Management Of Fistula In Ano Research Articles

A Comparative Study in the Management of Fistula in ANO

Abstract: Background- Fistula in ano is an abnormally communication between rectum or anal canal to skin around the anus. Fistula in ano is mostly seen after an anorectal abscess. According to Ayurveda “bhagandra” is formed after “guda pidika”. The principle of management of fistula are eradication of infected anal crypt and fistulous track and preserved function of sphincter. Methods- this is a randomized comparative study 30 case of fistula in ano presenting at opd of national resource center of kshar sutra in sir suderlal hospital institute of medical science Banaras Hindu university. from 15 patients were treated with IFTAK and 15 patients were treated with modified LIFT.

Ayurvedic management of fistula in ano: A case study

Ayurvedic management of fistula in ano: A case study

Antimicrobial effect of Uthamadi Choorna during Ksharasutra Therapy in Bhagandara

In the modern era, ano rectal diseases are increasing day by day due to the changes in life style especially the food habits. Fistula in ano is one among them. It is a chronic illness which is, though not fatal but quite discomforting and troublesome to the patient and often puts a deep impact on the quality of life of a patient. Fistula in ano is a track lined by granulation tissue which connects peri anal skin superficially to anal canal, ano rectum or rectum deeply. The main clinical symptoms consist of pain, swelling and pus discharge. Due to higher recurrence rate and postoperative complication, fistula-in-ano is a headache in current surgical practice. Bhagandara which is described in Ayurveda classics can be correlated with Fistula in ano. Ksharasuthra therapy is a parasurgical procedure in Ayurveda which is found more effective in the management of fistula in ano. Even after Ksharasuthra application, pus discharge from fistulous tract delays the healing and makes the post operative period more difficult. So there is a need a of some adjuvant drug which can manage these problems in a better way and promote healing process by reducing the microbial load.Uthamadi Choorna is mentioned in Bhagandara prathishedha adhyayam in Ashtamga hrdaya and it contains Guggulu, Thriphala, Khadira and Asana which are having various chemical constituents that showed antimicrobial activity in pharmacological studies. The objective of the present study is to evaluate the antimicrobial effect of Uthamadi choorna during Ksharasuthra therapy in Bhagandara.

UNDERSTANDING OF KSHALANA KARMA AND ITS APPLICATION IN THE MANAGEMENT OF BHAGANDARA (FISTULA IN ANO)

Therapeutically the word Kshalana(irrigation) means the irrigation of the affected site using a suitable solution for the purpose of purification[1]. It is mentioned in the classical textbooks of ayurveda as Poorvakarma, Pradhana karma, and Paschath karma. Kshalana is beneficial in controlling foul-smelling and slimy exudating conditions like ulcers, vaginal infections, etc. A fistula in an ano is an abnormal tract or cavity lined with unhealthy granulation tissue that connects a primary opening inside the anal canal to a secondary opening in the perianal skin[2]. Its prevalence is the second highest after haemorrhoids among anorectal diseases. In Ayurveda, fistula in ano is correlated with the vyadhi Bhagandara (fistula in ano). Modern medical managements have its own limitations, even with various surgical modalities. Due to the presence of irritant discharges and non-dependent drainage, fistula in ano seldom shows healing intention[3]. Although Ayurvedic classics explain various treatment modalities for the management of fistula in ano, Ksharasuthra therapy owes the glorious part of management. But improper pus drainage, pus stagnation, and microbial invasion hinder the action of Ksharasuthra. Kshalana is a simple and cost-effective therapeutic technique. The present review focuses on the understanding of Kshalana karma along with its mode of action and application in fistula in ano.

The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study

BackgroundFistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano.Material and methodsWe enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically.ResultsAt 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post–operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy.ConclusionLigation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

A Clinical Study of Interception of Fistulous Tract with Application of Kshar Sutra(IFTAK)Technique Using Madhu Saindhav Aragwadhadi Kshar Sutrain the Management of Bhagandara(Crypto Glandular Fistula).

