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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 95-99

Management of transsphincteric fistula-in-ano by modified conventional Ksharasutra therapy: A case report


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

Date of Submission26-Jun-2020
Date of Acceptance02-Sep-2021
Date of Web Publication14-Dec-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_39_20

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  Abstract 


Acharya Sushruta has mentioned Bhagandara (~fistula-in-ano) under Ashtamahagada (~eight conditions that are difficult to manage) on looking to its poor prognosis. It poses great impact in surgical community because of fear of recurrence and fecal incontinence. Complex anal fistulae are more difficult to manage, in spite of many new sphincter preserving techniques evolved. In Ayurveda, Ksharasutra is being practiced for the management of all types of anal fistulae with high success rate since centuries. Modified Conventional Ksharasutra Therapy (MC-KST) is technically modified to control sepsis, promote early healing by intercepting fistulous tract and preserving sphincteric function in cases of complex fistula-in-ano. A 50-year-old male patient of complex anal fistula for 2.5 years visited the outpatient department. The case was operated under local anesthesia by MC-KST technique. Total three sittings of Ksharasutra were done at an interval of a week. The wound was healed completely in 42 days, and no complaints of recurrence were reported in five months of follow-up. It was observed that MC-KST promotes early healing of fistulous tract by facilitating effective drainage and complete eradication of anal gland sepsis.

Keywords: Bhagandara, Fistula-in-ano, Ksharasutra, modified conventional Ksharasutra therapy


How to cite this article:
Faridi K, Sreenadh P, Mahanta V, Sherkhane R. Management of transsphincteric fistula-in-ano by modified conventional Ksharasutra therapy: A case report. J Ayurveda Case Rep 2021;4:95-9

How to cite this URL:
Faridi K, Sreenadh P, Mahanta V, Sherkhane R. Management of transsphincteric fistula-in-ano by modified conventional Ksharasutra therapy: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2022 Dec 2];4:95-9. Available from: http://www.ayucare.org/text.asp?2021/4/3/95/332435




  Introduction Top


In Ayurveda, Bhagandara has been mentioned under the list of eight major diseases that are difficult to manage.[1] The description of Bhagandara resembles with the fistula-in-ano in modern medicine. Being considered as a difficult entity, various surgical and parasurgical interventions are recommended in Ayurveda along with restrictions of diet and physical activities to check recurrence. The mean incidence of nonspecific fistula-in-ano is 8.6 cases/100,000 populations, 12.3 for males and 5.6 for females. The male: female ratio is 1.8:1. The mean patient age is 38.3 years.[2]

Transsphincteric anal fistula usually seen in 40% of the cases.[3] It has the involvement of ischioanal fossa, which contains only fat tissue and is less vascular.[4] Hence, following the conventional surgical interventions, healing of the wound in this area is very difficult to achieve. As it crosses both external and internal sphincters, it carries a risk of incontinence after fistulotomy.

Treatment of complex fistula-in-ano is a big challenge in front of medical as well as surgical world. It has a great impact in surgical community because of fear of recurrence and fecal incontinence and surgeons think twice before posting the case in spite of many new sphincter preserving techniques evolved till date. Ksharasutra therapy has been accepted as a minimal invasive parasurgical procedure for the management of fistula-in-ano with high success rate of 96.67%.[5]

Anal fistula is developed from cryptoglandular infection in 90% cases.[2] Interception of fistulous tract and eradication of infected anal crypt by modified conventional technique, i.e. application of Ksharasutra is a simple method and less time-consuming process, emphasize on no or minimal damage to anal sphincter, and complete healing of fistulous tract with negligible complications. It is based on the concept of eradication of the root cause that is, infected anal crypts and glands, which are the prime source of origin of fistula-in-ano.[6]


  Patient Information Top


A 50-year-old male, non-diabetic, normotensive working as an office assistant in private sector presented at Shalya Tantra outpatient department with the chief complaints of swelling at perianal region and intermittent pus discharge from an opening present over the swelling site for 2.5 years. He is hemodynamically stable, having regular bowel habits, and no history of any other systemic illness.


  Clinical Findings Top


The patient was taking antibiotic, analgesics [tablet Mahacef OZ twice daily with water after food, tablet Pantop (40 mg) twice daily before food and tablet Zerodol SP twice daily with water after food] under the consultation of allopathic physician and trying to avoid surgery due to fear of recurrence and associated complications. On local examination in lithotomy position, a small dimpling area with thinning of skin was found at the right gluteal region, 7 cm away from the anal verge at 5 o'clock position [Figure 1] and [Figure 2]. On palpation, it was observed that the tract was coursing toward the anal canal in a curvilinear manner. On digital rectal examination, an induration was felt with mild tenderness just above the dentate line at 6 o'clock position. Otherwise, the rectum was found normal on proctoscopy examination.
Figure 1: In lithotomy position

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Figure 2: Diagrammatic representation

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  Timeline Top


Timeline of the case is described in [Table 1].
Table 1: Timeline

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  Diagnostic Focus and Assessment Top


Magnetic Resonance Imaging (MRI) report suggested as a case of complex transsphincteric fistula-in-ano (Grade IV) with pus pocket at intersphincteric space. Hemogram was (complete blood count including hemoglobin, red blood cells count, platelet count, total leukocyte count, differential leukocyte count, bleeding time, clotting time, and random blood sugar) normal, while serological reports for HIV and HBsAg were negative.


