it's been around for 30 years, has had numerous studies.
- [17:08]
A
I'll talk a little more about that in a second. What's the recovery time from the fibroid procedure?
- [17:13]
B
You know, the UFC is actually a really amazing procedure. Now I do them in an outpatient basis and because I do a lot of them, they take about 20 minutes to do.
- [17:22]
A
Okay.
- [17:22]
B
The procedure is painless, done with sedation, which you can speak to a little bit about, but the recovery is a little bit more intense. It does take a good week to recover, the first couple of days.
- [17:33]
A
That's pretty great. Man. I can't. I can't tell you how happy I am to have met you. I'm going to go through a couple of the other ones before I get to me. Varicose veins are, is that, is that a, is that an insurance thing or is that considered cosmetic?
- [17:47]
B
I'm glad you asked that. So medical vein disease treatments are covered by insurance. It's no different than heart disease. It's an actual structural problem in the valves in your superficial veins. It's a very common Misconception, not just by patients, but by primary doctors and everybody, that it's just a. It's just cosmetic. And I can't tell you how many patients who have suffered for years with varicose veins on their legs and swelling and discoloration who are not sent by their primaries, because I'm sure they suspect that it's just cosmetic. And so vein disease is a medical problem. There is also a cosmetic problem, and we treat that as well. But medical. Vein disease is, in fact, a medical problem.
- [18:28]
A
Well, so the way I found you, and this is going to be. I know it's not going to be tough for me because I've practiced by talking about it in another episode. But, you know, you and I have talked about it, and I've talked about it here. It's interesting if I would have told somebody that periodically, two, three times a year, almost randomly, I started bleeding uncontrollably for a number of hours, and I couldn't stop it until it decided to stop. People would be horrified by it, and they, you know, they'd have a ton of compassion when you tell them that it comes from, you know, your rectum. Then all of a sudden, it's funny, you know, like, oh, you have hemorrhoids. And for my, you know, a lot of my adult life, that's kind of just what I thought. I thought, oh, I have hemorrhoids. Like, you know, and I did all the things, anything you can think of that somebody tells you do for it, I've done it. And I mean, from, like, simple creams and salves to, like, you know, baths and Epsom salt and significant dietary changes, significant weight loss. Like, seriously, you Google how to treat it. I've done it and it didn't change. Now, for perspective and because we're talking about it here, I. I'm going to tell. I could tell any number of stories, but one that I think the people listening will maybe appreciate and have some connection to is that I probably have spoken at the same event in Orlando six or seven years and about three or four years ago, I got done full day on my feet, you know, talking and moving around. Blood pressure was probably, you know, up most of the day and everything. I got back to my room, had some dinner. I was fine. Decided to jump in the shower late at night, got in the shower, relaxed, and looked down, and I was just bleeding. And it was significant. And I stood in the shower, panicked. I did not know what to do. I was in a hotel room. I thought, I can't get out of the shower, I'm bleeding. What do I do? Finally I realized because I was standing, this was never going to stop. Got out of the shower, just to be candid, grabbed a wad of toilet paper, you know, jammed it my up my. And like went over and laid on the floor because I didn't know what else to do. It's about 11 o' clock at night and I think the bleeding stopped around 3am and I was like, I had to get up in the morning, get on a plane. And I can't even begin to tell you about the fear and the panic about leaving that hotel room or getting on a plane or all that other stuff, right? But once the bleeding stopped, it kind of stopped. Then you get home and then the other stuff comes, right? The, the small bits that nobody talks about, like you're scared for it to happen again. So you start restricting how you eat, how you move. I don't want to stand up too long. I guess I'm just a person who has hemorrhoids and this is how they bleed. You don't want to tell anybody. You know, it's, you know, even it's embarrassing to tell your wife or anybody really. And these poor people that hire me to come to this event, they're going to hear this and be mortified. That has happened to me three times in that hotel room. It has happened to me on the cruise I took my listeners on last year. It has happened to me in my house. It has happened to me in a lot of places. So if you see me out doing a speaking event, I probably haven't eaten for three or four days before that. Just because I don't want to put myself in a position where I'm standing, talking, moving, and then need to use the bathroom. It's been significantly impactful on my life. When I lost weight and it didn't affect it, I have to be honest with you, I was lost. I thought, well, that's it. This is the rest of my life. And I started looking into the surgery, which sounds barbaric, the surgery that is commonly done for this problem, and it's the only thing that stopped me from going after it is it did not seem like the outcomes would be good, you know. And then one day, even though I had looked over and over and over again online, I never quite could find it. I asked Chat GPT one day, is this the only thing I can do? And it said, no, you could get a hemorrhoid embolization. I was like, right on. So I looked online, you're like 10 minutes from my house, which made me bang my head against the wall, you know, came and saw you. You asked me about my symptoms. I remember you saying, you are a perfect candidate for this. And then I went home to find out that my otherwise very good health insurance didn't want to pay for it. It was demoralizing, to say the very least, candidly, so that everybody understands the company that you work for in exchange for you. Being on the podcast today gave me a decreased rate, but I did end up still paying cash for the procedure, and it's still a hefty sum for a normal person to pay, but it seemed that important to me. Can you tell people, when you examine me what. What it is you saw and maybe explain to them why? I mean, we call them hemorrhoids, but I don't know if that's a great way to categorize what. What. What was wrong with me, really.
