An approach towards Complex Long Tract with Multiple Opening Fistula-In-Ano through Kshara Sutra - A Case Report

Priyadeep Raj; Rohitash Gurjar; B Swapna; P Hemantha Kumar

An approach towards Complex Long Tract with Multiple Opening Fistula-In-Ano through Kshara Sutra - A Case Report

Raj P.^1*, Gurjar R.², Swapna B.³, Hemantha Kumar P.⁴

DOI:

^1* Priyadeep Raj, Post Graduate Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda (Deemed To Be University), Jaipur, Rajasthan, India.

² Rohitash Gurjar, Post Graduate Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda (Deemed To Be University), Jaipur, Rajasthan, India.

³ B Swapna, Associate Professor, PG Department of Shalya Tantra, National Institute of Ayurveda (Deemed To Be University), Jaipur, Rajasthan, India.

⁴ P Hemantha Kumar, HOD and PG Dean, PG Department of Shalya Tantra, National Institute of Ayurveda (Deemed To Be University), Jaipur, Rajasthan, India.

Generally, fistulectomy is an acceptable surgical approach for treating a simple or low trans-sphincteric fistula. But in case of long fistulous tract with multiple external opening fistulectomy is not an adequate surgical procedure because of multiple and large size wounds. We present a case of a complicated fistula-in-ano with a low and a trans-sphinteric element that opens radially from the external opening to the anal canal. A 45-years-old man with a chronic discharging fistula, on clinical examination opening externally at 9 o’ clock position at gluteal region approximately 15 cm away from anal verge and internal opening also at 9 o’ clock position. Another external opening at 5 o’ clock position and internal opening found at 6 o’ clock position. He experienced discharge and pruritus for the previous 6 months and had been on antibiotics. The low fistulous tract from 5 to 6 o’ clock position was curettaged and Kshara was applied. The long fistulas were treated by the Kshara Sutra and multiple simple threads (linen no. 20) application method was adopted. The wound healed fully in 45 days and currently the patient is asymptomatic and has full continence at 6 months of follow-up.

Keywords: Bhagandar, complex Fistula-in-ano, Ksharasutra

Corresponding Author	How to Cite this Article	To Browse
Priyadeep Raj, Post Graduate Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda (Deemed To Be University), Jaipur, Rajasthan, India. Email:	Priyadeep Raj, Rohitash Gurjar, B Swapna, P Hemantha Kumar, An approach towards Complex Long Tract with Multiple Opening Fistula-In-Ano through Kshara Sutra - A Case Report. J Ayu Int Med Sci. 2022;7(1):420-423. Available From https://jaims.in/jaims/article/view/1602

Introduction

Bhagandar^[1] (Fistula-in-Ano) is explained as one among Ashta Mahagada^[2] (The eight intractable diseases) in Sushruta Samhita. This disease is recurring makes treatment more challenging. So, it produces inconvenience in routine life. The concept of Kshara Sutra has been explained in the context of Nadivrana^[3](sinus) by Acharya Sushruta. Fistula-in-ano is an infective disease of anal region and its prevalence is around 8.6 cases per 100,000 populations. The major cause is crypto glandular infection of anal glands which is a chronic aberrant communication frequently lined by unhealthy granulation tissue runs outwards from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock or scrotum (or rarely, in women, to the vagina). Kshara Sutra^[4] is a medicated thread containing Snuhi Kśīra (latex of euphorbia nerifolia), Apamarga Kshara (Achyranthes aspera) and Haridra (Curcuma longa) powder. It is a proven treatment modality in Ayurveda in many diseases especially fistula-in-ano. Use of Kshara Sutra causes extensive fibrosis and favors proper healing which reduces the chances of recurrence.^[5] Although there are many surgical techniques available for the management of fistula-in-ano. But in case of long fistulous tract with multiple external opening fistulectomy or other surgical techniques are not an adequate surgical procedure because of multiple, large size wounds, and very much healing time there is one or other complications or high recurrence rate. In this technique there is less chance of recurrence and very less healing time of fistulous tract.

Case Report

Chief complaints and duration: Patient complaints of pain, swelling, pus discharge from perianal region and gluteal region since six months.

H/O Present illness: On 14/7/21 a 45 years old male patient came to our OPD of PG department of Shalya Tantra, National Institute of Ayurveda Deemed to be University, Jaipur with chief complaints of pain, swelling and pus discharge from perianal and gluteal region since six months. Discharge was seen at 9 o’ clock position and 5 o’ clock positions. He had been on antibiotics from last six months for the same. But he got no relief.

H/o past illness: No previous h/o surgery or any other severe illness.

General Examination

GC - Moderate
Pulse - 86/min
BP - 140/84mmhg
RS - 16/min
Temp - 98.8F
Appetite - Normal
Bowel - Normal

Systemic Examination

Respiratory System	Inspection: B/L symmetrical chest Auscultation: AEBE
Central Nervous System	Orientation: Patient was conscious and well oriented
Cardiovascular system	Auscultation: Normal heart sounds

Local Examination

After taking patient in lithotomy positions the findings seen were opening externally at 9 o’ clock position at gluteal region approximately 15cm away from anal verge and internal opening at also 9 o’ clock position at level of dentate line. Another external opening at 5 o’ clock positions 4cm away from anal verge and internal opening found at 6 o’ clock positions. Digital rectal examination showed two internal openings at the dentate line at 9 and 6 o’ clock position. An MRI scan as well as probing under anaesthetic confirmed this. The MRI also showed gluteal extensions.

