Management of Parikshepi Bhagandar (Horse-shoe Fistula in Ano) by intercept of track followed by conventional Kshara Sutra

Manmahendra; Bhinya Ram; Ashok Kumar; P. Hemantha Kumar

doi:http://dx.doi.org/10.21760/jaims.8.5.44

Management of Parikshepi Bhagandar (Horse-shoe Fistula in Ano) by intercept of track followed by conventional Kshara Sutra

Manmahendra.^1*, Ram B.², Kumar A.³, Hemantha Kumar P.⁴

DOI: http://dx.doi.org/10.21760/jaims.8.5.44

^1* Manmahendra, PhD Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda, Deemed to University, Jaipur, Rajasthan, India.

² Bhinya Ram, PG Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda, Deemed to University, Jaipur, Rajasthan, India.

³ Ashok Kumar, Professor, PG Department of Shalya Tantra, National Institute of Ayurveda, Deemed to University, Jaipur, Rajasthan, India.

⁴ P. Hemantha Kumar, Professor, PG Department of Shalya Tantra, National Institute of Ayurveda, Deemed to University, Jaipur, Rajasthan, India.

In Ayurveda surgical sphere Acharya Sushruta and Vabhagta elaborated fistula in Ano properly. In which Parikshepi Bhagandar is the advance stage originated by Vata-Pitta Dosha. In contemporary science it is mentioned under heading of Complex horse-shoe Fistula-In-Ano (FIA). FIA is a common surgical Ano-rectal condition that occurs twofold as often in men as in women, present between the age group of 20 to 50 Years. According to parks classification > 65% coming under category of complex fistula in Ano is challenging to managed by Surgeons because of more chances of reoccurrence. In this manuscript successful management of Parikshepi (Horse-shoe FIA) Bhagandara by modified conventional Kshara Sutra Technique with significant post-operative outcome, minimum tissue damage and post-operative scar is described.

Keywords: Fistula-in-Ano, Kshara Sutra, Parikshepi Bhagandar

Corresponding Author	How to Cite this Article	To Browse
Manmahendra, PhD Scholar, PG Department of Shalya Tantra, National Institute of Ayurveda, Deemed to University, Jaipur, Rajasthan, India. Email:	Manmahendra, Bhinya Ram, Ashok Kumar, P. Hemantha Kumar, Management of Parikshepi Bhagandar (Horse-shoe Fistula in Ano) by intercept of track followed by conventional Kshara Sutra. J Ayu Int Med Sci. 2023;8(5):254-259. Available From https://jaims.in/jaims/article/view/2493

Introduction

Fistula-In-Ano (FIA) is a common surgical Ano-rectal condition that occurs twofold as often in men as in women, present between the age group of 20 to 50 Years. Cryptoglandular FIA started from small abscess present at inter-sphincteric place then move to difference direction.^[1]

In Ayurveda Science Acharya Sushruta and Vagbhata describe details classification of Fistula in ano under the heading of Bhagandar. In classification of Acharya Vagbhata total 8 types of Bhagandara are defined based on Dosha involvement. Parikshepi (Horse-shoe Fistula in Ano) Bhagandara coming under category of complicated fistula-in- Ano. In which infection start from inter-sphincteric grove to spread circumferentially by planes of inter-sphincteric grove and infection spread to contralateral site. If we are planned for modern surgical technique in this condition chances of sphincter damage and incontinence will occur.^[2] Apart from this problem another disadvantage of modern techniques is, reoccurrence also is of very high range 12% -78% (Success Rate 22% -88%). To overcome this problem, Apamarga Kshara Sutra minimize the complication and reoccurrence in complicated fistula in Ano.^[3,4]

In this case report a 18 years old male patient come into Shalya OPD (Outdoor Patient) with complaint of intermittent purulent discharge and pain. On examination he was diagnosed as complex horse-shoe fistula-in-Ano, categized in Ayurveda as Parikshepi Bhaganda.

This case treated with modified approach of Conventional Apamarga Kshara Sutra technique.^[5]

End after followig-up this patient is successfully healing of wound with minimum scar and without any deformity and reoccurrence.

Patient Information

A 18-years-old male patient came to Ano-rectal OPD with complaints of mild pain, intermittent pus discharge with boils around perianal region for 10 months. He is previously operated before 2 months in some private hospital. He is hemodynamically stable [Table 1], has irregular bowel habits, and has no history of any other systemic illness like Diabetes mellitus, Hypertension, etc.