- [23:17]
B
Right. Well, first of all, I mean, I think. And you mentioned some of these things to me before, Scott, but I didn't know the extent to which you had suffered. And, you know, it's interesting what you're describing, because this procedure really began as a treatment primarily for, as I mentioned to you, GI bleeding. So you probably, in the moment, and others might have gone to the emergency room at the time when you were having that fairly significant rectal bleed, and they just call you. And we used to get called like that day and night. GI doctors came on board and started trying to do things with a scope. But you can imagine your colon or rectum is full of blood. How can they see anything? And so then years of practice, radiology and interventional radiology develop techniques to deal with that, including figuring out where you're bleeding from, doing a tag red blood cell scan or CT angiogram, and then saying, oh, you're bleeding from the right colon, the. You know, the small bowel, the left colon, or in this case, the rectum, and going in there with a catheter, finding that source of bleeding. And when people are actively bleeding, we say they're extravasating. Or you can see, literally as you inject IV dye into the artery that you suspect, you can literally see it pumping into the colon.
- [24:29]
A
Okay.
- [24:30]
B
And you then direct. So this is where I talk about it like a video game. I have a monitor, I have a foot pedal, X rays, and I'm watching the monitor as I'm using my fingers to manipulate a tiny wire and catheter. And when I say tiny, they're the Size of, you know, one millimeter or so in diameter, the microcatheters to the source of the bleeding, and you plug it and it's like turning off a faucet. It's really amazing. Heroic, you know, feels lifesaving and all that. Like TV show.
- [24:56]
A
Yeah.
- [24:57]
B
So doctors like myself, determined, hey, if we can do this under extreme circumstances, why not treat people like yourself who are having intermittent yet significant hemorrhoidal bleeding? And that's how this procedure began to be developed, mostly in Europe and South America, where it's easier to get things done than in the United States, where, you know, you have to jump over 50 hurdles before it's somehow approved by some nebulous entity without clear guidance as to what guides their decision making. Not enough evidence. Not enough evidence. Not enough evidence. And as you pointed out, there are other treatment options. The most extreme, which you probably would have been offered, is the definitive hemorrhoidal surgery, which, though you're a relatively healthy guy, would have been a big deal. And the surgery itself, you know, let's say you get through without an issue. The recovery from those surgeries is really, really, really difficult. And that's why lots of patients have been steered away from it, either from their primaries that even colorectal surgeons are semi reluctant to do it because they know, God, this patient's going to be in awful, awful, awful pain. Not just for a couple of days, for weeks and months and months. And many patients I've spoken to over the last five years who've had that surgery and other people that I know personally will describe it as literally the worst experience they can go through in their entire life. They wouldn't wish it upon anybody else. So for that reason, people have developed less invasive things like rubber band ligation, like injections, like a procedure that's similar to what we do, which is a Doppler assisted ligation. But that's all because no one wants this definitive surgery. And so that's how this procedure sort of came to be. It is really unfortunate that in your particular case, your insurance did not.
- [26:52]
A
It was.
- [26:52]
B
Does not cover it. There are others that do, and we work very hard to try to change the narrative. And maybe things like what we're doing here will help with that. But it's. And the patients will advocate and you'll advocate, but.
- [27:05]
A
Well, I hope so. I'll tell you. I mean, listen, you're getting a slightly lower price is, you know, I'm happy to take that, but I am taking my platform and talking about this because you have no idea. Like, I started thinking, like, I don't know how many people are going through something like this, because I never would have told anybody, right. Like, had this not come up. And, you know, to be completely candid, I would have never said this out loud. And I've tried the banding twice. I've shared this on the podcast before, but I'm going to put it here for each. I've tried the banding twice. The banding was, like, presented to me as, like, oh, don't worry, it's a quick office procedure. It's not a big deal. Blah, blah, blah. Well, it was a big deal when the guy pulled out a speculum. And, you know, and I had my young. Like, my kid was still in a car seat. The first time I did this was, like, 24 years ago I tried this the first time. Right. Banding works. And incredibly painful. And, you know, you're good and then you're not again, and then it's going. What I think I've learned going through this procedure, because I tried that banding twice, and I was starting to think about doing it again. But I think what I've learned, and this is really. I. I can't believe I'm having trouble saying this out loud. Listen, if I'm saying this wrong, you'll make it more technical for me. But as soon as you were done the procedure, I was only out of that room for a couple of minutes. You walked over to me and asked me how I was, and I said, all the pressure in the lower part of my body is gone. I didn't realize I was living with so much pressure. And then I even. It happened so quickly that I thought I must be making it up, you know, but now we're. I don't know, how far are we out now from having it done? Maybe I'm a month or six weeks out of having it done. That has been completely true. The whole time. There was pressure inside of me constantly. I'm imagining in my mind it's from extra or too much blood. Being in a place right.
