Case Study : Fistula In Ano
Fistula in Ano is a condition where a deep wound is developed outside the anal opening close to the peri-anal region. Sometimes this wound will communicate or connect to the anal canal and as complication pus and fecal discharges will come out through the opening. It is a very painful condition and will irritate the patient by affecting his daily routine and activities.
In modern surgery Fistulectomy, Fistulotomy, new techniques like fistula plug, and LIFT (Ligation of Inter-sphincteric Fistula Tract) are the available options with their own limitations. On the other hand surgery in fistula is a headache for treating surgeons because of recurrence of fistula and complications like incontinence, particularly in cases of horse shoe fistula.
Sushruta, the father of surgery and one among the foremost masters of Ayurveda had described application of Kshara (alkaline ash) in Bhagandara (fistula-in-ano). A standard KSHARASUTRA is practiced in treatment of BHAGANDARA (fistula-in-ano) with high success and minimum recurrence rate.
In this study, a case of posterior multiple fistula in ano having external opening at 6 o’clock and 7 o’clock position and internal opening at 6 o’clock position was treated with the KSHARASUTRA application.
KSHARASUTRA is a cotton thread prepared by coating it with alkaline ash specially prepared from herbal ingredients. It is prepared and preserved by following aseptic techniques to prevent infections and other complications.
A 32 years old male patient consulted our ano rectal department with complaints of perianal pus discharge, itching, intermittent bleeding and swelling. These symptoms were started 20 days back compromising his quality of life during his duty schedule. Patient was an I T professional; with history of untimely food habits and more depended on fast foods. Another precipitating factor was the usage of two wheeler for long travels. Patient was also complaining of irritable bowel.
On inspection at peri-anal region two external opening at 6 O’clock and 7 O’clock positions were noted. After probing it was found that tract of 6 o’clock position and 7 O’clock positions both were connected to the internal opening at 6 O’clock position. For conformation a MRI fistulogram was done and report showed that 33 mm long linear fistula in right perianal region and 14 mm long linear fistula in posterior perianal region. Hence on the basis of clinical observations and MRI fistulogram the case diagnosed as posterior multiple fistula-in-ano.
The length of both external opening from anal verge was 3 cm and was opening internally below ano-rectal ring. The induration was noted at posterior and right side of anus of perianal region having two external openings. Routine blood and urine examinations of patient were done and found within normal range. There was no previous history of surgery and other illness noted by patient. So patient was diagnosed as a case of BHAGANDARA (multiple fistula-in-ano). The condition was well explained to the patient and was convinced with the benefits of KSHARASUTRA THERAPY over existing surgical modalities. The patient was then admitted for further management with Ksharasutra. In this case we resorted on APAMARGA KSHARASUTRA.
Method of Ksharasutra Application
Pre-operative: The written informed consent was taken for the procedure. The perianal part was prepared and soap water enema was given at night. Inj. T.T. 0.5cc IM and sensitivity test for inj. xylocaine intra-dermal was done. Glycerine enema was given in the early morning before procedure. Patient was kept under NBM on the day of the procedure.
Operative: Under sedation patient was kept in lithotomy position and painting (perianal part) and draping was done. Local anesthesia 2% xylocaine with adrenaline was infiltrated around the anal wall. MAD (manual anal dilatation) was done and achieved 5 finger dilatation. Installation of betadine solution in the track of 6 o clock opening and 7 o clock opening observed that the solution was going in upward direction to 9 o clock position with bulging which indicate a blind cavity at that position . So the track or cavity at 7 o clock to 9 o clock was laid open and drained . One KsharaSutra was applied form external opening at 7 o clock position to internal at 6 o clock position. Another KsharaSutra was also applied at 6 o’clock position and internal at 6 o’clock position .The open wound was packed with gauze and T-bandage applied.
Post-operative: From next morning, Sitz bath (AVAGAHA SWEDA) with TRIPHALA KASHAYAM was advised for twice a day. Oral Ayurvedic medications like Gulguluthikthakam kashaym, Gandhaka Rasayanam, Kaisora Gulgulu and Avipathi Churnam were prescribed to support the healing process and to avoid further infections. Patient was advised not to consume non-vegetarian, spicy and oily food, Junk foods, alcohol. He was given with more fresh vegetables and fiber rich diet. Patient was advised to avoid long sitting and riding / travelling. The Kshara Sutra was changed by rail-road technique on weekly intervals till complete cut through of fistulous tract. During each change length of Ksharasutra thread was recorded to assess the progress of treatment. The total duration of the treatment was 60 days. After 2 months patient was free from all symptoms of fistula with normal scar and without any complications..