Management of Complex Fistula in Ano, by IFTAK technique and Partial...

[Full title: Management of Complex Fistula in Ano, by IFTAK technique and Partial Fistulotomy - A Single Case Study]

[Find the meaning and references behind the names: Shri, Low, Long, Main, Prashanth]

CASE REPORT October 2024 Journal of Ayurveda and Integrated Medical Sciences | October 2024 | Vol. 9 | Issue 10 266 Management of Complex Fistula in Ano, by IFTAK technique and Partial Fistulotomy - A Single Case Study Prashanth K 1 , Prajapati Parth Rameshbhai 2 1 Associate Professor, Dept. of Shalya Tantra, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Hospital and Research Center, Udupi, Karnataka, India. 2 Post Graduate Scholar, Dept. of Shalya Tantra, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Hospital and Research Center, Udupi, Karnataka, India. I NTRODUCTION Acharya Sushruta discusses in detail about the extensive range of surgical methods including about how to deal with various types of tumors, internal and external injuries, fracture of bones, traumatic complications and their management. Fistula in ano is an abnormal tract connecting the anorectum with skin. Fistula connects two epithelial Address for correspondence: Dr. Prajapati Parth Rameshbhai Post Graduate Scholar, Dept. of Shalya Tantra, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Hospital and Research Center, Udupi, Karnataka, India. E-mail: parthr 120@gmail.com Submission Date: 13/09/2024 Accepted Date: 23/10/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.10.44 surfaces and the tract is usually lined by unhealthy granulation tissue. The main cause known for fistula in ano is crypto glandular infection of anal crypts [1] Mostly fistula in ano indicates the acute and chronic condition of the same disease process of infective origin. From the anal abscess the incidence of fistula ranges from 26 to 38%. Although there is uncertainty regarding the prevalence of fistula in ano, a study showed that the prevalence rate of fistula in ano is 8.6 cases per 100,000 populations. This disease is four times more common in males as compared to females and the mean age of affected population is about 38.3 years [2] Though the disease is not life-threatening, the discomfort and pain it causes disrupts the everday life. At first it presents as Pidika around the Guda and when it bursts out, it is called Bhagandara [3] Bhagandara is classified into five types as Vataja- Shatponaka, Pittaja-Ustragreeva, Kaphaja-Parisravi, Sannipataja-Shambuka and Agantuja-Unmargi [3] Bhagandara is one such disease where the morbidity can be significant due to complex presentation making the prognosis Kruchra Sadhya/Ashadhya. Hence, A B S T R A C T Since ancient time, fistula in ano has been the most prominent condition of all anorectal disorders. Despite two millennia of efforts, fistula in ano still remains a challenging surgical condition. Over the past few decades, various techniques have been evaluated in terms of preventing its recurrence and complications. The sign and symptoms of fistula in ano resembles with Bhagandara described in Ayurveda classics. Many treatment modalities are listed in Ayurveda classics for the management of this painful disease, Ksharasutra therapy is one among them that has been proved to be highly efficacious. Though Ksharsutra therapy is a popular treatment for fistula in ano, it does have few drawbacks. Long duration of treatment, post procedural pain and long scar are some to mention. As a result, in the present era IFTAK is emerging as an innovative technique for the management of fistula in ano, without compromising the outcome compared to traditional method of Ksharasutra treatment. In this case study, the IFTAK (Interception of Fistulous Tract and Application of Ksharasutra ) and partial fistulotomy was used in complex low anal fistula in ano which shows great potential in reducing both the treatment duration and post-procedural pain. Key words: Bhagandara, Fistula in ano, IFTAK technique, Partial Fistulotomy.