The humanity had been suffered from various diseases and among the many uncomfortable conditionsfrom the onset of civilization. Fistula in ano one of the most important one. Its anatomical situation makes it difficult to treat. It is known as Bhagandarain Ayurvedic classics. The disease was widely prevalent and numerous techniques were tried for its management. However, none of them could provide solace to the suffering mankind. Though there has been a lot of advancement in the modern surgery in recent years and many surgical diseases are treated with less invasive procedure such as laparoscopic and robotic surgeries which has revolutionized the management of surgical diseases. But fistula in ano is still the disease with high recurrence rates in present time also. Ayurveda offers an effective, safe, less invasive treatment modality called ksharsutratherapy which have been in since many centuries practice). Ksharsutratherapy has many advantages like the tract is completely excised by lekhanand improved healing simultaneously so, there are least chances of recurrence, minimal scaring and no chance of anal incontinence but Ksharsutracause certain discomfort such as long anxiety period, number of hospital visit, Discomfort and longer duration of treatment. The present study regarding interception of fistulous tract with application of ksharsutra(IFTAK) was done in the patient ofusually horse shoe type fistula, supralevator fistula, transsphinctor fistula, extra sphincter, fistula in ano which showed great potential in the management of fistula in ano by reducing the duration of treatment with minimal post operative scar.

A case report on management of recurrent pediatric fistula in ano with an udumber ksheersutra varti

A case report on management of recurrent pediatric fistula in ano with an udumber ksheersutra varti

Effectiveness of anal infiltration with Murivenna oil, internal administration of Triphala choorna, sitz bath, and fiber diet protocol in acute and chronic anal fissures

BACKGROUND: Anal fissure (fissure in ano) is an excruciating manifestation among common anorectal presentations. The condition inflicts significant personal and social ill health causing considerable morbidity. This study aimed at documenting the effect of Murivenna oil infiltration and Triphala choorna oral use along with sitz bath and fiber diet protocol in the management of fistula in ano. MATERIALS AND METHODS: Retrospective analysis of 15 cases diagnosed with primary fissure in ano who underwent prescribed conservative Ayurvedic treatment between March 2018 and February 2019 at the National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, is reported. All patients were managed with anal infiltration of Murivenna oil (30 ml), internal administration of Triphala choorna (10 g), sitz bath, and fiber diet. Retrospective outcome analysis of recorded change in each case on study variables, viz. pain, bleeding per rectum (BPR), anal discharge, inflammation and tenderness, and healing of fissure, was recorded in structured proforma, was carried out using the Statistical Package for the Social Sciences. A Friedman test for repeated measures, followed by Wilcoxon post hoc test, was conducted on the study variables. Results with P-value&lt;.01 were considered significant. RESULTS: Data of 15 patients was used for analysis. Complete healing of the fissure was documented in 93% of patients by the end of their respective 30th day. There was significant relief in symptoms of inflammation, tenderness, anal discharge, and bleeding per rectum (BPR) in most of the patients within their first 7 days of treatment. Median pain level assessed on VAS was significantly reduced from 9 (on the 1st day) to 1 (on the 7th day) and eventually to 0 on the 30th day. Statistically significant difference was observed in the percentage healing of fissure measured on the 8th day (78 ± 11.464), 15th day (91.33 ± 9.904), and 30th day (99.33 ± 2.582). CONCLUSION: The observatory report provides significant elementary evidence on the effectiveness of an Ayurvedic conservative treatment in managing acute and chronic primary fissure in ano.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BackgroundManagement of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.MethodsDutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.ResultsIn total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).ConclusionsDutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Novel Animal Model from Goat Ano Rectum and Pumpkin for Training of Surgeons in Management of Fistula in Ano