Table 1: General Examination

Built	Normal
Blood Pressure	116/80 mm Hg
Temperature	98° Fahrenheit
Pulse	82 per minutes
Sleep	Adequate
Bowel	Not Clear
Clubbing / Cyanosis / Lymphadenopathy	Absent

Clinical Finding: Patient taken in lithotomy position on table, on local examination, one small opening was observed at 2 o’clock position with previous scars mark on both side of the ischia-rectal fossa

External opening was approximately 3-4 cm away from the anal verge and purulent discharge also seen during pressing on posterior midline. On palpation, it was observed that the fibrous tract was palpated between external opening and posterior midline. This track extends up-to 7 O’clock and small pit also feel on previous scar in right side at 10’clock but it is not a active point. On digital rectal examination internal opening presented between dentate line and ARR (Ano-rectal Ring). Finally, he is diagnosed as complex horse shoe fistula in Ano, it is planned for Shalya Karma (Intercept of Track followed by Apamarga Kshara Sutra)

Timeline: In this case complete follow up period was continuing, the timeline of the case is describing in [Table 4]

Diagnostic Focus and Assessment

The confirmatory diagnosis of the patient was based on clinical findings, so no need for any radiological investigations e.g., Magnetic Resonance Imaging (MRI) and sinogram. All routine haematological investigation was done and mentioned in [Table 2]

Table 2: Haematological Investigation

Hb	15 gm %
TLC	8200/ mm3
ESR	22 mm in Ist hour
RBS	126 mg/dl
RFT / LFT	Within normal limit
Viral Markers (HIV I/II and HBsAg)	Negative

Materials and Methods

Therapeutic focus and assessment

Procedure: Before starting the procedure, prophylactic medications and sensitivity were checked.

After obtaining written informed consent and performing standard preoperative care (Mentioned in Table Number 3) and confirming vitals within a normal limit patient was shifted to the OT table in a lithotomy position and Painting (by 10 % Providing Iodine) and draping was done. Approximately 35 ml of Lignocaine with adrenaline in strength 1 % was infiltrated on the operative site through the diamond block along with pudendal block and after coming the effect of lignocaine. 2-3 ml Methylene blue was inserted through the external opening, die was coming from internal opening. After that Probe was inserted into the track from external opening. Direction of probe was going toward the posterior midline. Some die coming out from the contralateral side when pressing at 6 o’clock after removing of probe.

In procedure first probe was inserted from external opening then interception of fistulous track was done at inter-sphincteric grove with the help of blade (11 No Blade) and scissor. After proper interception of track, probe was withdrawn and another retrograde probing was done from 6 to 6 clock position. Finally Plain Thread inserted at posterior midline. External opening was widen-up for proper and fast healing local site. Window was packed with betadine gauze piece. Complete haemostasis achieved. The antiseptic dressing was applied then the patient was shifted to the recovery room. The patient was advised to take Tab. Triphala Guggulu (1000 mg) twice daily with lukewarm water after food, Compound formulation (Aamlaki Churna-3gm + Sudhdha Gandhak- 125 mg + Rasmankiya 125mg) twice daily with tap water and for local application Panchavalkal Kwath 15-20 ml one time for irrigation of track before dressing up-to 10 days followed by Antiseptic dressing with Jatyadi tail. [Table Number 3].

Table 3: Prophylactic and Post-operative Medicines

Date	Drug	Dose	Duration
03/12/2022	Inj. Tetanus Toxoid	0.5 ml I/M as a booster dose/Prophylactic dose	Before one day of surgery
	Inj. Ceftriaxone	1 gram IV (Single dose)	Day of Surgery
	Inj. Gentamycin	80 mg IV (Single dose)	Day of Surgery
	Inj. Diclofenac sodium	75 mg I/M (Single dose)	Just after surgery
	Inj. Lignocaine with Adrenaline	0.2 mg S/C	For Sensitivity Test
	Tab (Diclofenac Sodium +Paracetamol +Serratio peptidase)	(50mg +325mg +15mg) Orally BD	Post-operative up to 3 days

Post-Operative Ayurvedic Medicine

Date	Drug	Dose		Duration
03/12/2022	Triphala Guggulu	750 mg BD		30 Days
26/05/ 2022	Sudh Gandhak Rasmanikya Amalaki Churna	75 mg 125 mg 3 gm	BD	30 Days
26/05/2022	Jatyadi Taila for LA	1 Time/day		3 Days
29/05/2022	Daily Irrigation with Panchvalkal Kwatha	1 Time/day		7 Days

Inj. – Injectable, BD- Bis in die, IM- Intramuscular, IV- Intravascular, S/C-Subcutaneous