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Prashanth K. et al. Management of Complex Fistula in Ano ISSN: 2456-3110 CASE REPORT October 2024 Journal of Ayurveda and Integrated Medical Sciences | October 2024 | Vol. 9 | Issue 10 267 rightly the disease is named one among the Ashta Mahagada [4] Bhagandara is the disease occurring in and around Guda and is treated by Bhesaja, Shashtra, Kshara and Agnikarma . There are many treatment modalities available for the management of fistula in ano. Modern surgical management includes fistulotomy, fistulectomy, seton placing, ligation of inter-sphincteric fistula tract (LIFT), fibrin glues, advancement flaps, and expanded adipose derived stem cells (ASCs) [5] Acharya Sushruta has described different therapeutic measures for the management of Bhagandara in terms of various oral medications, local applications, surgical procedures and para-surgical interventions. Presently Ksharsutra therapy is found most approaching and attractive treatment modality for fistula in ano [6] Ksharsutra is prepared by a methodical coating of specific herbs and Kshara over Barbour’s linen no.20 thread. It is a standard surgical practice for the management of fistula in ano as the therapy has revolutionized the treatment of fistula in ano in terms of minimizing re-occurrence and anal incontinence. Although the treatment is popular and effective, it is not devoid of adversities. Disadvantages of Ksharasutra treatment are post procedural pain, mucopurulent discharge, longer duration of treatment and scar. IFTAK (Interception of Fistulous tract with application of Ksharasutra ), is a technique based on the concept of intercepting the fistulous tract close to the anal verge and treating the proximal part of the fistulous tract with Ksharasutra . As the primary site of infection involving the anal crypt is constantly treated by the Kshara and drained by Ksharasutra , cure ensues. Distal part of the tract is left untreated and heals eventually as this part of the tract is not in continuity with the infective focus. IFTAK approach with partial fistulotomy was planned in this case as the fistula was complex presenting with two external openings. Result was encouraging with complete healing of the Fistula, short treatment period, reduced discomfort in terms of pain and discharge and an acceptable scar. Presenting complaints and medical history A 30 year old male normotensive, non-diabetic patient came to Shalya OPD of Shri Dharmashthala Manjunatheswara Ayurveda Hospital, Udupi, Karnataka, with complaints of pain, itching and discharge from perianal region since 3 months. Patient also c/o pain and burning sensation during defecation since 3 months. History was not significant for any major medical illness, previous surgery and allergy. Clinical findings General and systemic examination was not significant for any systemic illness. On Per Rectal Examination, Two external fistulous openings were noted at 9’O Clock position 5 cm away from anal verge and at 11 O’clock position 4 cm away from anal verge. One Internal opening at 12 O’clock position was found on digital rectal examination and proctoscopy about 1 cm proximal to anal verge. Trans-rectal ultrasound clearly depicted the direction of the fistulous tract with its openings. Hematological reports before Surgery: Bleeding Time 2 Min 05 Sec Clotting Time 4 Min 25 Sec Blood Group and Rh Type A Positive