  Theraperutic Focus and Assessment Top


After obtaining written informed consent and performing standard preoperative care, the patient was shifted to operation theater table and placed in lithotomy position. Approximately 14 ml of injection lignocaine hydrochloride with adrenalin 0.5% was infiltrated at 6 o'clock and around the course of the fistulous tract. To perform Modified Conventional Ksharasutra Therapy (MC-KST procedure), a small vertical incision was made at the level of external sphincter at 6 o'clock position approximately 1.5 cm away from anal verge and after identifying fistulous tract, it was intercepted [Figure 3]. The interception site was widened adequately by using the dissecting scissor for proper drainage. Thereafter, diluted betadine with H2O2 solution was injected from external opening to confirm the complete interception. The solution came out freely through the site of interception. With the help of a malleable probe, plain barbour thread (No-20) was applied from the site of interception of fistula to the internal opening in anal canal and both the ends were tied loosely at outside the anus. Antiseptic dressing and gauze packing were done with Jatyadi taila. After observing subsidence in inflammatory signs, plain thread was replaced with Guggulu-based Ksharasutra on 7th day and changed it subsequently on weekly interval [Figure 4], [Figure 5] and [Table 1]. The part of the fistulous tract from the site of interception to external opening was left as such to achieve closure and healing simultaneously. The patient was advised to take Triphala guggulu (1000 mg) thrice daily with lukewarm water after food, Panchasakara churna (5 g) with lukewarm water at bedtime and Jatyadi taila for local application after sitz bath in Panchavalkala kwatha twice daily.
Figure 3: Diagrammatic representation of the site of interception

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Figure 4: Diagrammatic representation of Ksharasutra ligation through the interception site

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Figure 5: Ksharasutra ligation through the interception site

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  Follow-up and Outcomes Top


After two weeks of treatment, pus discharge from external opening as well as wound at the interception was reduced with reduction of other signs and symptoms and healed after three weeks of management. The interception site and distal part of fistulous tract were healed completely by 42nd postoperative day without disturbing the normal contour of anus [Figure 6]. The unit cutting time observed was approximately 1 cm/week. No transrectal ultrasonography/MRI performed after resolving the symptoms. Clinically, there were neither any signs of anal fistula nor any complications related to the fistula after six months of follow-up [Figure 7].
Figure 6: After treatment

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Figure 7: After complete healing

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  Discussion Top


Anal fistula, originating from cryptoglandular infection is a common presentation. Different surgical procedures starting from simple fistulotomy to newer advanced techniques such as anal flap, ligation of intersphincteric fistulous tract, and video-assisted anal fistula treatment are being used in the management.[7],[8] However, the chances of recurrence and incontinence are high in these techniques and the extensive surgical interventions often disrupt the normal anatomy and the postsurgical healed wounds are unpleasing. Ksharasutra is a time-tested conventional parasurgical tool for the management of Bhagandara. However, this technique is time consuming due to slow cutting, and healing of fistulous tract, pain, and pus discharge presents for long duration and need of weekly replacement of Ksharasutra that causes physical as well as psychological stress in many patients. In the present era, it is not convenient for all patients to visit hospital frequently for changing of Ksharasutra for long duration.

MC-KST is technically modified to covert complex fistula-in-ano to a simple one and effectively eliminates the infected anal gland/anal crypt by applying Ksharasutra. This technique facilitates proper curetting and healing of the fistulous tract as well. Duration of hospitalization will be less, and only mild postoperative pain will be observed during recovery period. In this technique, anal musculature can be preserved, thus, there won't be any fear of fecal incontinence. Recurrence, which is a major problem, due to persistent infection of anal crypt/glands will also be taken care by applying Ksharasutra.

Triphala guggulu[9] is a polyherbal formulation consisting of dried fruits of four plants (Terminalia chebula Retz., Terminalia bellerica Roxb., Emblica officinalis Gaetrn., and Piper longum L.) and exudate of Guggulu (Commiphora mukul Hook.). It possesses antimicrobial, hyaluronic inhibitory, and wound healing properties.[10] Panchasakara churna[11] contains drugs like Shunthi (Zingiber officinale Roscoe.) that has Deepana (~appetizer) and Pachana (~digestive)[12] properties, Haritaki (T. chebula Retz.) which is having Anulomana properties that helps to balance the Apana vata and facilitate easy evacuation of stools.[13] Jatyadi taila[14] contains ingredients such as Nimba (Azadirachta indica A. Juss.) and Daruharidra (Beriberis aristata DC.) which are reported to control the bacterial growth and promotes wound healing.[15],[16] Panchavalkala kwatha contains barks of five trees which are having Kashaya rasa (~astringent taste), Vrana shodhaka (~wound cleaning), and Vrana ropaka (~wound healing) properties.[17] Thus, these drugs were used in postoperative period for smooth healing of wound and early recovery. The patient was followed up for the next five months. The same medicines were continued during this period. No complications related to the fistulae were reported during this period. No relapses nor symptoms of incontinence were noticed that infers safety and efficacy of the procedure.


