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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 10-13

Management of Riju bhagandara (trans-sphincteric anal fistula) by modified conventional Ksarasutra therapy

Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, India

Date of Submission27-Mar-2020
Date of Acceptance12-May-2020
Date of Web Publication14-Jul-2020

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

DOI: 10.4103/JACR.JACR_6_20

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Management of anal fistula is always a big challenge for surgeons due to recurrence and associated anal incontinence. In spite of various advancements, failure rate is high even after surgery. Ksarasutra therapy is accepted as a successful modality with high cure rate in the management of anal fistula. In this case, a 45-year-old, hypertensive, and diabetic male patient visited to Shalya tantra outpatient department with complaints of intermittent pus discharge from the peri-anal region for seven months. On local examination, an external opening covered with hyper-granulation and pus discharge was observed nearer to the base of scrotum at approximately eight cm away from the anterior anal verge. On palpation, a thick fibrous cord-like structure was felt extending from the anal canal to the base of scrotum. On per rectal examination (P/R) examination, a tender point was felt at the 12'o clock position just above the dentate line. Magnetic resonance imaging revealed a trans-sphincteric anal fistula with internal opening at the 12 o' clock position and was managed by Modified Conventional Ksarasutra technique. The tract was completely healed within five weeks. No fecal incontinence was reported by the patient, nor signs of recurrence were observed after six months of follow-up.

Keywords: Anal fistula, Bhagandara, Ksarasutra

How to cite this article:
Sreenadh P, Mahanta V, Sherkhane R, Gupta SK. Management of Riju bhagandara (trans-sphincteric anal fistula) by modified conventional Ksarasutra therapy. J Ayurveda Case Rep 2020;3:10-3

How to cite this URL:
Sreenadh P, Mahanta V, Sherkhane R, Gupta SK. Management of Riju bhagandara (trans-sphincteric anal fistula) by modified conventional Ksarasutra therapy. J Ayurveda Case Rep [serial online] 2020 [cited 2022 Aug 8];3:10-3. Available from: http://www.ayucare.org/text.asp?2020/3/1/10/289377

  Introduction Top

Anal fistula is a chronic, abnormal communication usually lined with granulation tissue and runs outwards from the ano-rectal lumen to an external opening on the skin of the perineum and vagina in women.[1] The prevalence of anal fistula in the general population is 0.01%, with higher frequency in men than women at 2:1 ratio.[2] Usually, they manifest due to infection of anal glands. The initial clinical presentation will be perianal abscess.[3] Anal fistula is classified under K 60.3 as per the International Classification of Disease (ICD-10).[4] Different surgical treatment modalities such as fistulectomy, fistulotomy, anal advancement flaps, and ligation of the inter-sphincteric fistulous tract are available for treating anal fistulae, but chances of recurrence and fecal incontinence are high particularly in complex anal fistulae. These techniques are not affordable by all, as they are expensive. Considering the clinical presentation, anal fistula is compared with Bhagandara in Ayurveda, which is one of the Ashtamahagada.[5] There are eight types of Bhagandara as per Vagbhata, and long trans-sphincteric anal fistula can be correlated with Riju Bhagandara.

Ksarasutra is a simple, safe, minimally invasive para-surgical therapy and time-tested for treatment of anal fistula.[6],[7]Ksarasutra therapy is being widely practiced as a primary management in all types of Bhagandara. However, in case of conventional Ksarasutra therapy, there are some demerits such as need of changing Ksarasutra at regular intervals that is associated with mild-to-moderate pain, foreign body sensation at perianal region during entire course of treatment, stress due to repeated visits to the hospital and comparative longer time to completely heal the fistulous tract.

Modified conventional Ksharasutra therapy (MC-KST) is developed to manage cryptoglandular infection.[8] By this technique, the infected anal crypt and anal gland will be excised with minimal harm to anal sphincters for the management of simple as well as complex anal fistulae. In this technique, fistulous tract will be intercepted at the level of external sphincter followed by application of Ksarasutra from the site of interception to infected crypt of anal canal, which facilitate proper healing and cure by controlling cryptoglandular infection and reduces the chance of recurrence as well.

