Management of Bhagander-Fistula in Ano with

 Kshar-sutra and partial fistulectomy.

 

 

Dr.Mukul Patel. M.D. (Ayu.) Jamnagar

Dr.Medha Patel.  M.D. Ayu Jamnagar

 

Director

Shreyas Hospital & Ano-rectal Reaserch Centre

Opp. Majuragate circle Ring road Surat.Gujrat

Web: www.proctocure.com Email: drmukul@proctocure.com

Tel/Fax: (0091) 261 2462626,261 5544944, 261 2651718 (R)

 

 

 

A fistula, as we all knows is an abnormal passage leadingfrom one internal cavity to another or to the surface. It is either lined withmucosal membrane or may be lined with epithelium. Nearly all anal fistulas areresults of an infection of the anal glands that traveled down theintersphincteric plane to form a draining perianal abscess. These abscesses maydrain in any direction and in any planes thus giving rise to different kinds offistulas.

 

The classification of fistulasaccording to modern surgery has been done on the bases of the paths taken bythe fistulous track.

 

Subcutaneous, Low Intersphincteric,Transphincteric, Trans or Suprasphincteric with high blind intralevatorextension, & Extra sphincteric.

 

Classification is also done on thebases of the complexity of the tracks themselves i.e. depending upon the numberof opening in the bowel or externally. The simple fistulas have a single trackwith just one external and one internal opening where as the more complex typeshave more than one track. Rarely we find fistulas with one external opening andone track initially, which bifurcates inside giving rise to multiple internalopenings. Sometimes we find fistulas with a number of external openings andmultiple tracks leading to one or more openings internally.

 

What we are about to discuss here isthe treatment/procedure to be followed in the comparatively more complex andmore complicated types of fistulas. Extremely complex fistulas are nearlyalways caused by the mishandling of a simple fistula by a surgeon who did notunderstand the anatomy of the area and misdiagnosed the type of abscess-fistulacomplex. Some however develop due to neglect on the part of the patient andallowing long periods to elapse before approaching a proper doctor.

 

The procedure in discussion here is anexcellent combination of the conventional type of surgery i.e. Fistulectomy andthe age-old Kshar-Sutra ligation procedure, very well-known amongst presentAyurvedists. It is usually preferred in high anal transphincteric fistulas orfistulas involving the ischeo rectal fossa. Also where a single externalopening leads to a single track initially and then bifurcates into two or moretracks.

 

Before discussing the procedure itselfand the benefits of the combination let us first see the need for the treatmentitself.

 

Spontaneous healing of anal fistulas,especially complex anal fistulas is practically unheard. If neglected or illtreated fistulas may cause repeated abscesses and ill health and long-standingfistula may eventually lead to malignant disease. I have never seen in mypractice of 14 years, a really chronic fistula, especially one of the completevarieties with a thick fibrous wall lining its track, self healing or selfclosing in any way with just conservative treatment.

 

Indicationfor this procedure: -

 

Different fistulas are treated indifferent ways by both, the followers of the modern medical science as well asAyurvedists. Surgeons of the modern medical science prefer Fistulectomy. Thissometimes, especially in the complex types, is performed in two or more stepsinterspaced by duration of few weeks. Ayurvedists however prefer Kshar-Sutraligation in all types of fistulas irrespective of the position of the externalopening and the course, the complexity and length of the tracks and weather thefistulous track is single or multiple.

 

Wehave chosen this combination mainly for the following types of fistulas-

 

• High anal Trans-sphincteric fistulas
• Horse-Shoe fistula
• High anal supra-sphincteric fistulas
• In fistulas with multiple external openings and with tracks communicating with each other.

 

Thecombination is preferred to avail of the benefits of both the methods and isplanned in such a way that the two methods are applied to the parts of thefistulous track where they are best suited. That is, Fistulectomy is preferredfor the external part of the track where as Kshar-Sutra ligation for theinterior portion of the track or where the sphincteric muscles are involved.

 

We discusshere the application of partial Fistulectomy with Kshar-Sutra ligation in oneof the most complicated forms of anal fistulas i.e. The Horse shoe Fistula. Asthe name suggests the fistulous track in a Horse shoe fistula resembles theshape of horse shoe.

