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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 58-63

Two-staged surgical approach along with Ksharasutra therapy in the management of complex, non-specific, posterior, horse-shoe-shaped fistula-in-ano: A case report


Department of Shalya Tantra, Institute of Teaching & Research in Ayurveda (ITRA), Jamnagar, Gujarat, India

Date of Submission17-Aug-2020
Date of Acceptance17-Jun-2021
Date of Web Publication16-Aug-2021

Correspondence Address:
Dr. Pragnaben Bhikhabhai Baria
Room No. 221, PG Ladies Hostel, IPGT and RA, Gujarat Ayurveda University, Jamnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_62_20

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  Abstract 


Bhagandara is one of the Ashtamahagada (~eight grave diseases) that resembles with the anal fistula in modern parlance. Many surgical techniques are available in modern practice though management of the fistula is challenging due to its high recurrence rate and associated complications. This study aims to diagnose a case of fistula-in-ano and to treat the case by two-staged surgical approach along with Ksharasutra. A 28-year-old male patient came to out patient department (OPD) of Shalya tantra with complaints of painful swelling with pus discharge from perianal region, which was diagnosed as complex, nonspecific, posterior horse-shoe shaped fistula-in-ano with approximately 80 mm long track. The condition is not only difficult but also takes a longer period for complete cure with varied success rate, hence, two-staged surgical approach along with Ksharasutra has been employed. The fistulous track was completely healed by almost 13 weeks. Follow-up was done for the next three months. There was no recurrence of the condition, and normal sphincter tone was achieved. The result of the present case is encouraging, and the patient was treated effectively without any complications and without disturbing his daily social life.

Keywords: Ayurveda, Bhagandara, fistula-in-ano, Ksharasutra


How to cite this article:
Baria PB, Dudhamal TS. Two-staged surgical approach along with Ksharasutra therapy in the management of complex, non-specific, posterior, horse-shoe-shaped fistula-in-ano: A case report. J Ayurveda Case Rep 2021;4:58-63

How to cite this URL:
Baria PB, Dudhamal TS. Two-staged surgical approach along with Ksharasutra therapy in the management of complex, non-specific, posterior, horse-shoe-shaped fistula-in-ano: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Oct 25];4:58-63. Available from: http://www.ayucare.org/text.asp?2021/4/2/58/323908




  Introduction Top


Bhagandara (~fistula-in-ano) is included in Ashtamahagada (~eight grave diseases) due to its notorious nature.[1] The word Bhagandara literally means Darana (~splitting/piercing) around Guda (~anus), Yoni (~vagina), Basti pradesha (~urinary bladder). Initially, it appears like a Pidaka (~boil), and when it bursts out, it manifests as Bhagandara.[2] Fistula-in-ano is an inflammatory track, which has an external opening in the perianal skin and internal opening in the anal canal or rectum, lined by unhealthy granulation tissue and fibrous tissue.[3] Most of the fistulae (approximately 90% of them) are nonspecific and are of cryptoglandular origin that occurs as a result of the infection of anal glands. The rest of the cases are due to a specific etiology such as tuberculosis, Crohn's disease, ulcerative colitis, pelvic infections, radiations, carcinomas, and traumas to the anorectal region etc.[4] Horseshoe fistulae usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by the way of the deep postanal space. These can wrap around the body in a U shape, with external opening on both sides of the anus.[5]

Different treatment modalities such as fistulectomy, fistulotomy, seton division, and fistula plug are prescribed in the management of fistula-in-ano. As the wound is located in the anal region, it is more prone to infection, thus takes long time to heal and the condition remains troublesome. An operative procedure often leads to complications such as recurrences and fecal incontinence.[6] Ksharasutra, a medicated cotton thread coated with the latex of Snuhi (Euphorbia nerifolia Linn.), powder of turmeric (Curcuma longa Linn.), and Apamarga kshara (alkaline powder of Achyranthes aspera Linn). A study has been done in a large number of patients and established the treatment as an effective, ambulatory, and safer alternative treatment for patients with fistula-in-ano.[7] The efficacy studies revealed overall recurrence rate as 5.88%.[8] The Indian Council of Medical Research (ICMR) had validated this therapy and emphasized that Ksharasutra is better than the conventional surgery in fistula-in-ano.[9] Every treatment modality has its own limitations. Application of Ksharasutra in cases of complex, posterior horseshoe fistula when the length of track is approximately 80 mm is not only difficult in finding right course of track but also complete treatment takes very much time to heal also. Hence, this type of case can be treated with combined approach of surgery and Ksharasutra.

Considering the above, regarding problems during management of Bhagandara, the present study had been planned using standard Ksharasutra along with two-staged surgical approach in the management of complex, posterior horseshoe-shaped fistula-in-ano.