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Prashanth K. et al. Management of Complex Fistula in Ano ISSN: 2456-3110 CASE REPORT October 2024 Journal of Ayurveda and Integrated Medical Sciences | October 2024 | Vol. 9 | Issue 10 268 Blood Urea 22.0 Mg/Dl Serum Creatinine 1.0 Mg/Dl Serum Uric Acid 5.1 Mg/Dl Hiv Test Negative HbsAg Test Negative Diagnosis Complex low fistula in ano (Shataponaka Bhagandara) Treatment After obtaining an informed consent, patient was placed in lithotomy position (Fig. 1). Under Spinal Anesthesia, following aseptic precautions initially probing was done to assess the fistulous tract and Hydrogen peroxide was inserted through the external opening to identify the position of internal opening. A small vertical incision was made at perianal skin at 12 o’ clock position approx. 1.0 cm away from the anal verge to intercept the fistulous tract (Fig. 2). Hydrogen peroxide was again injected through the external opening to confirm the proper interception of the fistulous tract. Metallic probe threaded with Ksharasutra was introduced through this window at 12 o’ clock position and brought out from the internal opening and a snug knot was tied. (Fig. 3, 4) Partial fistulotomy was carried out on the primary tract at 9 o’clock, secondary tract at 11 o’ clock position was left as such (Fig. 5). Antiseptic dressing and packing was done with Jatyadi Taila . Patient was advised for regular Sitz bath with warm water from the next day and daily dressing with Jatyadi Taila until the fistulotomy wound healed. A short course of antibiotic was prescribed for 5 days. Patient was prescribed with, 1 Kaishora Guggulu 750 mg 1 tab TDS after food 2 Gandhak Rasayan 750 mg 1 tab TDS after food 3 Swadishta Virechan Churna 50 gm + Swarna Makshika 1 gm + Pravala Bhasma 5 gm} 5 gm HS with luke warm water 4 Panchtikta Kashaya 20 ml BD after food 5 Jatyadi Taila for local application. Follow-up and Outcomes Ksharasutra was changed once a week on OPD basis. Pus discharge was fluent in the first week through the fistulotomy wound which gradually changed to serous and became scanty and then completely disappeared after two weeks. Pain was moderate in the first week and later on gradually subsided. The discharge from the external opening at 11 o’ clock position reduced gradually within 4 to 5 days and totally dried up in one week (Fig. 6). Ksharasutra completely cut through the fistulous tract in three weeks after the first Ksharsutra change and complete healing of the wound was achieved with a scar in 10 days after the cut through. Patient was advised application of Jatyadi Taila . The fistulous tract was cut through and healed simultaneously by 4 th week with acceptable scar (Fig. 7). There was no complication seen during and after treatment and patient got relief from all the symptoms. After 6 months of follow-up, no recurrence was noted, patient was cured completely (Fig. 8). Figure 1: Pre-Operative image Figure 2: Opening of window

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Prashanth K. et al. Management of Complex Fistula in Ano ISSN: 2456-3110 CASE REPORT October 2024 Journal of Ayurveda and Integrated Medical Sciences | October 2024 | Vol. 9 | Issue 10 269 Figure 3: Probing during surgery at 9 o’clock position Figure 4: Probing during surgery at 11 o’clock position Figure 5: Partial fistulotomy and IFTAK done Figure 6: 2 nd week: follow-up Figure 7: 4 th Week: After Complete Cut through by Ksharasutra Figure 8: After 6 Months DISCUSSION Ksharasuta treatment is an effective treatment modality for fistula in ano. Ksharsutra treatment has high success rate [7] and least recurrence rate (3.33%) [8] When compared to standard treatment modalities, which call for hospitalization, regional or general anesthesia, and consistent post-operative care, it is a very simple, cost-effective, and a low-complication procedure. Conventional surgical treatments are associated with a significant risk of recurrence (0.7- 26.5%) and high risk of impaired continence (5-40%) [9] Although the Ksharsutra treatment is for fistula in ano and has a number of advantages, it also has a number of drawbacks which are discomfort caused due to discharge, post-procedural pain, frequent hospital visits, a longer treatment duration, and a large postoperative scar, causing low compliance and low acceptability in many patients. The IFTAK (Interception of Fistulous Tract and Application of Ksharsutra ) technique is used to get good outcomes. By reducing

[Find the meaning and references behind the names: Art, Sainio, Kumar, Ann, Rani, Pankaj, Ray, Nil, Med, Mir, Manoranjan]