- [28:46]
B
Right now.
- [28:47]
A
My question is, how far up are the things you. I can't believe I'm going to ask this, but from the hole, how far up was what you did?
- [28:56]
B
So that's. You know, maybe this is a good opportunity to segue. You did ask me what it looked like, and it should segue a bit into why the banding doesn't work and what is the pathophysiology and the actual root cause of the hemorrhoidal. Disease. Why. Why do I have this problem? You know, you. You know, and women who give birth, they get hemorrhoids and others. But you're a man. You didn't give birth. You have no specific reason for having it. And so what is the reason? Now, I can't tell you why, unfortunately, you're afflicted by this problem, but I can tell you what the problem is, so I'm going to try to answer several questions at once. In your particular case, when we did do the anoscopian look, we see internally a very vascular vein bubble or a hemorrhoid. Now, why is it there? Okay, so to your point, you have your anus. Then above that, you have something called the dentate line, which is where the sensitive area of the butt is. And the less sensitive or desensitized area of the rectum is in that area, just above the dentate line, there's a tubular, rounded area of tissue called the corpus cavernosum. Recti. Big word. Okay. But what that is, it's a very vascular bed fed by arteries from the superior rectal artery. So they are derivatives of the artery called the infer mesenteric artery, which feeds the rectum and sigmoid colon and also part of the descending colon.
- [30:19]
A
All right.
- [30:19]
B
There won't be a quiz for anatomy later.
- [30:21]
A
I appreciate this. Thank you.
- [30:22]
B
There are arteries called the superior rectal arteries. Now, they feed that area, and inside that area are large venous lakes, and so it can swell and decompress to assist in the pooping mechanism. The analogy that I tell patients, I may have told you, is in the male body, there's another corpus cavernosum. It's in the penis, and it's what allows men to get an erection. So men get simulated. That area fills with blood, that tissue type fills with blood, and you get an erection, and then later it decompresses. Now, that same type of tissue exists in all humans, men and women in their lower rectum and fill swells and decompresses those venous. This is my best understanding of this in the way that I think about it, is those venous channels are like bricks. And in a brick house, you have bricks and mortar. The mortar is what holds everything together. So in that area, the mortar is a matrix of connective tissue that. That is keeping that structurally intact. In patients with hemorrhoidal disease, that matrix has broken down. And because of that, there is a swelling that takes place in the venous side. And we see when we inject IV dye to do the imaging prior to the embolization, we see a lot of blood flow into that area, too much blood flow, just an increased vascularity. So what you really are having there is like an arterial venous malformation. So it's fed by big arteries, but the end outcome is a vein. So the other analogy that I probably told you, and I tell patients too, is that the hemorrhoid is like looking up in the ceiling and seeing a brown spot develop, a wet mark in your ceiling. Right. So you don't call a painter to call them and say, hey, I don't like how that looks. You better paint that up. Of course not. We both know that if you do that, it's just going to happen again. So that's what Banding does. Banding literally paints over the spot or replaces the ceiling tile without getting to the root of the problem. So what we're doing is we are getting to the source, to the root cause of the increased vascularity to that segment of rectum by putting that catheter in and directing the microcatheter into all four superior rectal arteries and blocking them with metal coils to reduce the pressure. And by depressurizing it, it allows those venous side on the vein side to decompress. It's no longer inflated. So that hemorrhoids, like a balloon that you inflated with your lips, and it's constantly being inflated by that pressure. And as soon as you cut that off, that balloon deflates. And I think that's why in your particular case, you felt a real rapid decompression, because that's what I did is I decompress that. Those balloons. Now, not every patient gets an immediate effect like you do. That's a fantastic effect. But you had a really, really, really chronic problem years and years, and it developed. You had many vessels, very vascular, and as soon as that was cut off, it was depressurized. So you felt that. And then to my understanding, from speaking to you before, that you're no longer bleeding. And. And I am just thrilled for you because I know from talking to patients like yourself and fibroid patients who have to worry about bleeding through their clothes and when am I going to bleed again? And not knowing it, it's an overwhelming, mental, mentally exhausting life to lead when you can't just relax and be like, well, I just live my life. And to free you of that is, you know, for me personally, a very rewarding and satisfying thing to be able to say, look, you know, just, you don't have to exhaust you know, how much mental energy did you spend on any given day worrying about this happening? And when it did happen, the thoughts that would get.