  Case Report Top

A 45-year-old male patient, known hypertensive (for three months) and diabetic (since one month), visited Shalya tantra outpatient department with the complaints of intermittent pus discharge from perianal region for seven months. He underwent incision and drainage four months ago for perianal abscess. No other systemic illness was observed except, diabetes and hypertension. On general examination, vital parameters were found within the normal limits. The patient was hemodynamically stable. On local examination, an external opening with mild pus discharge was present nearer to the base of scrotum, at about 12'o clock position and approximately eight cm away from the anterior anal verge. On palpation, a thick fibrous cord-like structure was felt under the subcutaneous plane extending from anal canal to base of scrotum. On Per Rectal (P/R) examination, sphincter tone was normal; a tender indurated lesion was felt at the 12'o clock position just above the dentate line. Finger was not stained with blood or pus or stool. On proctoscopic examination, the rectum was normal. Diagnosis was confirmed by Magnetic Resonance Imaging (MRI) and report suggested the manifestation as a case of Trans-sphincteric fistula, that is compared in Ayurvedic parlance with Riju Bhagandara. The case was managed with Ksarasutra application with modified technique.

  Treatment Protocol Top

After obtaining written informed consent, routine pre-operative care was given and planned for Apamarga ksarasutra application under local anesthesia. The patient was posted for operation in minor operation theatre. The patient was kept on lithotomy position on operating table [Figure 1]. The operative site was cleaned with betadine solution twice followed by spirit. Draping was done with sterile cut sheet. Injection lignocaine with adrenaline 0.5% was infiltrated surrounding the fistulous tract. Thereafter, P/R examination was done to confirm the tract. A malleable probe lubricated with Xylocaine jelly was pushed through the external opening towards the least resistance area, and the distal end of the probe was felt in the anal canal just above the dentate line at the 12'o clock position. After that the probe was removed. A small vertical incision was made at the midline of median raphe approximately two cm away from the anal verge at the 12'o clock position. The incision was widened by splitting the tissues using dissecting scissor and complete interception of fistulous tract was done. It was confirmed by injecting diluted betadine solution mixed with hydrogen peroxide from external opening; the solution fully came out through the interception site [Figure 2]. After that, Ksarasutra was applied from the interception site to internal opening of the fistulous tract with the help of malleable probe [Figure 3]. The thread was loosely tied at outside the anal verge [Figure 4]. Antiseptic dressing and packing was done with betadine and hydrogen peroxide solution after achieving complete haemostasis. The patient was stable during the procedure. No intra-operative complications were observed. During the course of treatment, the patient was advised to take Sitz bath in lukewarm water (10 lits) mixed with 20 g of Haridra churna (powder of Curcuma longa L.), Tab. Septilin in dose of 2 tablets thrice after meals, Triphala guggulu (500 mg) thrice after meals, Panchasakara churna (5 g) at bedtime with lukewarm water were advised, Jatyadi taila for local application was suggested. Regular antiseptic dressing from the next day onwards was also done. Further, the patient was recommended to take high-fiber diet, plenty of water and avoid spicy, non-vegetarian and frozen foods. Ksarasutra was changed once in a week and three sittings of Ksarasutra was done. The total duration of treatment was five weeks.
Figure 1: Patient in lithotomy position

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Figure 2: Introducing povidone iodine solution to confirm the interception

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Figure 3: Probe introduced into the tract from the site of interception toward the internal opening

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Figure 4: Ksharasutra tied outside the anal canal

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  Followup and Outcome Top

After 3 weeks of treatment, the tract was cut and the resultant wound was healed completely by the end of the 5th week [Figure 5]. After six months of follow-up, no fecal incontinence and no signs of recurrence were reported.
Figure 5: Healed wound after the 5th week of management