  Patient Information Top


A 28-year-old male patient came to the outpatient department (OPD) of Shalya tantra, with complaints of painful swelling with pus discharge in the right perianal region and throbbing pain in ano for four days. The patient was a businessman by occupation and does not have a history of any addiction. No other systemic illnesses were observed, and vitals were normal. No significant medical, family, and psychosocial history was found. On local examination, swelling with pus discharge was found in right perianal region at 10 o'clock. On digital rectal examination, the internal opening was felt near dentate line at 6 o'clock position and induration was felt from 5 to 9 o'clock position with normal sphincter tone. He had a history of similar complaints about 10 months back and consulted to a general surgeon at Rajkot (Gujarat, India). He was advised Magnetic Resonance Imaging (MRI) showing “An internal opening at 6 o'clock position. Distance of internal opening from anal verge is 3.2 cm. A track is noted arising from internal opening which extends on the right side at 9 o'clock. The track measures approximately 80 mm in length and 7 mm in diameter along with mild perilesional edema. Another track seen arising from 6 o'clock extending on left side piercing external sphincter, extending into left ischio-anal fossa, appear blind ended with no external opening and shows secondary track. One blind-ended branch seen at the left side of intersphincteric space which suggested a complex fistula-in-ano with horse shoe extension as described as per St. Jame's university hospital classification, Grade 4.[10] For that he was advised conservative medications and got symptomatic relief. Second time, the patient had developed similar complaints, and he came to Shalya tantra OPD for better relief. The patient was admitted in the ward for further management.

Transrectal ultrasound-guided prostate biopsy (TRUS) was advised that confirmed the diagnosis. TRUS showed 10–11 cm long fistula in right perianal region with external opening at 10 o'clock position and internal opening at 6 o'clock position. Internal opening was 13 mm proximal to anal verge. 44 mm long two wide calibered (12–15 mm) blind branches are seen at 5 o'clock region 10 mm deep to perianal skin. 40 mm long another blind branch is seen along left lateral wall extending up to 2 o'clock region, 14 mm deep to perianal skin. Maximum width of the fistula at 6 o'clock position is 10 mm. Maximum depth of the fistula at 7 o'clock position is 12 mm. Hence, on the basis of clinical observations and TRUS, the case was diagnosed as complex, trans-sphincteric, and posterior horseshoe fistula-in-ano.


  Treatment Protocol Top


All the hematological and biochemical examinations were done before planning surgery and were found within the normal limits. Pre- and post-operative measures were adopted as per standard surgical procedures.[11] Injection Ranitidine 2 ml (50 mg) and Injection Cefotaxime 1.5 g intravenous were given before surgery for prophylactic purpose. After obtaining written informed consent, under aseptic precautions, spinal anesthesia was given. The patient was laid down in the lithotomy position, painting, and draping was done [Figure 1]. Probe was passed through external opening at 10 o'clock to know the depth and direction of the track [Figure 2]. After identifying the course of the track, it was laid open, drained, and high anal extension was scooped. Left-sided perianal region's external opening was not found, but, on digital rectal examination, collection was felt so opening was made at perineal region posterior to the anal opening at 6 o'clock position for draining of both the tracks and Apamarga ksharasutra was placed [Figure 3]. Daily aseptic dressing with Panchavalkala ointment was performed. After two weeks, the patient was again taken in the lithotomy position. After achieving appropriate anaesthesia, external opening was extended and post anal spaces were opened. Probe was inserted through the wound and taken out through the internal opening. Apamarga ksharasutra was placed inside the track, and the wound was packed with tight bandages [Figure 4].
Figure 1: Pre-operative image

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Figure 2: Probing during surgery

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Figure 3: Post-operative third day image

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Figure 4: Second staged post-operative image after two weeks of first surgery

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General management

Daily aseptic dressing with Panchavalkala ointment, Avagaha (sitz bath) with Panchavalkala kwatha twice in a day, in morning after defecation and in the evening were advocated. Triphala guggulu 2 tablets (500 mg each) thrice in a day, Eranda bhrishta haritaki (5 gm) at bed time were prescribed along with using of diclofenac sodium (SOS) if pain is complained. The patient was assessed weekly for postoperative pain, discharge, and wound healing. Ksharasutra was changed weekly by rail-road method and was tightened progressively to cut through the track naturally [Figure 5]. The patient was advised not to consume nonvegetarian, spicy and oily food, junk food, and alcohol. The patient was advised to avoid long sitting and riding or travelling for the next one year.
Figure 5: Post-operative after one week of second surgery

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  Timeline Top


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

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  Follow-Up and Outcome Top


After nine weeks of treatment, both Ksharasutra was cut through and wound was healed partially [Figure 6]. After 13 weeks of treatment, postoperative wound was healed completely [Figure 7]. The patient was followed up for the next three months and no signs of recurrence or complications were noted.
Figure 6: Post-operative after ninth week

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Figure 7: Completely healed wound after 13 weeks

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  Discussion Top


This is a posterior horseshoe-shaped fistula-in-ano having external opening in right peri-anal region and blind track in left peri-anal region without external opening, involving both ischio-rectal fossae opening in anal canal midline posteriorly at 6 o'clock with the length of the left sided track of approximately 80 mm. The case was complex as there was no external opening in left peri-anal region, and external sphincter was involved. These clinical findings were also supported by the MRI of perianal region. Although MRI is a gold standard investigation in such kind of complex fistula to know the exact extension of tracks,[12] TRUS was advised as it is being a relevant, cost-effective investigation to diagnose and to assess the result of surgery.[4] As the case was complex, surgical management was planned in two stages.