- [34:07]
A
You know, you have no idea the kind of machinations that go on in the background, trying to obscure it, keep it from happening, get in front of it, stop it. Once it's happened. Happened to me once at the airport on the way out to somewhere. It's happened to me in my home. It's just it. And, you know, you could say, like, well, what brings it on? I don't even know. You know, it's not a change in my diet. It's not. It's. I. I can tell that if it's once, it's a problem. Having been on my feet for a while prior to that, added to it. And I think talking and keeping my heart rate up all day also had something to do with it, like, if I had to, like, break it down. But, no, you're absolutely right. I have had absolutely no bleeding since you and I got together. The procedure itself, I always think about when I first met you. You're like, I'm sorry. Like, it takes so long, but it took, like, 45 minutes, I think. Like, it didn't take very long at all. I remember, I think, having a fairly cogent conversation, even with the nursing staff. Like, I wasn't even out all the way when you did it. My recollection of it was, as funny as it sounds, is that, like, you'd go, you know, I guess you were in there with the wire. Then you inject a dye to look around to see what you were doing. I felt like I got very warm, you know, in the area where you injected the dye. You did the. You know, you did it, you did it, you did it. And then I remember maybe the. Even. The only part of it that I could even talk about being unpleasant might have been, like, at the end, you actually have to embolize where you went in with the wire.
- [35:32]
B
Yeah. We have to close the site of the artery to call it.
- [35:35]
A
Uncomfortable. I don't remember it. I can't even quantify it. But in that moment, I thought, oh, that pinched a little. And then that was. That was kind of like, you know, then it was it. I was outside, you know, on my. I think I was out of there in, like, an hour, to be perfectly honest with you, you know, after you were done.
- [35:50]
B
Yeah.
- [35:50]
A
And I have not had any issues, I'll tell you, beyond the pressure being gone up inside. That's the reason I asked you how far it is up Inside where the pressure was, because I didn't understand that's where the bleeding was coming from. Because I actually also have an external hemorrhoid. And I think that the pressure from the inside is what created the hemorrhoid at the external area. So you and I talked at my, at my follow up that we're just gonna wait some time and hope that my body kind of reforms and reshapes now that that pressure is not there anymore. And it is much better already because there's nothing behind it like pushing constantly, you know, but other odd little. Not odd, but even the shape of my stool is normal now. And I didn't realize it really wasn't before. And now as I think about it, it was being sent through a play DOH fun factory trying to get out instead of like, you know, coming out the way it was supposed to. I can't tell you how awesome it is. I would, 100%. I'd pay the whole amount. And if you told me it was going to fail in 20 years and I had to come back, I just started saving money now because it changed my life in a split second. Really did well.
- [36:59]
B
Hopefully. Listen, hopefully it won't. I mean, in all honesty, for myself, I've learned so much over the last five years about the pathophysiology of this particular disease. If you asked me 20 years ago if I'd be putting in speculums when I did ir, I probably would have been like, no way. But, you know, it is helpful and instructive. And now seeing patients, seeing them later, and then learning more and more about the variations in the anatomy. And then the one thing that we've done in our group, myself and the other docs who do this primarily in New York, as we are refining the technique by discussing it. And I think amongst the group of doctors in my company, there's probably nobody, maybe in the United States, doing as many hemorrhoid embolizations as we are. So we have a large amount of experience now and we have sort of refined the technique. And one of the things that we're doing as, not only are we looking at the superior rectal arteries, which are the main supply, we also look at sort of the side doors that supply that area, and they're called middle rectal arteries. And it used to be that we. No one touched those. And then it was like, only if the treatment failed. And now on every single case, I did one today where I thought, oh, I did a great job on the sras. Looks great, but I'm going to go and look. And on the left side, there was nothing. I mean, it was nothing to talk about. On the right side, a huge artery feeding that area and other docs and other places. And maybe five years ago, I would have not even bothered with it. And today I went in and I know this guy's going to do fantastic. There's just a lot. It's a very complex area. There's no two people who are the same arterially in the rectum. You know, sometimes I do four arteries, sometimes I do seven once we're done. I think now that we've refined the technique to where we're at, the success rate, particularly for patients like yourself with chronic internal hemorrhoids that are bleeding, is really, really, really great. I mean, I'd say 90 to 100%. It's challenging in that you can't block every artery, because if you do and if you completely block it off, that area will die. We don't want that, obviously. So we have to be cautious to some degree that we can't overdo it, can't overcook it. So, again, because of our joint experience and my own personal experience now, I think we've refined it. And so for patients like yourself, it's really an amazing, amazing, amazing treatment, and I'm really confident it helps people.