There is no perfect treatment for different types of fistulae in ano. Training in fistula management carries a long learning curve; an animal model from goat anal canal and rectum was prepared for training of surgeons in the management of benign anorectal diseases, especially fistula in ano. Simple material was used for creating this animal model. The hindgut portion of the goat was fixed in pumpkin. A hole was created in the pumpkin, and the pulp was removed to make space for the goat specimen. Anatomy was explained after dissection and fistulae were artificially created for simulation purposes. Model was used for training in a workshop conducted at our hospital, and feedback was taken from the participants on its utility, in learning anatomy of the area, primary sphincter repair, and use of endoscope and LASERs for fistula management. Model costs only rupees 500/-. Anatomy of the goat anal canal and rectum is quite similar to human beings. All the participants could appreciate the anal canal anatomy, different perianal spaces and sphincters were demonstrated, and fistulectomy and primary sphincter repair were taught. Consultant and participants appreciated the use of endoscope and LASERs in fistulous tracks in a simulated environment. All the consultants and participants strongly recommended the use of this model for future hands-on workshops. Our model was more realistic for practicing suturing in closed anal space, demonstration of perianal spaces, fistulae, and their management.

A comparative study of Ligation of Intesphincteric Fistula Tract versus conventional fistulectomy in management of low fistula in ano: a randomized control trial

Background: Fistula in ano (FIA) is a chronic complex condition of ano-rectal sepsis characterized by cylical-pain and intermittent chronic purulent discharge. The management of fistula is challenging. In spite of all the advances in the management of FIA, no single method is univresally applicable to all types of FIA due to incontinence and recurrences associated with the individual procedures.Methods: Aims of this study were to compare the outcomes between ligation of intersphincteric fistula tract (LIFT) and conventional fistulectomy (CF) with 60 patients randomized into 2 groups, 30 in each group.Results: Mean age in LIFT was 44.17 years and in CF was 41.1 years. Successful primary healing was observed in 86.7% of LIFT and 100% of CF. Mean pain scores were lower in LIFT compared to CF when checked on Postoperative days 1, 3 and 7 significantly. Anal incontinence was seen in 10% of CF and none in LIFT and recurrence was seen at same site in LIFT in 6.66% of LIFT and none in CF both being not statistically significant.Conclusions: LIFT is a promising and sphincter saving technique which is simple and easy to learn with faster healing rates and better patient contentment but with risk of failure and recurrence. Modifications of LIFT have to be probed for minimizing the failures.

COMPREHENSIVE EVALUATION OF VARIOUS AVAILABLE SURGICAL MANAGEMENT OF FISTULA IN ANO :EXPERIENCE IN A TERTIARY CARE CENTRE OF INDIA

BACKGROUND: There are various conventional and emerging surgical modalities for management of fistula in ano. But every modality has its own pros and cons. The aim of our study was to compare various surgical modalities in term of its recurrence rate, cost and their complication rates Materials and methods: A prospective observational study was conducted with 50 patients from July 2016 to June 2018. Prospective data was collected on proforma basis regarding clinical presentation, imaging findings, various surgical modalities, complications and reoperation rate. RESULTS: The mean age of the patients was 40.04 ± 10.77 years. The most common type of surgery was Fistulectomy (28%) and Fistula plug (28%) followed by Fistulotomy (20%), Seton Application (16%) and Video Assisted Anal Fistula Treatment (VAAFT) (8%).8 (16%) patients required reoperation. There was no significant association of reoperation and type of surgery in patients (p&gt;0.05). The mean values of post-operative recovery (VAS Score) at different time intervals (post-op, post-op 3 months and post-op 6 months) was comparable and statistically not significant as per ANOVA test (p&gt;0.05). There was no significant association of post-operative recovery (VAS Score) and type of surgery in patients. There was no significant association of post-operative complications after 3 months and 6 months and type of surgery in patients (p&gt;0.05). CONCLUSION: All the surgical modalities used in our study revealed comparable success rate and no significant differences in complication rates. A large randomised controlled trial comparing various surgical modalities is required in future to decide the best surgical method to treat fistula in ano.

