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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 11-15

A case report on the management of Riju bhagandara (low anal trans-sphincteric fistula) by modified conventional Ksharasutra therapy


1 Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, India
2 Department of Shalya Tantra, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh, India

Date of Submission11-Jun-2020
Date of Acceptance04-May-2021
Date of Web Publication17-Jun-2021

Correspondence Address:
Dr. Vyasadeva Mahanta
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_33_20

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  Abstract 


Bhagandara (~anal fistula) is a challenging surgical condition due to its high recurrence rate and anal incontinence. Acharya sushruta has explained surgical and para-surgical techniques for its management. Ksharasutra therapy is a time-tested para-surgical modality for Bhagandara with least recurrence (3.33%). Modified conventional technique of application of Ksharasutra is aimed to eliminate infected source and facilitate healing in short duration. A 30-year-old male patient presented with recurrent painful swelling with intermittent pus discharge from the base of the scrotum for one and half years. He underwent incision and drainage twice in the last six months. Magnetic resonance imaging revealed an anterior fistulous tract representing as St. James Type 1 Fistula, which varied from clinical features. He was treated with Modified Conventional Kshara Sutra Therapy (MC-KST) and whole length of fistulous tract was healed completely within five weeks. Anal fistula with scrotal extension is considered a complex manifestation to manage. In MC-KST method, tract was intercepted nearer to sphincter and infected crypto-glandular lesion was eradicated by Ksharasutra. The study concluded that MC-KST is one option to manage anal fistula with scrotal extension to preserve normal perineal structures.

Keywords: Bhagandara, fistula in ano, Ksharasutra


How to cite this article:
Hanifa N, Mahanta V, Sherkhane R, Gupta SK. A case report on the management of Riju bhagandara (low anal trans-sphincteric fistula) by modified conventional Ksharasutra therapy. J Ayurveda Case Rep 2021;4:11-5

How to cite this URL:
Hanifa N, Mahanta V, Sherkhane R, Gupta SK. A case report on the management of Riju bhagandara (low anal trans-sphincteric fistula) by modified conventional Ksharasutra therapy. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Jul 26];4:11-5. Available from: http://www.ayucare.org/text.asp?2021/4/1/11/318659




  Introduction Top


Fistula in-ano (FIA) is a chronic abnormal communication usually lined to some degree of granulation tissues and it runs outward from the opening in the ano-rectal canal at one end and surface of perineum/peri-anal skin on the other end.[1] FIA can develop in approximately 40% of patients during acute phase of sepsis. It can be reoccur within six months of initial therapy.[2] The prevalence of FIA is estimated to be 1–2 per 10,000 patients.[3] It is four times more common in males as compared to females, and the mean age of affected population is about 38.3 years.[4] Although the disease is not life-threatening, it poses severe discomfort in routine life due to recurrent pus discharge, swelling, pain, and other related inconvenience.

Based upon the signs and symptoms, Bhagandara is correlated with FIA. Classical literature has considered Bhagandara among Ashtamahagada (~eight incurable imperative diseases), which are difficult to treat.[5] Initially, Pidika (~boil) will develop around the Guda and when it burst open to outside to from Bhagandara.[6] In modern parlance, the most common anal fistula is an inter-sphincteric fistula. The most widespread useful classification of anal fistula is based on the Park's concept of anal gland sepsis.[7]

