E-ISSN:2456-3110

Case Report

Pilonidal sinus

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 2 March
Publisherwww.maharshicharaka.in

Posterior High Anal Fistula can mimic Pilonidal Sinus - A Case Report

Mallinath I.1*, Aradhyamath S.2
DOI:

1* I T Mallinath, Final Year Post Graduate Scholar, Department of PG & Ph.D. Studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Mysore, Karnataka, India.

2 Siddesh Aradhyamath, Professor & HOD, Department of PG & Ph.D. Studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Mysore, Karnataka, India.

Acharya Sushruta – Very aptly considered as 'Father of Surgery’, - Authored Sushruta Samhita, which is the main source of knowledge about surgery. He has mentioned Bhagandara, as Ashta-Mahagada (Eight grave disorders) which essentially means difficult to treat. The ultimate goal of Fistula surgery is to eradicate it without disturbing or disturbing minimally the anal sphincter mechanism. To achieve the objective in high anal Fistula, different surgical techniques have been described in literature from time to time. There is no single established way of treating these high anal fistulas. Conventional laying-open technique in high perianal fistula may involve sacrifice of part or whole of the sphincter muscle impairing continence. So, these surgical techniques proved fruitless due to high reoccurrence and post-operative complications. Here we are reporting a case whose MRI fistulogram findings suggestive of Pilonidal sinus /Abscess in right paramedian location in right gluteal region. But on table during surgery case got diagnosed differently that, it was totally Right high anal fistula giving ramifications on both buttocks. The case is detailed as below.

Keywords: Pilonidal sinus, Fistula-In-Ano, Haemorrhoids, Piles, Arsho-Bhagandhara, Ayurveda, Apamarga Ksara Sutra, Case Report

Corresponding Author How to Cite this Article To Browse
I T Mallinath, Final Year Post Graduate Scholar, Department of PG & Ph.D. Studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Mysore, Karnataka, India.
Email: 		I T Mallinath, Siddesh Aradhyamath, Posterior High Anal Fistula can mimic Pilonidal Sinus - A Case Report. J Ayu Int Med Sci. 2022;7(2):113-119.
Available From
https://jaims.in/jaims/article/view/1754

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-02-02 2022-02-04 2022-02-11 2022-02-18 2022-02-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 16%

© 2022by I T Mallinath, Siddesh Aradhyamathand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)113
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

Introduction

Acharya Sushruta – Very aptly considered 'Father of Surgery’, - Authored Sushruta Samhita, which is the main source of knowledge about surgery. He has mentioned Bhagandara, as Ashta-Mahagada (Eight grave disorders) which essentially means diffcult to treat. The disease so named from the fact that,[1]

Te Tu Bhagagudabasti Pradesha Daranancha Bhagandhara Ity Ucchyate |Apakvah Pidakah, Pakvastu Bhagandharah || (Su.Ni.4/4)

On the base of Doshic involvement & clinical features, Acharya Sushruta further classified them into 5 types, Sataponaka, Ushtragreeva, Parisravi, Sambhukavarta and Unmargi.[2]

Fistuala in Ano - It is a track lined by unhealthy granulation tissue which connects perianal skin superficially to anal canal, anorectum or rectum deeply. It is usually occurring in pre-existing anorectal abscess which bursts spontaneously.[3]

It can be (1) cryptoglandular - 90%, (2) non-cryptoglandular - 10%. Fistula-in-ano is well known cause of morbidity, irrespective of socio-economic status & gender.[3]

According to the recent study conducted by Indian Proctology Society, on the prevalence of Anal Fistula in a defined population of some states in India, is approximately varied from 17 to 20%. In men prevalence is 12.3 cases and in women 5.6 cases per 1,00,000 population. The male-to-female ratio is 1.8:1, The mean patient age is 38.3yrs.

Low Fistula (low inter-sphincteric and low trans-sphincteric) are the commonest Anal Fistula and can be treated easily by conventional laying-open technique, High Fistula-in- ano (high trans-sphincteric, supra-sphincteric or extra-sphincteric) are difficult to treat since the conventional laying-open will lead to division of most of the anal sphincter muscles resulting in incontinence.[4]

Fistulotomy is having delayed healing with more chances of failure & reoccurrence, Fistulectomy & LIFT are having more chances of incontinence, VAAFT fails to treat curved fistula tracks, gluing of the fistula track is having success rate of only 70%, AFP repair is used with 85% success rate only in simple fistula.[5]

Because of this, there a stigma is always related

with this ano-rectal disease. But, Kshara-Sutra is one of the gold standard techniques, which is approved by the ICMR, and It has highest success rate in all types of Fistulas, with least reoccurrence rate & complications.