Prashanth K. et al. Management of Complex Fistula in Ano ISSN: 2456-3110 CASE REPORT October 2024 Journal of Ayurveda and Integrated Medical Sciences | October 2024 | Vol. 9 | Issue 10 270 the length of the tract and treating the crypto glandular infection where there was no need to treat the remaining tract, the duration of treatment is reduced. In the conventional approach the entire tract is exposed along the axis during the Ksharsutra change, increasing the discomfort and burning sensation due to more tissue strangulation. Whereas pain is reduced because of less tissue mutilation following interception (IFTAK). In this case study, the fistula in ano did not adhere to the rules of the Good sall’s forming a complex tract with 2 external openings at 9 and 11 o’clock position respectively connecting to one internal opening at 12 o’clock position. Hence, interception of this complex tract was carried out at 12 o’clock position on the perianal skin and Ksharasutra ligation of the tract was done to clear the primary source of infection. Tract connecting with 9 o clock opening, which was more horizontal was treated with sphincter saving fistulotomy to facilitate effective drainage. Tract connecting with 11 o clock position was vertical, causing effective drainage and was left untouched. As a result, the IFTAK technique shortened the duration of complete healing and the pain was also significantly reduced with acceptable scar. The patient was completely cured within one month, and had no recurrence after six months of follow-up. IFTAK is a useful technique in the field of fistula-in-ano which has lot of benefits. CONCLUSION IFTAK combined with partial sphincter saving fistulotomy is a safe, efficient, and useful technique that significantly reduces pain while achieving complete healing with acceptable scar and reduced duration of treatment. REFERENCES 1 Kumar A, Bilyan A. IFTAK an innovative technique in fistula in ano-A case study. Ayurpub 2018; 2:771 e 5. 2 Sainio P. Fistula in ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol 1984; 73(4):219 e 24. 3 Sushruta Sushruta Samhita. In: Shastri A, editor. Nidanasthana, Bhagander Nidan. 4/3. 12 th ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. p. 319. 4 Sushruta Sushruta Samhita. In: Shastri A, editor. Sutra sthana, avaraniyaadhayay. 33/4. 12 th ed., Varanasi: Chaukhamba Sanskrita Sansthana; 2009. p. 163. 5 Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol 2015; 21(1):12 e 20. https://doi.org/10.3748/wjg.v 21.i 1.12. 6 Mir SA, Kumar PH. Bhagandara and its management in Ayurveda: a conceptual study. Int J Ayurveda Pharma Res 2017; 5(8). 7 Pankaj S, Manoranjan S. Efficacy of Ksharsutra (medicated seton), therapy in the management of fistula-in-ano. World J Colorectal Surg 2010; 2(2) (Art. 6: 01 e 10). 8 Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical evaluation of Ksharasutra therapy in the management of Bhagandara (fistula-in-ano) da prospective study. Anc Sci Life 2009; 28(3):29 e 35 [PMC free article] [PubMed]. 9 Dutta G, Bain J, Ray AK, Dey S, Das N, Das B. Comparing Ksharasutra (Ayurvedic Seton) and open fistulotomy in the management of fistula-in-ano. J Nat Sci Biol Med 2015; 6(2):406 e 10. https://doi.org/10.4103/0976- 9668.160022. PMID: 26283840; PMCID: PMC 4518420. ******************************* How to cite this article: Prashanth K, Prajapati Parth Rameshbhai. Management of Complex Fistula in Ano, by IFTAK technique and Partial Fistulotomy - A Single Case Study. J Ayurveda Integr Med Sci 2024;10:266-270. http://dx.doi.org/10.21760/jaims.9.10.44 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Ayurveda, Sushruta-samhita, Bhagandara, Shalyatantra, Kaishoraguggulu, Burning sensation, Local application, Painful disease, Complete healing, Fistula in ano, Treatment modalities, Sitz-bath, Granulation tissue, Treatment duration, Jatyadi taila, Aseptic precaution, Ksharasutra ligation, Surgical Procedure, Per rectal examination, Mucopurulent discharge, Oral medication, Antiseptic dressing, Spinal anesthesia, Ksharasutra therapy, Perianal skin, Perianal region, Fistulous tract, Post-operative care, Digital rectal examination, Anal abscess, Anal incontinence, Ashta Mahagada, Ksharsutra therapy, Infective origin, Anorectal disorder, Anal verge, Partial fistulotomy, Gandhak Rasayan, Crypto glandular infection, Complex Fistula in Ano, Low anal fistula, Anal Crypts, External opening, Internal opening, Lithotomy position, Ayurveda Classic, Internal injuries, Innovative technique, Surgical method, Vertical incision, Post-procedural pain, IFTAK technique, Conventional approach, Surgical condition, External injuries.