Adequate and appropriate treatment is dependent on the correct classification and identification of internal and external openings, the course of track, and amount of sphincter muscle involved. There are many treatment modalities available for the management of FIA. Management includes fistulotomy, fistulectomy, seton placing, ligation of inter-sphincteric fistula tract, fibrin glues, advancement flaps, and expanded adipose derived stem cells. All have been emerged as a standard treatment option with their own advantages and disadvantages.[8] Acharya Sushruta has described the management of Bhagandara very appropriately and guided to take care of nearby structures during excision of tracts, advised using Kshara (~caustic substance) and Agni (~fire) judiciously and promote healing of formed wound by using oral medications, local applications. Currently Ksharasutra therapy has been incorporated as standard operating care for FIA with least chance of recurrence and incontinence.[9] Ksharasutra, is a medicated seton prepared by using plant materials. It is widely accepted as a standard treatment modality for the management of FIA and it has revolutionized the surgical management of FIA.[10] However, there are some difficulties while practicing conventional Ksharasutra therapy in complex anal fistula. It leads to discomfort, post-procedural pain, repeated hospital visit and thus causes more inconvenience to the patients.[11] With considering the Park's concept of manifestation, anal fistula can be cured by destroying the infected crypt, so that rest of the tract will heal by itself. Based upon this concept, Modified Conventional Kshara Sutra Therapy (MC-KST) method is postulated to intercept fistulous tract nearer to sphincter and infected crypto-glandular lesion eradicated by Ksharasutra.[12] Thus, making it more convenient to patient as well as to exclude the drawbacks of conventional method. Thus, anal fistula operated by this technique may yield good encouraging results.


  Case ReporT Top


A 30-year-old male patient working as bank manager by occupation, asthmatic, nondiabetic and normotensive visited Ano-Rectal OPD with complaints of repeated episodes of painful swelling at the base of the scrotum associated with intermittent pus discharge for one and half years. He consulted to allopathic physician, and was diagnosed as a case of perianal cyst. He underwent excision of cyst. However, the episodes of his complaints of swelling at perianal region and pus discharge did not subsided. On local examination, there was an external opening at the base of scrotum approximately 6 cm away from anal verge and a sentinel tag with chronic fissure at 6 o' clock position [Figure 1] and [Figure 2]. On palpation, the tissues of external opening were firm and thin pus came out on gently squeezing of tract. Digital rectal examination revealed tender point at 12 o' clock position nearer to dentate line, sphincter tone was normal. A gentle probing was done and tip of the probe felt at 12 o' clock position. However, Magnetic Resonance Imaging (MRI) findings were differed from the clinical findings suggested that a low lying anterior fistulous tract with possible internal opening at 6 o' clock position of lower anal canal and external opening in the left para-median/inter-gluteal region representing as St. James type 1 fistula. All the laboratory investigations were found within the normal limit. The patient was planned for MC-KST considering clinical findings.
Figure 1: Diagrammatic representation of inspection observations

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Figure 2: On inspection, local examination

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  Timeline Top


After obtaining informed consent, the patient was kept in the lithotomy position. Under local anesthesia, probing was done to assess the fistulous tract. A small vertical incision was made at 12'o clock approximately 2.0 cm away from anal verge and interception of fistulous tract was done by smooth splitting the perineal tissues [Figure 3]. Then, normal saline was injected from external opening and it came out from the intercepted area. It was confirmed that fistulous tract is completely intercepted. A metallic malleable probe was inserted through the window (interception site) and taken out from the anal canal (internal opening) and Ksharasutra was placed in the tract [Figure 4] and [Figure 5]. Unhealthy tissue at external opening was excised and sent for histopathological examination. Antiseptic dressing and packing was done with Jatyadi taila. The patient was advised for regular sitz bath with luke warm water from the next day and dressing with Jatyadi taila. Triphlala guggulu (1 g TDS) after food, Tab. Septilin (1 g TDS) after food, Triphala churna (5 g HS) after food, Jatyadi taila for Matravasti at bed time for next five weeks was prescribed [Table 1].
Table 1: Timeline

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Figure 3: Diagrammatic representation of site of Interception

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Figure 4: Interception and Ksharasutra placed

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Figure 5: Diagrammatic representation of interception and Ksharasutra placed

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  Follow up and outcome Top


Regular follow-up was advised with weekly Ksharasutra change. Changing of thread was followed as per standard procedure. 7th day after first change of Ksharasutra, pus discharge was increased from the window. After that pus was gradually reduced and completely ceased after two weeks. Moderate pain was noticed in the 1st week and later on gradually relieved. The discharge from the external opening was stopped after the 4th post-operative day and completely dried up at the end of 2nd week. Average unit cutting time was 10.5 days/cm. Cut through of the tract was done after three weeks when discharge completely diminished and window site covered with healthy granulation. Complete healing was achieved in eight days after cut through. Patient was advised for Matravasti per rectally with Jatyadi taila. The fistulous tract was completely healed by the 5th week with minimal scar. There was no complication seen during and after treatment. No signs and symptoms of anal fistula were found in five months of follow-up [Figure 6].
Figure 6: After treatment