Table 4: Timeline of Case Repot

Date	Events	Intervention
02/12/2022	Visited Ano-rectal Unit with complaints of mild pain, Intermittent discharge and Boil for last 10 months.
02/12/2022	On Examination in lithotomy position, Previous scar marks were seen, External Opening Present at 12 clock position with internal opening at posterior mid line along track extension up-to 7th clock position. Finally, case was diagnosed as complex horse shoe Fistula in Ano. [Figure 1]
03/05/2022	Diagnosis is confirmed under Local Anaesthesia before starting of procedure.	Routine Investigation Pre-anaesthetic check-up completed
03/12/2022	On table Re -examined	Modified Conventional Kshar Sutra Technique (Intercept of track into inter-sphincteric groove at posterior mid line and Plain Thread in-situ) under Local Anaesthesia [Figure-2]
04/12/2022	Moderate pain was noted on 1st pod (Post-operative day)	The dressing was changed by Jatyadi Taila [Figure 3], Oral medication was started as per [Table 4]
06/12/2022	Mild pain and discharge present on 3rd POD	Plain Thread replaced with Apamarga Kshara Sutra. The dressing was applied and the remaining treatment was continued. [Figure-4]
10/12/2022	Mild pain present during dressing,	Irrigate of track by Panchavalkal Kwath and Dressing changed with Jatyadi Taila
17/12/2022	Pain and discharge reduce.	-
24/12/2022	Healthy granulation tissue was seen on the wound. Pain and discharge completely ceased in 2nd week.
01/01/2023	The wound was completely healed with Minimum scar without any tenderness.	Dressing stopped but prescribed oral medicine continue for next 7 days
18/01/2023	The wound was totally healed with minimum scar [Figure 5]	All oral medication was stopped

Follow-up and outcome: Regular follow-up was advised, the first post-operative dressing was open after 24 hours, and moderate seropurulent discharge was present up to the 3^rd POD (Post-Operative Day). After that Plain thread replaced with Apamrga Kshara Sutra. After that discharge was gradually reduced and completely ceased after 10^th POD. Analgesia (Tablet Diclofenac Sodium) was needed for up to 3 days due to moderate pain that was observed in 1^st week and later on gradually subside. The discharge was completely stopped after the 15^th post-operative day and completely dried up at the end of the 4^th week.

In 5^th week all external openings were closed remaining posterior window. Kshara Sutra Was changed every week, Total six Kshara Sutra Changed final Kshara Sutra Changed at 6^th Week. After that wound was completely heal within and minimum scar was there. All medications were stopped after the completion of 7^th week. There was no complication seen during and after treatment. Follow up was taken up-to next 2 months by telephonic measure, no reoccurrence seen.

Patient follow-up was taken Continue up to 2 months by telephonic communication. Patient feedback- No complaint or re-occurrence.

Figure 1: Pre-operative Image

Figure 2: Operative Image

Figure 3: 1^st POD

Figure 4: 3^rd POD

Figure 5: 5^th POD

Discussion

Ample of Surgical and para-surgical techniques are available for fistula in Ano in contemporary science but there is a limitation of every technique that ensures successful management of these conditions. recurrence and complications always upset the surgical team and patients. The financial burden on the patient because of long hospital stays, excessive pain due to extensive loss of tissue, Ugly scar marks because of the surgical procedures, etc. are the other demerits of already-established surgical procedures.^[6]

All FIA surgical techniques are based on management of primary and proper drainage of post-operative secretions. According to the previous database complete fistulotomy is gold standard surgical treatment for low level FIA. After that sphincter saving technique developed but no any of them can minimize the risk of reoccurrence as old Apamarga Kshara Technique. Conventional Kshara Sutra technique was a long duration therapy and painful stimulation was there in every sitting. To overcome this problem interception of track was came into light.

To minimalize above mentioned drawback, Ayurvedic Surgeons also modified the conventional therapy for better post-operative outcome. In post-operative period Triphala Guggulu used for reduction of inflammatory sign on local site.^[7] Another compound Amalaki formulation prevent the infection source and enhance the wound healing because of Vit-C.^[8] As a local application Panchavalkal Kwatha is very potent for Shodhan and Ropan Properties.^[9] Application of Jatyadi Taila is very effective for wound healing and prevention of bacterial colony formation on local site, ample of clinical evidence available.^[10]

Conclusion

This case report describes a modified Conventional Kshara Sutra Technique. In this technique main aim is damage of main culprit of focus followed by fast healing with minimum post-operative scar. According to literature 45% of fistula come under the category of Inter-sphincteric fistula, fistulotomy is gold standard treatment for inters-sphincteric and trans-sphincteric (low level <30% involvement of Sphincter) fistula in Ano.^[11]

Apart from these categories other fistula management is very difficult. In this condition our proposed technique (Intercept of fistula in ano followed by Apamarga Kshara Sutra) is very useful. Interception minimizes the tissue destruction, healing time, post-operative pain and hospital stay and intervention of Kshra Sutra is for proper drainage of wound secretion, Cutting and healing Simultaneously occur and prevent reoccurrence. The patient in this case report underwent this technique successfully and had a good postoperative outcome and a reduce financial burden. However, further studies are needed to determine the efficacy of this technique in larger sample size.