- [39:36]
A
Yeah. No, I can't. Again, I can't tell you how happy I am. I got an email from a woman after I mentioned on the podcast the first time, and she said, oh, my poor husband just had that surgery, and it really left him in a bad way. I wish I would have known about this before. And I thought, I'm doing the right thing talking about it. So, you know, hopefully the Internet will leave me alone a little bit. You know what the other thing is, is that this podcast is mainly about type 1 diabetes, right? And it's. People have autoimmune issues, and a lot of them, autoimmune issues are invisible to other people. And I thought, boy, this really does fit in with that because, you know, in a million years, I've done an amazing job of hiding this from people. And it is no different than. As far as the impact on you. It's no different. You shouldn't be hiding anything. You know what I mean? Like, it's tough, like, walk through the house. What's wrong? Nothing's wrong. I'm fine, you know. Are you okay? I'm fine. I'm fine. You know, you appear to be in a bad mood for a second. You're not In a bad mood. You just, you know, you just thought you just bled out in the bathroom and you're wondering if you're going to pass out now. And everybody in the apartment, in the house wants to know, like, it's dinner time. Do you want to eat? I'm like, no, I'm not hungry. And then, you know, what's wrong with him? And you just. You don't say anything because it's just. It was embarrassing. I'm not embarrassed by it anymore. And I can't believe I. It took AI to send me in the right direction.
- [40:53]
B
It's a shame, Scott. You know, I think that we need to do a better job. Myself and others, we're doing the best we can to educate the community, the primary doctors. You know, that there are these things. We actually are experts in orphan diseases, you know, to your point, things that people suffer from in silence. Fibroid disease.
- [41:12]
A
They.
- [41:12]
B
Women bleed and become anemic, and they're allowed to do so. And they. A lot of women won't talk to each other or to their doctors about how bad their fibroid bleeding is. So I think, you know, hopefully we can remove the stigma and the shame from it and get more patients treated and not have them feel that same, you know, shame of what's going on. They don't have anyone to talk to, you know, and listen. The treatment's not for everyone. I just want to be clear. I mean, I get patients who come in with a single painful thrombos, which is clotted external hemorrhoid, that have a hard time sitting. And those patients probably don't need this. They need supportive care. We give them medications and do what's necessary for those patients. But for many patients who have internal hemorrhoids, which is a large number of people.
- [42:01]
A
Yeah.
- [42:02]
B
And those especially that are bleeding, we know how vascular those are. They are prime candidates to have this minimally invasive treatment done and, you know, completely change and improve their lives.
- [42:15]
A
It's fantastic. And it felt like I. It felt like I went to lunch and came out. Do you know what I mean? Like, it. I wasn't in a hospital or like, it just. I, you know, I went into the front of your clinic, they took me in the back, got me set up. You said, hey, I'll be right. You were working on somebody else. You're. I think you were doing someone's fibroids, honestly. And you said, hey, when they come out, you know, you'll be next. And they cleaned up the room and brought me in, and I Felt like I was home, like two hours later. It was crazy.
- [42:39]
B
Yeah, you know, you know, moderate sedation is what we've been, what we use. I mean, to your point, some patients are sleepier than others. The, you know, because the fibroid embolizations take 20 minutes, those patients tend to remember nothing because hemorrhoid embolization can take 45 minutes to an hour depending upon how many arteries are done. You know, sometimes patients are a little bit more awake. But the beauty of it is that the procedure itself is not painful. You know, the warmth that you experience during the procedure is from the injection of the IV dye.
- [43:07]
A
Right.
- [43:07]
B
I myself have experienced it. I've had CAT scans for other reasons. And even if you get an injection of IV dye in your arm, it makes you feel warm in your pelvis and like you peed yourself. So when you're directly injecting the dye into that area, it definitely feels warm. So that's very common. But from a painful standpoint, I think you would attest that it's not a painful procedure. It's all done using image guidance. Tiny little hole and what you felt was me probably holding pressure after deploying a device to close the artery. We can actually do the procedure from an artery in the wrist, which means that you don't have to have your groin accessed. Personally, I'm still favoring the leg, but because of various factors, there's different shapes of catheters that the groin lets me have more options, whereas the wrist, you're stuck with one type of catheter. If it doesn't work, then you have a problem.