Benefit of two stage surgery is that, it requires less hospital stay. The patient can be ambulatory after 6 h of surgery and postoperative wound size will be less. Thus, daily routine of the patient will not hamper, and the patient can live his normal social life as postoperative pain will also be minimal.

As Ksharasutra was placed in the track, it cauterizes the unhealthy granulation tissue and drains the debris from the track, which induces early healing by providing healthy environment for the wound healing. Ksharasutra has cutting and draining properties. It also prevents damage to the sphincter and treats the cryptoglandular infection which leads to speedy recovery of the disease.[13] Panchavalkala has anti-inflammatory, analgesic, and antimicrobial activities; thus, it prevents secondary infection in the postsurgical wound.[14] Panchavalkala ointment is used as dressing material. It promotes wound cleaning and healing due to its Kashaya rasa. It has soothing and antimicrobial activities.[15] Eranda bhrishta haritaki acts as a mild laxative and thus prevents constipation, further support in healing postoperative pain. After 13 weeks of treatment, track was healed completely and posttreatment TRUS was done, which showed “superficial subcutaneous hypoechoic scar in right peri-anal region between 6 and 8 o'clock position. No evidence of peri-anal abscess or fistula was observed. The patient was followed up for the next three months after treatment and no signs of recurrence or complications were noticed, which indicates efficacy of the treatment.


  Conclusion Top


It is difficult to conclude that two-staged surgical approach along with Ksharasutra will always be beneficial for complex, posterior, trans-sphincteric, horseshoe-shaped fistula-in-ano or not. However, in the present case, results were encouraging. It was managed, without any complications or fecal incontinence at minimal cost. No complications nor recurrences were noticed during the follow-up period. Hence, it can be considered that two-staged surgical approach along with Ksharasutra can be considered as good alternative for management of fistula-in-ano.

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.
Shastri AD, editor. Sushruta Samhita of Sushruta, Sutra Sthana. Ch. 33., Ver. 4. Varanasi: Chaukhambha Sanskrit Sansthan; 2015. p. 163.  Back to cited text no. 1
    
2.
Shastri AD, editor. Sushruta Samhita of Sushruta, Nidana Sthana. Ch. 4., Ver. 4. Varanasi: Chaukhambha Sanskrit Sansthan; 2015. p. 317.  Back to cited text no. 2
    
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Goligher J. Surgery of Anus, Rectum and Colon. 5th ed. New Delhi: A.I.T.B.S. Publishers and Distributers; 2004. p. 178.  Back to cited text no. 3
    
4.
Shrama A, Yadav P, Sahu M, Verma A. Current imaging techniques for evaluation of fistula in ano: A review. Egypt J Radiol Nucl Med 2020;130:DOI: I:10.1186/s43055-020-00252-9.  Back to cited text no. 4
    
5.
Harit MK, Dwivedi AP. Modified ksharasutra chikitsa for 'shambukawarta bhagandara'. Ayu 2011;32:418-21.  Back to cited text no. 5
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7.
Murthy KN. Prof PJ Despande – Reinventor of ksharasutra therapy. Ann Ayurvedic Med 2012;1:173.  Back to cited text no. 7
    
8.
Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical evaluation of Ksharasutra therapy in the management of Bhagandara (Fistula in ano) – A prospective study. Ancient Sci Life 2009;28:29-5.  Back to cited text no. 8
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Shukla NK, Narang R, Nair NG, Radhakrishna S, Satyavati GV. Multicentric randomized controlled clinical trial of Ksharasutra (Ayurvedic Medicated thread) in the management of Fistula in ano. Indian J Med Res 1991;94:177-85.  Back to cited text no. 9
    
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Kulvinder D, Navdeep S, Thukral CL, Kunwarpal S, Varun B. Magnetic Resonance Imaging (MRI) evaluation of perianal surgical correlation. J Clin Diagn Res 2014;8:RC01-4.  Back to cited text no. 10
    
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Lobo SJ, Bhuyan C, Gupta SK, Dudhamal TS. A comparative clinical study of Snuhi Ksheera Sutra, Tilanala Ksharasutra and Apamarga Kshara Sutra in Bhagandara (Fistula in ano). Ayu 2012;33:85-91.  Back to cited text no. 11
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Lunniss PJ, Armstrong P, Barker PG, Reznek RH, Phillips RK. Magnetic resonance imaging of anal fistulae. Lancet 1992;340:394-6.  Back to cited text no. 12
    
13.
Dudhamal TS, Baghel MS, Bhuyan C, Gupta SK. Comparative study of ksharasutra suturing and lord's anal dilatation in the management of parikartika (chronic fissure-in-ano). Ayu 2014;35:141-7.  Back to cited text no. 13
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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. 14
    
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Meena RK, Dudhamal T, Gupta SK, Mahanta V. Wound healing potential of Panchavalkala formulations in a post fistulectomy wound. Ancient Sci Life 2015;35:118-21.  Back to cited text no. 15
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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Abstract
Introduction
Patient Information
Treatment Protocol
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