Innovative approach in the management of horse-shoe fistula-in-ano with Kṣārasūtra.

Fistula-in-ano is a common surgical problem. Horse-shoe fistulas usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep potential space. The "Śambukāvarta Bhagandara" described by Suśruta can be correlated with the horse-shoe type of fistula. In this condition, neither fistulotomy nor "Kṣārasūtra" treatment alone, are useful hence there is a need for newer innovative surgical techniques to tackle this challenging disease. An integral approach of incision and drainage of both the abscess on the arms of the horse-shoe fistula with Kṣārasūtra ligation at 6 o' clock position proves to be successful. We have tried the same technique with good results. No recurrence was found in the patients during the follow-up period of 6 months. A 45-year-old female with a known case of diabetes mellitus and hypertension approached with both right and left ischiorectal fossa inflammatory swelling. An innovative approach was used to manage horse-shoe fistula by making an additional opening below the anus at 6 o'clock position. Apāmārga Kṣārasūtra (medicated thread made using apāmārga) was ligated through the additional opening to the internal opening at 6 o'clock position for draining through both the cavities. Kṣārasūtra was changed weekly and the fistula healed completely by 3 months.

INTRODUCTION

A fistula-in-ano is a chronic abnormal communication, usually lined to some degree by granulation tissue, which runs outwards from the anorectal lumen to an external opening on the skin of perineum or buttock.[1] It usually results from an anorectal abscess that either burst spontaneously or opened without laying open the entire track.[2] Drainage of an anorectal abscess results in cure for about 50% of patient and the remaining 50% develop a persistent fistula-in-ano.[3] Horse-shoe fistulas usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep potential space.[3] These can wrap around the body in a U shape, with external openings on both sides of the anus.

The prevalence rate of fistula-in-ano is 8.6 cases/100,000 population. The prevalence in men is 12.3 cases/100,000, and in women, 5.6 cases/100,000. The male:female ratio is 1.8:1. The mean age of patients is 38.3 years.[4]

Different treatment modalities like fistulectomy, fistulotomy, seton division are prescribed for fistula. 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 like recurrences and incontinence.

Ayurvedic classics, especially the Suśruta Saṃhitā have described various types of Bhagandara and among them, the Śambukāvarta Bhagandara's signs and symptoms can be correlated with fistula-in-ano.[5] Kṣārasūtra is a thread prepared by applying alkaline substances derived from plants. Kṣārasūtra is prepared by repeated coatings of Snuhi kṣīra (latex of Euphorbia Nerrifolia), Apāmārga kṣīra (ash of Achyranthus aspera) and Haridrā powder over surgical linen thread number 20. The thread so obtained is used in a popular treatment modality for the management of fistula-in-ano. Kṣārasūtra ligation (medicated herbal seton) that is, exploration of fistulous track by ligating Kṣārasūtra in the track is described as a para surgical procedure in the Ayurvedic classics.[6]Apāmārga Kṣārasūtra used in this case was prepared with 21 coatings, which included 11 coatings of latex of Snuhi (Euphorbia Nerrifolia), 7 coatings of Apāmārga kṣīra (A. aspera)and three coatings of Haridrā (Curcuma longa).[7]

CASE REPORT

A 45-year-old female patient came to us with complaints of swelling and redness around the perianal region since 1-month with a history of fever. She also had diabetes mellitus and hypertension since 2 years and was taking metformin hydrochloride 1000 mg SR (Melmet SR) twice daily for her diabetes and losartan potassium 50 mg with hydrochlorothiazide 12.5 mg (Repace-H) once a day for her hypertension.

On inspection, on both right and left ischiorectal fossa inflammatory swelling was noticed [Figure 1]. On palpation, local rise of temperature with marked induration and tenderness was elicited and was identified as ischiorectal abscess bilaterally. By doing digital examination using hypertonic sphincter an internal opening at 6 o’clock position was felt. Also along the posterior border of anal canal hard tensed induration was felt. On proctoscopic examination internal opening at 6 o’clock position was found, which made us to suspect a horse-shoe fistula. After the diagnosis, we planned the treatment using Kṣārasūtra.

Figure 1

Horse-shoe fistula tracts

Aim and objective of the study

To evaluate the effect of a modified technique of surgery with Kṣārasūtra Chikitsa in Śambukāvarta Bhagandara (horse-shoe fistula-in-ano).

Type of study: Single case study

Plan of surgery: Incision and drainage of both the abscess of right and left ischiorectal fossa and connecting the fistula tract to skin at 6 o’clock position, and Kshārasūtra ligation at 6 o’ clock position for draining through both the cavities

Drug material: Standard Kṣārasūtra with 21 coatings.

Plan of modified surgery in horse-shoe fistula

Preoperative procedure

As a preoperative measure blood and urine investigations, which include complete blood count, bleeding time, clotting time, blood urea, serum creatinine, fasting and postprandial blood sugar, HIV, HBsAg, urine routine were done.