Investigations

Complete blood count, CT, BT, random blood sugar was normal and HIV I & II, and HBsAg were non-reactive.

Chest X-rays, ECG were normal study.

Fig. 1: Clinical picture of patient before surgery

Operative Procedure: The treatment adopted for this case was Kshara Sutra therapy using multistage bifurcation of fistulous tract with the application of Kshara Sutra technique. The procedure was as follows: the patient was taken in lithotomy position, after painting and draping perianal block was given and along the fistulous tract. Probing of the fistulous tract done which was communicating external opening at gluteal region to 6cm away from anal verge, second probing was done from second opening to inter-sphincteric space and third probing was done to an internal opening at 9 o’ clock position at the level of dentate line with a malleable copper probe. Another probing was done from another external opening from 5 o’ clock to an internal opening situated at dentate line posteriorly at 6 o’clock. Then a small opening was created posteriorly at 6 o’clock approximately 3cm from the anal verge. The external opening was widened and three primary threadings were done with linen thread no. 20. The 1^st thread was introduced between gluteal external opening to 6cm away from anal verge opening, the 2^nd thread between second opening and inter-sphincteric space and the 3^rd thread was placed between artificial inter-sphincteric space opening at 9 o’clock to internal opening at 9 o’ clock position at the level of dentate line (Fig 2). And another fistula in ano 5 to 6 o’ clock position was well curettaged and Apamarga Kshara was applied and leave it. On the next day, Kshara Sutra was applied into the tracts replacing only primary threading from inter-sphincteric space to internal opening at 9 o’ clock position. The patient was advised warm sitz bath daily with Tankan Bhasm and dressing with Jatyadi Taila. Oral medications such as Ṭriphala Guggulu 2 tablets (250 mg) and Triphala Churna 3gm were given twice daily for one month. After two days, the patient was discharged with regular follow-up and weekly Kshara Sutra was changed.

Fig. 2: Clinical picture of the patient during procedur

Post - Operative follow up

Since Kshara Sutra is a multi-stage therapy, debriding with every follow-up is necessary. After a 7-days follow-up, no pus discharge was observed, so the 1^st primary fillet was removed from the gluteal orifice to 6cm from the anal border. In the next follow-up, gluteal extension was seen to totally cure and no complaints of discomfort. The 2^nd thread was terminated after 2 weeks and only one Kshara Sutra was maintained locally. The injury gradually recovered around 5 o' clock. After 5 Kshara Sutra changes which were done at the weekly interval, the tract at 9 o’ clock was spontaneously cut through after 45 days and packing of Jatyadi Taila after cut through continually was done till complete healing of tract. The fistula tract healed in 45 days completely with minimum scarring.

Fig. 3: During follow up & after complete healing

Discussion

There are several therapeutic options, however virtually all have fistula-in-ano recurrence. Today various methods of Kshara Sutra treatment are highly beneficial. It is a multistage operation which in the follow-up period needs minor procedures. Ksharasutra is shown as a viable way of therapy in fistula-in-ano utilizing the Fistula-in-ano multi-stage bifurcation with the use of the Kshara Sutra technique. It avoided a worse wound caused by a standard fistulotomy or fistulectomy and lowers Kshara Sutra treatment healing time. This technological process bifurcates the distal section of the fistulous tract at an external sphincter and uses the linen thread 20 at the inter-spherical spatial site, while the interceptor site for the infected crypt is used on an anal channel by Kshara Sutra. This is intended to eliminate diseased anal crypt by means of Kshara Sutra without or with little harm to anal sphincters (medicated seton). Time for cure is decreased too.

Conclusion

The case of fistula-in-ano is processed extremely efficiently and with improved technique with the multistage bifurcation of the fistula tract. The fistula-in-ano multiple-stage method

in this situation is preferable for fistula-in-ano therapy if the opening tract is lengthy. As long as Ksharasutra's interval is fairly tough and there is a risk of sphincter injury between exterior and interior opening. In this method, the postoperative scar is similarly small.

Reference

Shastri Kaviraj Ambikadatta, Sushruta Samhita, Ayurveda Tatva Sandeepika, 2016 edition, Varanasi, Chaukhambha Sanskrit Samsthana, Nidana Sthana 4/4, page no.-317
Shastri Kaviraj Ambikadatta, Sushruta Samhita, Ayurveda Tatva Sandeepika, Hindi commentary, 1997th edition, Reedition 2016, Varanasi, Chaukhamba Sanskrit Samsthana, Sutrasthana 30/4-5, page no.-165
Sharma PV, Susruta Samhita with English Translation of Text and Dalhana’s Commentary along with Critical Notes, 2000, Vol II, Chaukhambha Visvabharati, Varanasi Cikitsasthana, 17/29, Page No. 430.
Rao G. P, Cakrapanidatta Cikitsa Sangraha of Cakrapanidatta, 2014, Chaukhambha Orientalia, Varanasi. 5/148, Page No. 95
Sharma PV, Susruta Samhita With English Translation of Text and Dalhana’s Commentary along with Critical Notes, 2000, Vol I Chaukhambha Visvabharati, Varanasi. Sutrasthana, 11/04, Page No. 113

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-01-22	2022-01-24	2022-01-31	2022-02-07	2022-02-14
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	16%

Case Report

Fistula-In-Ano

Journal of Ayurveda and Integrated Medical Sciences