  Conclusion Top


MC-KST is found as an effective method in managing the complex anal fistula. It reduces overall healing time, postoperative pain and minimizes the chances of recurrence and incontinence. Further studies are required in larger sample size to demonstrate its wider acceptability.

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

1.
Srikanthamurthy KR, editor. Illustrated Susruta Samhita, Sutra Sthana; Avaraniya Adhyaya. Ch. 33. Ver. 4., 1st ed. Varanasi: Chaukhambha Orientalia; 2017. p. 233.  Back to cited text no. 1
    
2.
Sainio P. Fistula-in-ano in a defined population-Incidence and epidemiological aspects. Ann Chir Gynaecol 1984;73:219-24.  Back to cited text no. 2
    
3.
Williams NS, O'Connell RP, McCaskie A. Bailey and Love's Short Practice of Surgery. 27th ed. Boca Raton, FL: CRC Press; 2017. p. 1364.  Back to cited text no. 3
    
4.
Drake RL, Vogl AW, Mitchell AW. Gray's Anatomy for Students. 4th ed. Philadelphia: Elsevier Inc.; 2020. p. 498.  Back to cited text no. 4
    
5.
Sahu M. A Manual on Fistula in Ano and Ksarasutra Therapy, Interception of Fistulous Tract with Application of Ksharasutra (Iftak) in the Management of Fistula in Ano. Varanasi: National Resource Centre on Ksarasutra Therapy; 2015. p. 184.  Back to cited text no. 5
    
6.
Parks AG. Pathogenesis and treatment of fistula-in-ano. Br Med J 1961;1:463-9.  Back to cited text no. 6
    
7.
Song KH. New techniques for treating an anal fistula. J Korean Soc Coloproctol 2012;28:7-12.  Back to cited text no. 7
    
8.
Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): A novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 2011;15:417-22.  Back to cited text no. 8
    
9.
Shastry AD, editor. Bhaishajya Ratnavali of Sen GD. Ch. 47. Ver. 51., 13th ed. Varanasi: Chaukambha Sanskrit Samstan; 1997. p. 596.  Back to cited text no. 9
    
10.
Sumantran VN, Kulkarni AA, Harsulkar A, Wele A, Koppikar SJ, Chandwaskar R, et al. Hyaluronidase and collagenase inhibitory activities of the herbal formulation Triphala guggulu. J Biosci 2007;32:75561.  Back to cited text no. 10
    
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Trikamji Y, editor. Siddha Yoga Samgraha. 5th ed. Kolkata:Shree Baidyanath Ayurveda Bhavan Ltd; 1967. p. 55.  Back to cited text no. 11
    
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Murthy SKR, editor. Illustrated Sushruta Samhita of Agnivesha, Sutra Sthana; Chapter 46. Verse 226-227. 1st ed. Varanasi: Chaukhambha Orientalia; 2017. p. 407.  Back to cited text no. 12
    
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Jirankalgikar YM, Ashok BK, Dwivedi RR. A comparative evaluation of intestinal transit time of two dosage forms of Haritaki [Terminalia chebula Retz]. Ayu 2012;33:447-9.  Back to cited text no. 13
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14.
Shastri AD, editor. Bahishajya Ratnavali, Vranashotha Chikitsa. Ch. 47. Ver. 64-66., 15th ed. Varanasi: Chaukhambha Sanskrita Bhavan; 2002. p. 597.  Back to cited text no. 14
    
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Dorababu M, Prabha T, Priyambada S, Agrawal VK, Aryya NC, Goel RK. Effect of Bacopa monniera and Azadirachta indica on gastric ulceration and healing in experimental NIDDM rats. Indian J Exp Biol 2004;42:389-97.  Back to cited text no. 15
    
16.
Pai MR, Acharya LD, Udupa N. Evaluation of antiplaque activity of Azadirachta indica leaf extract gel--a 6-week clinical study. J Ethnopharmacol 2004;90:99-103.  Back to cited text no. 16
    
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Bhat KS, Vishwesh BN, Sahu M, Shukla VK. A clinical study on the efficacy of Panchavalkala cream in Vrana Shodhana w.s.r to its action on microbial load and wound infection. Ayu 2014;35:135-40.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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Abstract
Introduction
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