A Literature review on various methods of Ksharsutra preparation

Fistula-in-ano is a condition which has been recognized as troublesome surgical disease due to its recurrent nature. Almost all the surgeons starting from Acharya Sushruta to the reputed surgeons up to the minute have realized the difficult course of this disorder as far as its surgical as well as medical management is considered. Treatment of fistula-in-ano is always a challenging task for the surgeons and the patients as well. The Ray of hope is provided by Ayurveda in combating this ailment. "Ksharsutra " is an excellent Para surgical procedure for management of Fistula in ano and possible decrease in its reoccurrence. An attempt has been made to review all the references mentioned regarding the preparations of ksharsutras and modifications made in it to improve its utility.

Assessing Surgeons' Preferences in the Management of Fistula In Ano

Background Fistula in ano is a common condition treated by surgeons worldwide. Despite this, there is a paucity of high-quality data to aid decision-making. Hence, management presents a difficult and frustrating dilemma for the treating surgeon. Methods A prospective regional survey was sent to all members of General Surgeons Australia. Questions regarding surgeon demographics, patient evaluation, perianal abscess, and simple and complex fistula in ano were presented. Results Equipoise exists in the management of fistula in ano among general surgeons. This was noted in the management of simple and complex fistula in ano. Conclusion Because of the uncertainty in certain clinical scenarios and a paucity of high-quality randomized controlled trials on the management of fistula in ano, evidence-based practice is a challenge to the treating surgeon.

Management of Fistula in ANO in a Tertiary Care Hospital of Northern Andhra Pradesh

Management of Fistula in ANO in a Tertiary Care Hospital of Northern Andhra Pradesh

A clinical trial of feeding tube with metallic guide wire insertion for ‘Ksharsutra’ technique in a case of fistula in ano.

‘Kshar-sutra’ therapy in cases of fistula in ano, despite a long medical history of credentials &amp; conduct, still possess a challenge to medical fraternity in terms of finding a satisfactory cure of the disease.&#x0D; ‘Ksharsutra’ is a popular treatment modality in India for the management of fistula in ano. It works by the action of excision, scraping, draining, penetrating, debridement &amp; sclerosing as well as healing simultaneously without surgical excision.&#x0D; The conventional method to insert a ksharsutra by using a metallic probe through an external opening may cause pain and discomfort to the patients. In some cases, this intervention is not possible without general anesthesia. The Ksharsutra may be inserted through an external opening by using an infant feeding tube (no.5 or 6) with the metallic guide wire to finding out the track easily &amp; keep it in the track steady without causing pain as a day care procedure.

Ayurvedic Management of Fistula in Ano

Introduction: Fistula in ano is considered to be complicated and vicious due to its nature of recurrences and exacerbations. Ayurveda includes this disease under the list of Asta Mahagada (eight serious diseases that are difficult to treat by nature itself) due to this attribute. Ayurvedic literature offers various effective and safe management strategies for fistula in ano. Several works have been conducted to prove the efficacy and effectiveness of various treatment modalities mentioned in Ayurvedic texts. Kshara sutra, Kshara karma, Agnikarma, and Ksharavarti are a few to name in this list. A lacuna exists in not analyzing or compiling these works. Hence, the purpose of this systematic review is to generate evidence for efficacy, effectiveness, and safety profile of Ayurvedic interventions in the management of fistula in ano. Materials and methods: Electronic search from various online databases and clinical trial registers will be done. Manual search for gray literatures will be done from various colleges and universities. There will be no language restrictions. Three authors independently will screen all citations and abstracts to identify potentially eligible trials. Based on the inclusion criteria, full articles will be evaluated and disagreements will be discussed among the three authors. Data extraction from the included studies will be done by the three reviewers independently with extraction forms containing methods, participants, interventions, comparators/controls, and outcomes. Each of the included trials will be assessed for risk of bias. Primary data analysis will be done for both qualitative and quantitative data. Heterogeneity among trials will be assessed by inspecting forest plots. If heterogeneity is detected, and it is still considered clinically meaningful to combine studies, a random- effects model will be used. Meta-analysis will be done for pooled estimates and others would be presented as narrative synthesis and shall be represented in tabular and graphical forms. Dissemination: The systematic review will be published in a peer-reviewed journal. It will also be disseminated electronically and in print. The review may guide healthcare practices and policy framing regarding the treatment of fistula in ano with Ayurvedic interventions. Study registration: PROSPERO registration no. CRD42019131911.