- [44:00]
A
Listen, there was bruising at the site, like, but that was the extent of. Like, you would have not known. I. Listen, I came home, I ate something, I took a nap. You know, I felt, you know, to say pain is even wrong. Like, I think I took Advil for a Tylenol for a day or two just for the local, like, I don't know, soreness at where you went in, there was some, you know, there was some bruising, and the bruising was gone in a couple of weeks. There was this one thing. I can't believe I'm just gonna say this to you, but I'm going to anyway. I haven't had a chance to ask you about this because it. It occurred to me after I met with you as my follow up. Is this common after something like this? Gosh, I can't believe I'm gonna look away from you when I say this. Randomly at least a dozen times. The head of My penis has gotten very warm, out of nowhere, almost like there was like more blood flow down there. Is there anything about what we did that would change it? It stopped now, but it happened for a few weeks in a row afterwards. And I'm wondering, is there anything about changing blood flow that could have changed that feeling or that it's didn't? I guess as I'm possible.
- [45:03]
B
It's possible. Look, I'd have to re review your particular case because I don't have it memorized.
- [45:09]
A
Right.
- [45:10]
B
But I think I embolized at least one or both of your middle rectal arteries. The arteries that supply that area are also very, very close to the arteries that supply the penis, the pudendal artery. And so it is possible that by reducing the flow there, it increased the flow elsewhere. And so there is a possibility that by shutting down one spot, more flow
- [45:34]
A
went in, another spot, rerouted somehow.
- [45:36]
B
Yeah, so there is a possibility because those arteries, the, the superior rectal arteries are entirely for the rectum. They come from the arteries to that area.
- [45:46]
A
Right.
- [45:47]
B
The middle rectals are derived from arteries that also, like I said, near arteries that supply the skin inside your groin. And of course, you know, some of your, your penis, testicles, etc. So it is possible. I haven't heard that particular.
- [46:05]
A
Well, if it's your head, see if somebody else brings it up, maybe they just don't want to tell you.
- [46:09]
B
Maybe they didn't want to say. But it is, it is possible, involuntary.
- [46:14]
A
It's nothing like that. It's just, it just would get warm and then stay warm for 10 seconds and then go away. And I'd be like, this is interesting. Is this going to happen forever? But it just, it stopped and doesn't happen anymore.
- [46:25]
B
Well, I'm glad it stopped. I, I, I, I'll have to think about it more and I guess, you know, at some point I'll get back to you. But I, what I, what you're suggesting, and my original, my initial thought is, what I just mentioned is it's just some redistribution of flow.
- [46:40]
A
Well, you'll be happy to know that two different AI models agree with you because that's what I, I didn't want to bother you, so I just asked there. Yeah. Is there anything that we're leaving out or anything we're not telling people? Like, I want to make sure they understand if they have this specific issue, how impactful I think that what you do is. And I just want to make sure we feel like we've covered it.
- [47:01]
B
The only thing I would say, is, so if you want to come in and be evaluated, whether it's me or someone else, number one, not all rectal bleeding is hemorrhoids. So let's just make that clear. So one of the things that we are very careful about is not to make assumptions most of the time, particularly in patients who are of an age where colonoscopy would be warranted. If they come in and say, like you said, I'm bleeding a ton. And I say, have you had a colonoscopy and they're 55 years old, the answer is no, they will. I will not do anything until they get a colonoscopy, not to say that they don't have hemorrhoids. It's very common. And even if I did an anoscopy and I found a hemorrhoid, I don't like to make assumptions. You can certainly have two problems simultaneously. So unexplained rectal bleeding and change in bowel habits should be evaluated for, you know, colorectal cancer. Number one. I just want to make that clear. Not every bleeding is hemorrhoid or bleeding. There's other problems.
- [47:55]
A
Right?
- [47:56]
B
Once that is excluded, then we can focus our attention on the hemorrhoidal problem. So if a patient, as far as, like, what's a consultation look like? If you were to come to me as a new patient, like you did, I would like to see a recent colonoscopy report. So let's say you had one in the last year or two. It showed no problems, but internal hemorrhoids, you're cleared. If, on the other hand, you haven't had that, what we will usually do is do an anoscopy, which is basically, as you pointed out, a small speculum. It looks like a piece of plastic that you can insert into the rectum. It's only about as this width and length of a finger. So for me, it replaces the rectal exam. I would rather see with my eyes than feel with my finger because I think I have a better sense as to what's going on. So we do that. Determine if you have a hemorrhoid, if you have another problem or not, if. And then we can discuss what options there are. Sometimes patients should have some, what's called conservative management, change in their diet, medication before we proceed immediately with this particular treatment. There are patients like yourself, who I know no amount of steroid cream or suppository is going to change their outcome. But there are people who. It's their first episode of hemorrhoidal problems, it may not be in their best interest to jump right in to something to fix it. They may get relief with something else. So there are some patients for whom I prescribe medications to try first to see if I can alleviate their issues just medically, conservatively, without immediately diving into doing something. So just to be clear, there are other things that we need to think about. We don't immediately make assumptions, but if we get to the point of saying you have a chronic internal hemorrhoids, you're bleeding is, you know, and many patients are like you, they failed rubber band ligation, there are really very few options. And as you pointed out when someone messaged you about a friend who or husband who had the surgery, it's, it's no joke. It's really no joke. And compared, I know you might have had a little hematoma or bruising in your groin, which doesn't happen to everyone, but it's unfortunately happened to you. But it's, it's a minor consequence relative to you. I'm sure you did test to the change that then happened in your life after that.