The case is detailed as below.

Case Report

A 31-year-old male patient got admitted to Shalya Tantra department of JSS Ayurveda Hospital with complaints of painful swelling on gluteal region associated with pustules formation & purulent discharge on & off, since 2-3years.

History of Illness

As per the statement of the patient, he was apparently healthy before 3 years. Gradually he developed pustule formation associated with pain & discharge then sometimes spontaneous recovery.

Then he got treatment from several nearest doctors, but didn’t get complete relief, so approached to our hospital for further management.

History of Past Illness

N/K/C/O - DM / HTN / IHD / COPD / Epilepsy / Thyroid Dysfunction

K/C/O - Chronic gastritis in the last 10 years on Irregular, OTC medicines.

Surgical History - Underwent surgery for Haemorrhoids 7 years back.

Incision & Drainage for the above complaint, total 4 times in a span of 3 years.

Family History: Nothing significant

Personal History: He was both vegetarian & non-vegetarian

Vyasana: Tea/Coffee & Smoking 4-5 episodes/day

Clinical Findings

On Examination: BP - 130/80mmHg, PR - 78 bpm, R.R - 18cpm.

General Examination

Built: Moderate, Nourishment: Moderate, Temp: Afebrile.

No evidence of Pallor / Icterus / Cyanosis / Clubbing / Oedema / Koilonychia / Lymphadenopathy


Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)114
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

Systemic Examination

CNS: Conscious, well oriented to time, place and person, Gait: Normal

CVS: S1 S2 heard, no added sounds,

RS: B/L NVBS heard on all lobes.

P/A: Inverted centrally placed umbilicus, Soft, non-distended, Tenderness at epigastric region. Normal bowel sounds heard.

Musculoskeletal system - NAD, All ROM possible.

Per-Rectal/Others/Local Examination

Location - Swelling over the Right gluteal region, 3cm away from the anal verge at 8 0’clock position. No of swellings - One

On Inspection

Discolouration – Present; reddish, Swelling – Present, Pigmentation – Absent, Scar marks – Present; at mucocutaneous junction of previously operated haemorrhoids. Scar marks of I&D present surrounding to the abscess; in right gluteal region.

On Palpation

Tenderness - Present, Temperature - raised locally, Size - 2*3cm. Shape - Semi-spherical, Transillumination test - Positive, Fluctuation test - Positive.

P/R Digital Examination

Stricture – Present; Mild, Sphincter tone – Reduced, Tenderness at 7 0’clock position above the dentate line (5cm from the anal verge). No E/O palpable haemorrhoids.

Proctoscopy Examination

Hyperaemia noted between 5 & 8 o’clock position, Fibrosed & healed internal opening at 7 o’clock position.

Investigations 12-01-2022


  • HB% : 17.1gm/dl
  • WBC (TC) : 8800 Cells/Cumm
  • DC : N : 56, L : 38, E : 03, M : 03
  • ESR : 08mm 1st hour
  • HIV : Negative
  • HBsAg : Negative

Urine Routine  

  • Urine Albumin : Nil
  • Urine Sugar : Nil
  • Pus Cells : 1-2 hpf
  • RBS : 86mg/dl
  • Urea : 23mg/dl
  • Creatinine : 1.0mg/dl
  • Platelet Count : 3.43Lakhs/Cumm
  • BT : 2.35 Min
  • CT : 4.40 Min

LFT & Lipid profile found within normal limits.

ECG: Within normal limits.

USG Abdomen & Pelvis (30/08/21): Normal abdominopelvic scan.

X-RAY Chest – PA View (30/08/21): No significant abnormality detected.

MRI – Fistulogram (31/08/21): Features likely of pilonidal sinus / Abscess in right paramedian location in right gluteal region.

Diagnosis Before Surgery: Pilonidal Sinus/Ischiorectal Abscess.