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  Discussion Top


The conventional technique of Ksharasutra for the management of FIA is well-established but due to slow cutting and healing of fistulous tract, it takes more time and causes inconvenience to the patients. To overcome the limitations and consequences of conventional method, MC-KST has been developed to evaluate its effectiveness and to convert complex anal fistula into a simple one for better recovery and to preserve anal structures. Duration of therapy was shortened by intercepting the tract nearer to sphincter with utmost taking care of crypto glandular infection. So that no residual pathology remains and no chances of recurrence. Pain was significantly reduced as minimum tissue trauma caused with MC-KST whereas in conventional method, whole tract is ligated along the axis and during Ksharasutra change, it increases the pain and burning sensation. In this study, the length of the fistulous tract was 6 cm. After MC-KST, it was reduced up to 2 cm that was easily managed.

Local application of Jatyadi taila once daily along with Ksharasutra is beneficial. It produces soothing effect at anal canal and lower part of rectum and pacifies vitiated Apana vayu,[13] facilitating smooth bowel evacuation and reduced pain during passing stools. In classic, Jatyadi taila is indicated in Bhagandara, Upadansha vrana (~syphilitic ulcer) and Dushta vrana (~infected wound) due to its Shodhana (~cleaning) and Ropana (~healing) properties.[14] It contains Nimba (Azadirechta indica A. Juss) and Daruharidra (Beriberis aristate DC.) which are proven drugs to check bacterial growth and promotes wound healing.[15],[16],[17],[18] Previous studies reported that increases protein, hydroxyproline and hexosamine content in the granulation tissue and reduces wound area faster. The phytochemical constituents such as flavonoids, essential oils, tannins, glycosides, steroids, and alkaloids are found in Jatyadi taila also helps in wound healing.[19]

Triphala guggulu was prescribed in tablet form (1 g three times a day) up to completion of the treatment. Triphala guggulu has proven antimicrobial property by inhibiting hyaluronidase and collagenase activity.[20] Guggulu is a potent anti-inflammatory drug that help in the postoperative pain management and fasten healing of the tract.[21] Tablet Septilin has potency in modulating immune functions in animal models.[22] It helps in the prevention of various types of infection. In addition to that Septilin has properties to inhibit both Gram-positive and Gram-negative organisms.[23] Thus, the combination of these drugs helps in the management of anal fistula.


  Conclusion Top


Anal fistula with scrotal extension is considered as complex type of fistula and it was managed by MC-KST. The patient was recovered without any inconvenience and the structural integrity of perineum was maintained leaving a minimal scar mark. MC-KST is a minimal invasive technique required less visit to hospital and can be performed in minor setup.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical Evaluation of Kshara sutra Therapy in the management of bhagandara (Fistula- in-ano) – A prospective study. Anc Sci Life 2009;28:29-35.  Back to cited text no. 9
    
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Sreenadh P, Mahanta V, Sherkhane R, Gupta S. Management of Riju bhagandara (trans-sphincteric anal fistula) by modified conventional Ksarasutra therapy. J Ayurveda Case Rep 2020;3:10-13.  Back to cited text no. 12
  [Full text]  
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Dwivedi L, editor. Charaka Samhita of Agnivesha, Sutra Sthana. 1st ed., Ch. 4., Ver. 41-7. Varanasi: Chowkhamba Krishnadas Academy; 2013. p. 120-1.  Back to cited text no. 15
    
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Shailajan S, Menon S, Pednekar S, Singh A. Wound healing efficacy of Jatyadi Taila: In vivo evaluation in rat using excision wound model. J Ethnopharmacol 2011;138:99-104.  Back to cited text no. 19
    
20.
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