- [50:11]
A
Listen, I stood up in a paper gown and hugged you. I, I do it again. I'd come. If you called me right now and said you needed somebody to run your trash out, I'd come do it for you. So I can't tell you how thrilled I am. I mean, just to not think about it anymore or, or to even to be able to tell you that for the last six weeks, I just go to the bathroom and I'm not there forever. And it's not like you're pushing something around something else then hoping that it doesn't explode afterwards because it's really what was happening. You know, I was on all kinds of like, you know, taking like softeners and stool. I was trying everything I could to just avoid when it was going to happen and I just, I couldn't help. Listen, I, you know, I'm, I'm gonna, I'm gonna make an ad for you and put it in here because I appreciate it so much. But where would you want people to go? Is it a website or how would they find you?
- [51:01]
B
So, yeah, I mean, there's many ways to find us. You know, number one, we're. If you just type in USA hemorrhoid centers, we should be the first thing to pop up though. I just think it's important that we get the word out there, Scott, and that we, you know, find a way not just to educate patients, but, but primary doctors. So I hope that yourself, and I'm hopeful that some of my own other patients go back to their primaries and say, hey, man or woman? Excuse me. What's up? I. I wish that, you know, you had thought about this and sent me to this doctor or someone like him sooner.
- [51:35]
A
Yeah.
- [51:35]
B
And why did I have to suffer for years this way?
- [51:37]
A
Yeah, you were very clear earlier. But I'll say that, you know, it's. If you go, you know, I'm going to use the fibroid thing as an example. By the way, all those fibroid questions came from my wife. So you might be meeting more people in my family. You really got to do your. Your, Your diligence and, and figure out what's best for you. As far as this internal bleeding from this. These hemorrhoids go. My experience has been nothing but positive. And. And I can't tell you how happy am. I did it. And I really do appreciate you taking the time to come on and talk about this.
- [52:06]
B
That was. I appreciate that a lot, Scott. I was just telling someone the other day that, you know, I feel like I'm. I mean, I could do the math, but I'm like 70 to 80,000 procedures in. I should probably be glowing in the dark at this point, but I'm not. And, you know, there is something to be said, and especially in this particular field with the hemorrhoids, experience does matter. I know. Just speaking for myself, I feel so much better about it now than I did five years ago. And like we discussed, you know, in the hospitals, we do some other rather complex things as well. And to be able to do these procedures for people in an outpatient setting without the hospital. And it's an. I mean, I know you had to pay some out of pocket, but you can only imagine what that cost would have been like inside a hospital with the amount they charge. So it's an order of magnitude. You could have added a zero to the number because that's how it works. You know, everything there is exponentially larger.
- [53:06]
A
I was stunned that my insurance company told, by the way, cigna, go to hell. I was done that CIGNA told me that. And apparently it was maybe the only major insurance company that wouldn't have covered this procedure for me. Lucky me. But whatever. So Cygnus said to me, well, the next time the bleeding happens, just go to the ER and they'll embolize it. And I went, yes, somebody who doesn't know what they're doing. And it was like. I was like, why? And I said, isn't that going to cost you more money than if I just go let Dr. Shiloh do it? And everyone I spoke to along the way said, yes. They all agreed with me. Like, nobody was like, oh, no, you're crazy. They were all like, yeah, it's going to be cheaper if he does it. You're going to have somebody who's more, you know, practiced at it, but this is what we'll cover. So next time you bleed, run into the er, you know, and yell, help me. And I was like, the only problem.
- [53:54]
B
And that's. That's legit. I told you, you could have gone to the er. But here's the rub. With hemorrhoidal disease, the problem is it isn't actually as much as you were bleeding. It's not an arterial bleeding. Arterial bleeds are really brisk and are life threatening. And so what would happen is you'd go to the er, they would try to find the bleeding. And if we. And when. When. The way that we treat GI bleeds is if we do not see an active pumper blood coming, like, pumping out, we don't embolize.
- [54:24]
A
Right.
- [54:25]
B
Because one of the unfortunate things with GI bleeds is that they're intermittent and they're off and on. So, number one, you could have walked into the ER by the time you were seen, by the time you got back, by the time they called ir, by the time they came in, hours pass, hours pass, hours pass, you stop bleeding, they show up, oh, we can't find it. Or on top of that, as I said, it's a vein, not an artery. So they would never have found this source of bleeding anyway. And you would have left, having been through all that, having undergone a procedure, the bleeding would not have been found. It would have cost the insurance company $50,000 for your ER visit, the testing, the procedure, yada yada, and. And all to end up in the same place again, which is the fallacy in all of this.