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  Discussion Top

Clinical presentation of anal fistula originating from anal canal at 12 o' clock usually extend upwards to the base of scrotum. Because trans-sphincteric fistula with an internal opening at 12 o' clock penetrates the superficial external sphincter and directly enters the Colle's Fascia, which is composed of soft connective tissue. The fistula proceeds through the Colle's Fascia or in the potential space between the Colle's Fascia and deep perineal fascia towards the scrotum.[9] As per the treatment guideline, anal fistula developed at anywhere of the anal canal are to be treated by either lay open the tract or by excision of the whole length of the tract with or without partial closure. Due to extensive surgical intervention, the normal structures may alter and the area becomes deformed which gives ugly look. Apart from that, there is also high chance of fecal incontinence due to sphincter damage, particularly in complex anal fistulae.

Ksarasutra is a medicated thread used to treat simple, complex, and recurrent anal fistulae with success rate of 96.76%.[7] The Ksara is capable to dissolve the unhealthy epithelialized tissues, granulation tissues and facilitates smooth healing by destroying the infected anal crypt and anal gland. In conventional technique of Ksarasutra application, a thread is applied from the external opening to internal opening and it cuts slowly from external opening towards internal along the course of the fistulous tract. It takes long time for cutting and healing of whole length of the fistulous tract. But, in case of MC-KST, a thread is applied from the interception site to internal opening of the fistulous tract to eliminate the affected anal crypt as well as involved glands. In this case, the length of the fistulous tract was eight cm which was reduced to two cm by modified method. So that, the cutting and healing time can be reduced without causing much harm to other healthy surrounding tissues with minimal damage to anal sphincter.

Along with the course of Ksarasutra therapy, tablet Septilin and tablet Triphala guggulu were used to counter inflammation, pain and to prevent infection. Triphala guggulu has proven antimicrobial agent that helps in inhibiting hyaluronidase and collagenase activity.[10] Clinical studies have reported that oral administration of tablet Septilin possesses significant anti-inflammatory, analgesic effects and useful in strengthening body immunity.[11],[12] In addition, Septilin can also inhibit both gram-positive and gram-negative organisms.[13] Thus, it prevents the infection and promote wound healing process. Panchasakara churna which is indicated in Vibandha (~constipation), is made up of Shunthi (Zingiber officinale Roscoe), Haritaki (Terminalia chebula Retz.), Saindhava (rock salt), Swarnapatri (Cassia angustifolia Vahl) and Shatapushpa (Anethum sowa Roxb.).[14]Shunthi has Deepana (~appetizer) and Pachana (~digestive) effect, which improves digestion. Haritaki, Swarnapatri and Shatapushpa have Anulomana action, which regulates Apana vata and facilitates easy bowel evacuation. Lukewarm water sitz bath with Haridra churna help in maintaining the perineal hygiene. It also relieves perineal congestion, promote drainage in the tract and reduce pain as well. Jatyadi taila is composed of drugs having the actions Shonitasthapana (~haemostatic effect), Vedanasthapana (~analgesic, anti-inflammatory), Dahaprashamana (~cooling effect) and Ropaka (~healing) that are important requirements for tissue healing. Jatyadi taila was instilled per rectally and applied locally for smooth healing and evacuation of feces. Nimba (Azadirachta indica A. Juss.) and Daruharidra (Berberis aristata DC.) are the ingredients of the Jatyadi taila, which are proven drugs to check bacterial growth and promotes wound healing.[15],[16],[17],[18],[19],[20] Local application of Jatyadi taila reported to significantly increase protein, hydroxyproline and hexosamine contents in the granulation tissue and reduced wound area faster.[20]

  Conclusion Top

Anal fistula with scrotal extension was managed by modified conventional Ksarasutra therapy (MC-KST). It is a minimal invasive technique to intercept the fistulous tract nearer to external sphincter to shorten the length of the original tract with keeping more attention to eradicate the infected anal crypt and gland. The tract was healed in comparatively shorter time without developing any complications or deformities. No recurrence was noticed during the follow-up period of six months. The study has to be carried out in larger sample size to establish efficacy of this technique as standard and better alternative to the conventional Ksarasutra therapy in the management of anal fistulae.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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