 

The main trackof an ischiorectal fistula follows the roof of the ischiorectal fossa i.e. itlies on the under surface of the Puborectalis muscle. The track is therefore ofhorse shoe shape, if both sides are involved, with the anterior extension oneach side passing deep to the transverse perineal muscle. The communicationwith the anal canal is most frequently in the mid line posteriorly but not invariablyso. The track leading to the external opening on the skin is usually a verticaltrack which may descend from any part of the main one.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis: -

 

Inspection ofthe anal region will usually reveal an external opening or openings. A singleopening is more common. Sometimes the opening may be temporarily healed and maybe detected only when the surrounding skin is palpated or lightly pressed andpus escapes from the opening. Now, a careful palpation of the perianal regionis performed. The position of the external opening and the palpation of theperianal region may give some indication of the possible course of the track.Horse shoe fistulas however are usually impalpable in the perianal regionbecause of their high position relative to the anal canal. Now, a per/rectaldigital examination (P/R) is performed. Palpation of the anal canal may revealan area of induration or the actual internal opening. P/R is of primeimportance in diagnosing a horse shoe fistula. The track of a posterior horseshoe fistula lies close along the Puborectalis sling and hence is felt verydistinctly as a thick horizontal rod of induration on one or the both sides (asthe case may be) and posteriorly at or just above the level of the anorectalring. This can be palpated and distinguished more perfectly when the horse shoefistula is unilateral i.e. incomplete, because the palpation of the two sidesreveals a striking difference. Sometimes in inexperienced hands a completehorse shoe fistula, is missed as the symmetrical posterior and lateralinduration gives a feeling similar to that of an abnormally prominent and firmPuborectalis sling.

 

An internalopening is generally in the midline of the posterior wall of the canal at thelevel of the anal crypt or even up to or above the anorectal ring is frequently(not always) detected in such fistulas.

It is alsovery important to access the amount of sphincter musculature that has remainedif the patient has undergone previous Ano-rectal procedures.

 

Probing: -

 

Probing isadvisable only after proper inspection and palpation. Also, probing should bedone following the Goodsall’s rule to minimize the risk of hurting the patientby pursuing a faulty direction. A malleable medium sized silver probe is used.The terminal 2.5 to 4 c.m. part should be bent into aslight curve as required to probe a horse shoe fistula. When the probe ispassed as far as possible into the fistula, hold it in the position. Now theforefinger of the other hand is inserted into the anal canal.

 

The examinerwill be able to feel the tip of the probe emerging through the internal openinginto the anal canal or it may be palpable through the anal or rectal wallseparated from the finger by the whole thickness of the wall or by the mucosa.The probe can be brought out by further manipulation with the help of theguidance of the finger inside the canal. However the examiner should be verycareful not to create an artificial opening by force.

 

Proctoscopy: -

 

Proctoscopymay reveal an internal opening which may not have been detected by palpation orby passing the probe. Proctoscopy is also useful in determining weather theopening is in the anal canal or above the anorectal ring in the rectum. Besidesthis, Proctoscopy shows us the state of the rectal mucosa and helps us todecide if any other underlying factors like proctocolitis are present.

 

Radiological examination: -

 

Radiologicalexamination of the fistulous track after injecting ConeryDye is useful in the course of the track is doubtful or when a track issuspected to lead to more than one opening i.e. if the track is suspected tobifurcate. This is of value only for high anorectal fistulas or fistulas withone or multiple tracks and one or more opening. As MRI or CT scan of thefistula is more helpful in complex cases.

 

Radiological examination of chest: -

 

Anal fistulasespecially long standing ones with complex tracks are sometimes associated withactive pulmonary tuberculosis. A radiological examination of the chest shouldbe performed. The pulmonary disease must be controlled before the fistula isoperated upon.

 

A fullradiological investigation of both small and large bowl should be undertaken ifthere is any suggestion of Chrohn’s disease. Any other abdominal symptomsparticularly diarrhoea should be investigated. Sigmoidoscopy is also necessaryto exclude any rectal tumor or inflammatory bowel disease involving the rectum.

 

Pre operative preparation:-

 

The lowerbowel should be emptied by an enema about an hour before the operation. Sterilizationof the bowel is not necessary as routine measure.

 

Anesthesia:-

 

General or lowspinal anesthesia is necessary.

 

Position of the patient:-

 

The patientshould be in the lithotomy position with buttocks pulled down over the edge ofthe table. The procedure can also be performed in Jack knife position.

 

A preoperative examination should be performed.

 

The main procedure:-

 

Properextensive shaving and painting of the perianal region should be performed.

 

Dilatation:-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A gentle andcontrolled dilatation procedure is carried out. The degree of dilatation variesand it is advisable not to risk damage to the sphincter by dilating too much.Usually six to eight fingers can be inserted. A pack is secured to a thread tofacilitate pulling it out when the procedure is completed. It is now introducedin the rectal canal to absorb any discharge or blood so that it does not flowout during the procedure.