- [55:07]
A
Yeah. And the same exact spot, by the way, is. Is hopelessness and bleeding. And so I just. Once I found you, I said, I don't care what this takes. I'm doing this. Like, I have a serious conversation. My wife, I was like, look, the insurance company isn't going to pay for this. I'm like, what? I'm doing it. Like, we have to figure this out, you know? And she's like, well, Merry Christmas. And I was like, awesome.
- [55:26]
B
I do want to mention, though, that there are other insurances that do cover the procedure, which is also a little problematic. I Mean, first of all, Medicare, which is obviously one of the largest insurer in the United States, but there are others. I'm 99% sure. I'm trying to remember if Aetna does or doesn't, but like other Blue Cross Blue Shield currently does. Yeah, you know, I think United does. I mean, we're talking about the big insurers, United, Blue Cross, Blue Shield. I'm not 100% sure about it and I'd have to recheck that. And it doesn't, I don't want your listeners to believe that all insurance doesn't cover it. It absolutely it, it's dependent on each individual.
- [56:04]
A
I' three insurances as an adult, an employed adult, and two of the three of them would have covered this, not the one I currently have. So I was like, right, awesome.
- [56:13]
B
And you would never, and listen, you would never know that. You'd have to think about every medical problem that's potential. And you probably talk about insurance coverage with, with, you know, what you deal with on a regular basis because I'm sure that some insurances don't want to pay for the better pump and others do and, and different treatments that are out there and are available for some patients and not to others. And you know, the different tiers of, of health care and medicine that we live with dependent upon this insurance concept that we've come to accept, which is probably a podcast for another day.
- [56:44]
A
It certainly is.
- [56:45]
B
Yeah, it is really challenging that we do that. But I will say we work with everybody. We try to find solutions. You know, even in situations like this, we offer, you know, cash options, payment options to the best of our ability. It's, you know, I always tell patients I wish I could do something different. Unfortunately, even in your case, you do appear to peer and the person falls back on their policy statement. And you speak to a doctor who's not in your field, who might not even have any experience with this, and they read the piece of paper and say, we believe this treatment is what's called E and I, experimental and investigative and that's it. And they're paid by the insurance company to be the adjudicator. It's like in a trial where, where I'm sue you in a civil lawsuit, but you pay the judge, the judge decides, you pay them and they decide which way it's going to go. Like, how is that going to go? Yeah, it's clear you're in a position where it's not going to be in your favor.
- [57:40]
A
Yeah, they offered me a peer to peer review And I was like, in what world is that going to end up in my favor? It's. It's you making.
- [57:47]
B
We can provide them with all the data that we want and which we have and we will do, but at the same time, they dismiss it as not enough. And I think I discussed this with you. The kind of work that they want people to do. Would you have undergone what's called a sham procedure, where I stick a catheter in your arteries to your rectum, but I don't embolize it? And then I ask you later, a month to three months, six months, a year, how are you doing? And compare you to a patient who actually got an embolization. Then take a. Do a thousand of those patients so 500 get embolized, 500 don't. And then make an assessment like, what patient's going to sign up to maybe have a sham procedure? Nobody. Not in the United States, at least.
- [58:25]
A
Yeah, no, I hear you. Well, Dr. Shiloh, again, let me thank you very much for doing this. I'm taking up enough of your time. But I do really appreciate you helping me unburden myself the rest of the way from any embarrassment I felt about this, because it's gone now. I. As I sit here and record this, I know how many people are going to hear it, so I know I'm not embarrassed anymore. And I hope nobody else is, too. I hope if you're having a problem like this that you don't run around hiding and. And doing what I did. I hope you just go get it taken care of. It wasn't that bad to show Dr. Shiloh my butt. I only had to do it one time. And then when the procedure. Yeah, yeah, yeah. He's like, don't. And then once we did the procedure, honestly, it was a. It still felt like a very private thing. Like, it wasn't. You didn't feel exposed during it or anything like that. It was. It was really. It just kind of easy to be perfectly honest. So.
- [59:13]
B
One last thing, Scott, I'd like to say is that I'm honored by every patient, and I'm honored to have been here with you. And I also will offer to connect with anybody, even if it's a matter of redirecting them to where they need to go. You know, my goal is to help as many people as possible with this disease and certainly the others that we described a little earlier as well.
- [59:32]
A
Yeah. Reach out. Dr. Shiloh is a solid guy, so thank you, man. I really do appreciate your time. Happy New Year.
- [59:37]
B
Happy New year. Thanks for having me on.
- [59:39]
A
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