Diagnosis After Surgery: High Anal Fistula-In-Ano

Treatment/Operative Procedure

Pre-operative

1. Consent for both surgery & anaesthesia taken

2. Fitness for surgery taken from physician

3. Pre-anaesthetic evaluation done

4. Part preparation done

5. Patient was kept NBM, 6 hours prior to surgery

6. Inj T.T 0.5cc /IM/stat & Inj. Xylocaine 0.3cc/SC/stat as test dose given

7. Bowels cleared by giving proctoglysis enema twice 1 hour apart each & 2 hours before surgery

Operative

With all aseptic precaution patient was shifted to operation theatre & spinal anaesthesia given. Patient was placed on lithotomy position. After cleaning & draping 4 fingers Lord’s anal dilatation achieved. Fistulas found as described below.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)115
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

Right gluteal region - One of the primary external fistulas opening found at 7 o’clock position 4cm away from the anal verge, which was probed posteriorly, it gave external opening at 8cm away from the anal verge at 6.30 o’clock position & towards the anal canal internal opening at 7 o’clock position above the dentate line 5cm from the anal verge.

The probe from the 7 o’clock primary external opening probed towards left buttock giving rise to external opening at 4 o’clock position 2cm away from the anal verge, but from here primary threading not done, only opening made.

Now on left side, the probe from this external opening probed posteriorly giving rise to another external opening at 5 o’clock position 7cm away from the anal verge & towards the anal canal internal opening at 4 o’clock position below dentate line 3cm from the anal verge. Now all the necrotised tissue excised & de-sloughing done.

Through all these fistula openings primary threading done, then at the end Ksara-Sutra transfixation done. Then opened fistula tracks plugged with ribbon gauze soaked with Jatyadi Taila. Then surgical wound closed with suitable dressing pad & Madhyama Bandha applied.

Post-operative

1. Foley’s catheterisation done to ease the patient. De-catheterisation done next day morning.

2. NBM to be continued for another 4 hours post-operatively & then relieved by giving sips of water followed by Ganji, after appreciation of bowel sounds.

3. Foot end elevation & Restricted head movements advised for 8 hours.

4. Advised daily dressing with Jatyadi Taila, Fistula openings plugged by ribbon gauze soaked with Jatyadi Taila.

5. Per rectal Taila-Purana done with Jatyadi Taila.

6. Ksara-Sutra changing done every week for 3 sittings alternatively.

Treatment Given

Under the advice of consultant physician

1. Monocef 1gm IV/ 12th hourly for 3 days

2. Tramadol 2ml/ IM sos for 3 days.

Oral Medications

1. Kaishora Guggulu 1-0-1 with water after food

2. Kamadugdha with Mouktika 1-0-1 with water before food

3. Anuloma DS 0-0-1 with water after food

4. Drakshasava 20ml-0-20ml with water after food

5. Abhayarishta 20ml-0-20ml with water after food

6. Triphala Guggulu 1-0-1 with water after food

7. Gandhaka Rasayana 1-0-1 with water after food

Condition at the time of discharge

1. All vitals were normal,

2. Patient's general condition was fair,

3. No any fresh complaints related to surgery,

4. Patient was haemodynamically stable.

Advice on discharge

1. Kaishora Guggulu 1-0-1 with water after food

2. Kamadugdha with Mouktika 1-0-1 with water before food

3. Anuloma DS 0-0-1 with water after food

4. Drakshasava 20ml-0-20ml with water after food

5. Abhayarishta 20ml-0-20ml with water after food

6. Triphala Guggulu 1-0-1 with water after food

7. Gandhaka Rasayana 1-0-1 with water after food

Pathya-Apathya

Avoid sexual intercourse, physical exercise, Riding bike or on camel etc animals, anger, and intake of heavy food for a period of one year after the complete healing of wound in Bhagandhara.[6] Even when the wound gets healed one should avoid things like Ajirna, Vyayama, Vyavaya along with these mental blemishes like - Harsha, Krodha, Bhaya. These have to be avoided till the stability is not attained.[7]

Review: Daily for dressing / SOS / for Ksara-Sutra thread changing every week as advised from time to time.