 

The externalopening is located and a probe is passed into it. It will enter deeply parallelto the anal canal and the tip of the probe can be palpated through the rectalwall at a level usually above the Ano rectal ring. It must never be forcedthrough because the real internal opening is nearly always below the Ano-rectalring, still following the under surface of the Puborectalis. The probe isbrought out from the internal opening with the help to the index finger insidethe canal leaving the probe in place. We now begin to cut the track with ascalpel. Starting from the external opening we move towards the internalopening, but we do not cut and lay open the whole track. Only the external andlateral part of the track is laid open. Dissection is performed only up to thesphincteric muscles. We stop as soon as we reach this point. The remainingtrack entering the bowel is not dissected. Now a Kshar-Sutra is passed from thenew external opening (within the dissected part) to the internal opening withthe help of probe and tied loosely around the remaining sphincteric fibers. Thepart of the track which is laid open does not require meticulous curetting andscraping out since this work is gradually done by the drugs coated on thethread. Minimal or no excision of the sides of the wound is needed and henceinstead of a big deep wound as in the case of conventional Fistulectomy. Wemake a comparatively smaller wound. Flat gauze dressing moistened with anyantiseptic Ayurvedic formula is applied lightly (gently pushed in to wound) tokeep the edges of the wound apart and ensure the healing of the wound inside outwards.

 

TheKshar-Sutra is periodically changed as per the requirement; it gradually cutsthe remaining part of the fistula Healing takes place simultaneously.

 

The benefits of the combination are obvious.

 

·       In the conventional Fistulectomy we leave a big, deep andwide wound which takes weeks to heal. Days of painful dressings follow the mainprocedure, rendering the patient unable to carry out his routine work for days.

 

·       The procedure many times needs to be completed in two stepsand hence the patient has to be operated twice. Naturally an Anesthesia too hasto be administered twice. The patient has to go through the whole ordeal twice.

 

·       The post operative dressings require more detailed attentionand have to be carried out by qualified nurses. In some cases the first fewpost operative dressings have to be carried out under general anesthesia.

 

·       There is some tendency for the large deep wounds to formpockets which delay healing. Hence the patient should be examined at least oncea week by the surgeon and any pockets of the track that may have beenoverlooked should be laid open.

 

·       In spite of such extensive postoperative care recurrencesare very common.

 

·       One more very important negative aspect of Fistulectomy isthat in many such cases division of the greater part of the anal sphincter isnecessary leading to partial incontinence which is a very uncomfortable andstress rendering condition for the patient.

 

·       We can claim without any exaggeration that all thesenegative aspects of Fistulectomy can be avoided to a very great extent in theprocedure mentioned above.

 

·       As we have already seen the wound left after the procedureare very small in comparison to the wounds left after conventionalFistulectomy.

 

·       The post operative days of the patient are much more comfortable.

 

·       Dressings are sometimes needed for just a few days in placeof weeks and even these post operative dressings do not need very extensivecleaning or irrigating of the wounds.

 

·       The sphincteric muscles are not dissected and hence thepossibility of incontinence is ruled out.

 

·       The drugs coated on the Kshar-Sutra are slowly and graduallyreleased into the track and the wound, leaving no pockets overseen. Thesepockets are drained out by the action of the drugs.

 

·       And last but not the least, the cosmetic aspect of theprocedures should not be neglected just because the region involved does notusually come in view. As the late professor Dr. P K Zaver(Ex President, Colorectal Surgeon Society of India) used to state, ‘Ananorectal and perianal surgery should be performed as precisely as Maxilo-Facial cosmetic surgery’. The appearance of theperianal part, after complete healing has occurred should be as near normal aspossible. Clearly, this is more possible when minimum dissection and extensionof the wounds is performed. The wounds after a partial Fistulectomy withKshar-Sutra are much smaller and hence leave a better appearance after healing.

 

The combination procedure has befitsover the Kshar-Sutra procedure also.

 

In a typical Horse Shoe fistula,Kshar-Sutra ligation procedure has to be performed in such a way that we willhave two or sometimes three different threads in the track. Changing threedifferent threads at a sitting (during dressing) may be very painful andinconvenient to the patient.

 

The gradual cutting of the track takesa very long time which is significantly shortened by combining the procedures.

 

In some cases it is not possible toprovide adequate drainage without laying a part of the track open.

 

I hope, the benefits of combining twomethods judiciously have been made clear.

 

 

 

 

DRMEDHA PATEL M.D. Ayu

DRMUKUL PATEL M.D. Ayu

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Email: drmukul@proctocure.com, drmedha@nisargayurveda.com