A comparative study in the management of fistula in ANO using various modalities

Background: Fistula in ano is a track that connects deeply the anal canal or rectum to the skin around the anus. Fistula in ano most commonly follows an anorectal sepsis1. The main principles of management of anal fistula are closure of internal opening of fistula tract, drainage of infection or necrotic tissue, and eradication of fistulous tract with preservation of sphincter function. The objectives were to compare the various aspects like per operative complications, post-operative complications, mean hospital stay in the treatment of fistula in ano using various modalities like fistulotomy, fistulectomy, setons and lift procedure.Methods: This is a randomised, comparative, prospective study of 80 cases of fistula in ano, presenting at surgical opd of K.R. Hospital, Mysore attached to Mysore Medical College and research Institute. Out of which, 20 cases are treated by fistulectomy, 20 by seton, 20 by fistulotomy and the rest 20 cases by LIFT procedure by random selection method, during period of NOVEMBER 1, 2016 to 31st October 2017.Results: Most common age of presentation is 31-40 years and more common in males then females (M:F= 2.3:1 ). Per operative complications include bleeding seen more in patients undergoing fistulectomy. Per operative course of LIFT procedure patients was complication free. Postoperative pain seen more in patients undergoing setons procedure.Conclusions: we conclude that LIFT procedure and Fistulotomy were acceptable procedures for simple, uncomplicated low lying and high lying fistula.

Current trends in the usage of Ksharakarma (Alkaline therapy) and Ksharasutra (Alkaline Seton) for managing Bhagandhara (Fistula -In -Ano)

Background: Anal fistula is an abnormal track with an external opening in the perianal skin region and internal opening in the modified skin or mucosa of anal canal or rectum. The description of Bhagandara described in Ayurveda can be correlated to anal fistula. Managing of high anal fistula is a very tedious job and fecal incontinence may be developed after surgery due to damage of anorectal ring. Kshara (alkali) work effectively on various stages of a wound and is helpful in treating fistula-in ano. Ksharasutra (alkaline seton) is a type of para surgical procedure described in Ayurveda classics. Aim: The present review aims at analysing the current trends in the usage of Ksharakarma (alkaline therapy) and Ksharasutra in the management of fistula–in-ano. Materials & Methods: The present study is a procedural review on techniques of application of Ksharakarma and Ksharasutra employed upon the patients with various types of fistula-in ano. Observations: Four techniques employed in various types of fistula-in any were analysed. These include Apamarga Theekhsna Pratisarniya Kshara applied on nonspecific low anal subcutaneous fistula-in ano, Ksharasutra Varti (alkaline wick) applied on non-specific inter-sphincteric grade Grade II fistula-in ano where there was no internal opening, Multistage Ksharasutra technique employed in an inter-sphincteric grade Grade II fistula in ano with gradual extension of track and technique of Interception of fistula track by application of Ksharasutra (IFTAK) was employed in Grade IV fistula. Conclusion: All the above four techniques employed were effective in managing fistula–in ano. The techniques described here are the modifications of classical procedures, which acts at different level and produce intended effect of healing the fistulous track without any complication or reoccurrence. However, larger comparative clinical studies may be required to further substantiate the effectiveness of these techniques.

Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience.

Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown. This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up. Retrospective analysis of single-center data from May 2006 to October 2010 was performed. This study was conducted at a large tertiary hospital in Bangkok, Thailand. All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded. Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016. In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery. This study was limited by its retrospective design. Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.