References

1. Sammut, M., & Skaife, P. (2020). The management of cryptoglandular fistula-in-ano. British journal of hospital medicine (London, England: 2005), 81(1), 1–9. https://doi.org/10.12968/hmed.2019.0353

2. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula‐in‐ano. British Journal of Surgery. 1976 Jan;63(1):1-2.

3. Seow‐Choen F, Nicholls RJ. Anal fistula. British Journal of Surgery. 1992 Mar;79(3):197-205.

4. Limura E, Giordano P. Modern management of anal fistula. World Journal of Gastroenterology: WJG. 2015 Jan 1;21(1):12.

5. Lobo, S. J., Bhuyan, C., Gupta, S. K., & Dudhamal, T. S. (2012). A comparative clinical study of Snuhi Ksheera Sutra, Tilanala Kshara Sutra and Apamarga Kshara Sutra in Bhagandara (Fistula in Ano). Ayu, 33(1), 85–91. https://doi.org/10.4103/0974-8520.100319

6. Shawki, S., & Wexner, S. D. (2011). Idiopathic fistula-in-ano. World journal of gastroenterology, 17(28), 3277–3285. https://doi.org/10.3748/wjg.v17.i28.3277

7. Vishwanatha, U., Guruprasad, K. P., Gopinath, P. M., Acharya, R. V., Prasanna, B. V., Nayak, J., Ganesh, R., Rao, J., Shree, R., Anchan, S., Raghu, K. S., Joshi, M. B., Paladhi, P., Varier, P. M., Muraleedharan, K., Muraleedharan, T. S., & Satyamoorthy, K. (2016). Effect of Amalaki rasayana on DNA damage and repair in randomized aged human individuals. Journal of ethnopharmacology, 191, 387–397. https://doi.org/10.1016/j.jep.2016.06.062 sciences. 2007 Jun;32(4):755-61.

8. Vishwanatha, U., Guruprasad, K. P., Gopinath, P. M., Acharya, R. V., Prasanna, B. V., Nayak, J., Ganesh, R., Rao, J., Shree, R., Anchan, S., Raghu, K. S., Joshi, M. B., Paladhi, P., Varier, P. M., Muraleedharan, K., Muraleedharan, T. S., & Satyamoorthy, K. (2016). Effect of Amalaki rasayana on DNA damage and repair in randomized aged human individuals. Journal of ethnopharmacology, 191, 387–397. https://doi.org/10.1016/j.jep.2016.06.062

9. Paudel D, Dudhamal TS. Effect of Panchavalkal formulation in the Management of Post-operative Fistulectomy Wound-A Case Report. International Journal of AYUSH Case Reports. 2023 Mar 19;7(1):16-23.

10. Shailajan S, Menon S, Pednekar S, Singh A. Wound healing efficacy of Jatyadi Taila: in vivo evaluation in rat using excision wound model. Journal of Ethnopharmacology. 2011 Oct 31;138(1):99-104.

11. Litta, F., Parello, A., Ferri, L., Torrecilla, N. O., Marra, A. A., Orefice, R., De Simone, V., Campennì, P., Goglia, M., & Ratto, C. (2021). Simple fistula-in-ano: is it all simple? A systematic review. Techniques in coloproctology, 25(4), 385–399. https://doi.org/10.1007/s10151-020-02385-5

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2023-03-29	2023-03-31	2023-04-07	2023-04-14	2023-04-21
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	17%

Case Report

Fistula-in-Ano

Journal of Ayurveda and Integrated Medical Sciences

Management of Parikshepi Bhagandar (Horse-shoe Fistula in Ano) by intercept of track followed by conventional Kshara Sutra

Manmahendra.1*, Ram B.2, Kumar A.3, Hemantha Kumar P.4

Introduction

Patient Information

Materials and Methods

Discussion

Conclusion

References

Manmahendra.^1*, Ram B.², Kumar A.³, Hemantha Kumar P.⁴