Operative procedure

After giving spinal anesthesia, the patient is placed in the lithotomy position

Painting of the area is done with betadine, and the area is covered with sterilized drape

The incision was made on the right and left ischiorectal fossa to drain the abscess [Figure 2]. About 5 ml and 20 ml of pus were drained from right and left ischiorectal fossa respectively

Figure 2

Incision and drainage of both the abscess

Slit proctoscope was introduced, and the track was confirmed by pushing the betadine mixed with hydrogen peroxide from both the external openings

Probing was done through both the external opening. An internal opening was identified at 6 o’clock position

Another opening was made at perineal region posterior to the anal opening at 6 o’clock position [Figure 3]. Apāmārga Kṣārasūtra which is made up off Apāmārga, Haridrā, and Snuhi was ligated through the opening made to the internal opening at 6 o’clock position for draining through both the cavities [Figure 4]. Openings were irrigated with betadine and hydrogen peroxide. All three tracts were kept the patent and an anal pack containing Jātyādi tailam was placed.[8]

Figure 3

An opening is made at 6 o’ clock position joining both the tracts

Figure 4

Kṣārasūtra application at 6 o’ clock position joining both the tracts

Postoperative management

Regular dressing of both the external openings was done and they were packed with roller gauze soaked with betadine solution to keep the wound clean and to encourage granulation tissue growth

Injection intravenous antibiotic was given to avoid further infection, antacids were prescribed to avoid hyperacidity and analgesics were advised for 5 days

Sits bath with Pañcavalkala kaṣāya was given to achieve sphincter relaxation and for vraṇa śodhana and ropaṇa.

A diet guideline was counseled to the patient as she was diabetic. After 5 days, the patient was discharged. The following medications were prescribed to the patient to reduce inflammation and to promote healing:

Tablet Gandhaka Rasāyana (250 mg thrice a day after food for 1-month)[9]

Tablet Triphalā Guggula (250 mg thrice a day before food for 1-month)[10]

Tablet Kāmadudhā with mauktika (250 mg twice a day before food for 15 days)[11

Asanādigaṇa Kaṣāyam (15 ml with water twice daily after food for 1-month). 12

Patient was asked to attend the outpatient department for dressing with Jātyādi taila and follow-up medication. Kṣārasūtra, which was ligated in the track communicating to the anal canal, was changed weekly for eight sittings. The communicating track was cut by 8 weeks and left for healing by secondary intension. Complete recovery of deep wound took about 3 months from the day of treatment [Figure 5]

Figure 5

Healing tracts

During follow-ups patient was observed for discharge, tenderness, inflammation, and induration and her progress is recorded in Table 1.

Table 1

Assessment of the patient

RESULTS

On the basis of this case study, it can be concluded that the surgical management of Śambukāvarta Bhagandara (horse-shoe fistula) can be done by a modified procedure described above, that is, incision and drainage of both the abscess and ligation of Kṣārasūtra at 6 o’clock position to drain the abscess cavity and fistula tract, which has given good results, with no recurrence

There is a need to evaluate the effect of this technique on more number of cases in order to establish this line of treatment for this challenging disease.

CASE DISCUSSION

“Horse-shoe” is a descriptive term to indicate the usual pathway of the spread of an abscess originating in the deep posterior anal space. Anorectal abscess fistula disease is most commonly crypto glandular in origin. If the anorectal abscess is not drained spontaneously or surgically, the infection may spread rapidly and may result in extensive tissue loss. Even if the abscess is drained, a fistula-in-ano may develop subsequently.[13]

Allied sciences have posterior midline sphincterotomy, fistulotomy, wide debridement, seton division etc., as treatment modalities for fistula. A large, slow-healing wound, more prone to infection as located at anal region indicates high recurrence rates in fistula. Inadequate therapy results in incomplete resolution of symptoms, recurrence of abscess and persistent fistulous tracts.[14]

Ayurvedic classics describe a para-surgical procedure Kṣārasūtra, which helps for simultaneous cutting and healing of the fistula track and avoids recurrence. Modes of action of the various drugs/procedures used in the above treatment protocol are described below:

Modes of action of drugs/procedures

Kṣārasūtra

It aided continuous drainage from the entire three tracks

It helped simultaneous cutting and healing of the fistula track. This helped avoid sphincteric complications that would cause incontinence

Helped debridement of the tissue, that is, curette unhealthy granulation tissue and stimulated healthy granulation tissue

It has anti-inflammatory and antimicrobial action, which promoted healing and there by prevented recurrence.

Pañcavalkala kaṣāyam

Pañcavalkala comprises of the following ingredients: Nyagrodha (Ficus bengalensis Linn.), Udumbara (Ficus glomerata Roxb.), Aśvattha (Ficus religiosa Linn.), Pāriśa (Thespesia populnea Soland ex correa.), Plakṣa (Ficus infectoria Roxb.)[15]

As the patient had pitta prakṛti we selected pañcavalkala kaṣāyam. Pañcavalkala has śītavīrya (cold potency) and has pittahara property. Hence, Pañcavalkala decoction for sitz bath provided significant relief in pain and burning sensation

Kaṣāya rasa, kleda śoṣana (drying action) and lekhana guṇa (scrapping) of Pañcavalkala helped in reducing the vraṇasrāva (wound discharge).

Jātyādi taila

The drugs in Jātyādi taila have tikta-kaṣāya rasa (bitter and astringent taste). This helped drying up of secretions [1617]

Its vraṇaropaka guṇa (wound healing property) led to an improvement in the healing process, and śothahara (anti-inflammatory property) helped in the management of the inflamed wound.

CONCLUSION

The management of horse-shoe fistula is difficult and complicated because of the involvement of sphincters. Management of these cases by making an external opening at 6 o’ clock position and by Kṣārasūtra is effective and in that, it helps by cutting and healing of fistulous track simultaneously with reduced bleeding, minimal pain and scar with no fecal incontinence. There is lesser chance of infection and almost no postoperative complications. This treatment is minimally invasive and patients will be ambulatory.

Take home message

A challenging horse-shoe fistula can be managed with Kṣārasūtra by innovative and integral methodologies.