Follow-up: Once in a month for 6 months to check for complications and recurrence. No E/O complications found during follow-up period.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)116
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

jaims_1754_01.JPG

During Examination

jaims_1754_02.JPG

On left lateral position

jaims_1754_03.JPG

MRI Fistulogram 31/08/2021

jaims_1754_04.JPG

7th Day After Surgery

jaims_1754_05 (2).JPG

15th Day After Surgery

jaims_1754_05.JPG

21st Day After Surgery

jaims_1754_06.JPG

28th After Surgery



Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)117
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

Discussion

The ultimate goal of Fistula surgery is to eradicate it without disturbing or disturbing minimally the anal sphincter mechanism. To achieve the objective in high anal Fistula, different surgical techniques have been described in literature from time to time. These include Park's fistulotomy, fistulotomy with primary repair of the sphincter, primary fistulectomy with occlusion of the internal ostium, insertion of a seton, LIFT, VAAFT, endorectal & ano-cutaneous advancement flaps, repair of fistula using fibrin glue and re-routing the fistula. The number of procedures mentioned indicates that there is no single established way of treating these high anal fistulas. Besides conventional laying-open technique in high perianal fistula may involve sacrifice of part or whole of the sphincter muscle impairing continence, more the part of sphincter muscle damaged, more is the incontinence. So, these surgical techniques proved fruitless due to high reoccurrence and post-operative complications.

Acharya Sushruta mentioned the use of Ekadasha upakramas from Apatarpana to Virechana for the treatment of non-suppurated stage of Bhagandhara named Bhagandhara Pidaka. In suppurated stage advised surgery by proper probing, followed by cauterization with fire or an alkali is a general remedial measure which may be resorted to all types of this disease.[8] Kshara-Sutra by the action of chemical cauterisation divides the muscle slowly without allowing it to spring apart avoiding the deformity. It will well-preserve the sphincter function and pressure. Kshara allows the Fistula to granulate and heal from the floor and to close completely. IFTAK is one of advanced technique in Ksara-Sutra procedures of fistula-in-ano.

Dr. Siddesh Aradhyamath Sir, HOD & Prof, Department of Shalya-Tantra, always used to say that “don’t sold out your brain to the radiologists/other doctor’s, investigations are just references, the success of surgery is always depends on the surgeon’s discretion, proper preoperative evaluation, proper probing, and his skills based on individual experience” We also get the direct reference for the same in Sushruta Samhita that,

Yato-Yato Gatim Vidhyat Utsango Yatra Yatra Cha|

Tatra Tatra Vranam Kuryat Yatha Dosho Na Tishtati || (Su.Su.5/11-12)

Pathya-Apathya advised to the patient is totally according to Sushruta. Now-a-days also it is proved to be relevant that, if any patient who don’t follow it will be going to develop complications & reoccurrence.

Conclusion

Especially in coloproctology cases, one should not completely rely on radiology reports, they are to be used as just reference; one should correlate clinically & one should use their own discretion during the surgery. The Kshara-Sutra therapy by its gradual and sustained chemical action is capable of dissolving the tough fibrous tissue and ultimately draining it out with creating a healthy base for healing. The recurrence and sphincteric loss are two major problems of the Anorectal surgery, which are well addressed by this technique. It not only cures but also eradicates the root cause of the disease. Hence, it is getting the recognition worldwide and now being identified by WHO as an alternative technique for these disorders. Kshara-Sutra therapy (combo of surgical & para-surgical techniques-gold standard) of Fistula-in-ano is now well accepted everywhere and has found an honorable place in the text books of Colorectal surgery also, owing to its complication-free curative results.

Reference

1. Vasant C Patil, Rajeshwari N M. Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes. Chaukhambha Publications, Varanasi. 1st edition, 2018, Vol 1, p355.

2. Vasant C Patil, Rajeshwari N M. Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes. Chaukhambha Publications, Varanasi. 1st edition, 2018, Vol 2, p32-33.

3. Sriram Bhat M. SRB’s Manual of Surgery. Jaypee Brothers Medical Publishers. 6th Edition, p971.

4. Sriram Bhat M. SRB’s Manual of Surgery. Jaypee Brothers Medical Publishers. 6th Edition, p971.

5. Sriram Bhat M. SRB’s Manual of Surgery. Jaypee Brothers Medical Publishers. 6th Edition, p975.

6. Vasant C Patil, Rajeshwari N M. Sushruta Samhita of Maharsi Sushruta with English Translation of


Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)118
Mallinath T et al: Posterior High Anal Fistula can mimic Pilonidal Sinus

Text and Dalhana’s Commentary with Critical Notes. Chaukhambha Publications, Varanasi. 1st edition, 2018, Vol 2, p362.

7. Vasant C Patil, Rajeshwari N M. Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes. Chaukhambha Publications, Varanasi. 1st edition, 2018, Vol 1,p73


Journal of Ayurveda and Integrated Medical Sciences 2022;7(2)119