Bhagander-Fistula in Ano with
Kshar-sutra and partial fistulectomy.
Dr. Mukul Patel. M.D. (Ayu.) Jamnagar
Dr. Medha Patel. M.D. Ayu Jamnagar
Shreyas Hospital & Ano-rectal Reaserch Centre
Opp. Majuragate circle Ring road Surat. Gujrat
Tel/Fax: (0091) 261 2462626, 261 5544944, 261 2651718 (R)
A fistula, as we all knows is an abnormal passage leading from one internal cavity to another or to the surface. It is either lined with mucosal membrane or may be lined with epithelium. Nearly all anal fistulas are results of an infection of the anal glands that traveled down the intersphincteric plane to form a draining perianal abscess. These abscesses may drain in any direction and in any planes thus giving rise to different kinds of fistulas.
The classification of fistulas according to modern surgery has been done on the bases of the paths taken by the fistulous track.
Subcutaneous, Low Intersphincteric, Transphincteric, Trans or Suprasphincteric with high blind intralevator extension, & Extra sphincteric.
Classification is also done on the bases of the complexity of the tracks themselves i.e. depending upon the number of opening in the bowel or externally. The simple fistulas have a single track with just one external and one internal opening where as the more complex types have more than one track. Rarely we find fistulas with one external opening and one track initially, which bifurcates inside giving rise to multiple internal openings. Sometimes we find fistulas with a number of external openings and multiple tracks leading to one or more openings internally.
What we are about to discuss here is the treatment/procedure to be followed in the comparatively more complex and more complicated types of fistulas. Extremely complex fistulas are nearly always caused by the mishandling of a simple fistula by a surgeon who did not understand the anatomy of the area and misdiagnosed the type of abscess-fistula complex. Some however develop due to neglect on the part of the patient and allowing long periods to elapse before approaching a proper doctor.
The procedure in discussion here is an excellent combination of the conventional type of surgery i.e. Fistulectomy and the age-old Kshar-Sutra ligation procedure, very well-known amongst present Ayurvedists. It is usually preferred in high anal transphincteric fistulas or fistulas involving the ischeo rectal fossa. Also where a single external opening leads to a single track initially and then bifurcates into two or more tracks.
Before discussing the procedure itself and the benefits of the combination let us first see the need for the treatment itself.
Spontaneous healing of anal fistulas, especially complex anal fistulas is practically unheard. If neglected or ill treated fistulas may cause repeated abscesses and ill health and long-standing fistula may eventually lead to malignant disease. I have never seen in my practice of 14 years, a really chronic fistula, especially one of the complete varieties with a thick fibrous wall lining its track, self healing or self closing in any way with just conservative treatment.
Indication for this procedure: -
Different fistulas are treated in different ways by both, the followers of the modern medical science as well as Ayurvedists. Surgeons of the modern medical science prefer Fistulectomy. This sometimes, especially in the complex types, is performed in two or more steps interspaced by duration of few weeks. Ayurvedists however prefer Kshar-Sutra ligation in all types of fistulas irrespective of the position of the external opening and the course, the complexity and length of the tracks and weather the fistulous track is single or multiple.
We have chosen this combination mainly for the following types of fistulas-
The combination is preferred to avail of the benefits of both the methods and is planned in such a way that the two methods are applied to the parts of the fistulous track where they are best suited. That is, Fistulectomy is preferred for the external part of the track where as Kshar-Sutra ligation for the interior portion of the track or where the sphincteric muscles are involved.
We discuss here the application of partial Fistulectomy with Kshar-Sutra ligation in one of the most complicated forms of anal fistulas i.e. The Horse shoe Fistula. As the name suggests the fistulous track in a Horse shoe fistula resembles the shape of horse shoe.
The main track of an ischiorectal fistula follows the roof of the ischiorectal fossa i.e. it lies on the under surface of the Puborectalis muscle. The track is therefore of horse shoe shape, if both sides are involved, with the anterior extension on each side passing deep to the transverse perineal muscle. The communication with the anal canal is most frequently in the mid line posteriorly but not invariably so. The track leading to the external opening on the skin is usually a vertical track which may descend from any part of the main one.
Inspection of the anal region will usually reveal an external opening or openings. A single opening is more common. Sometimes the opening may be temporarily healed and may be detected only when the surrounding skin is palpated or lightly pressed and pus escapes from the opening. Now, a careful palpation of the perianal region is performed. The position of the external opening and the palpation of the perianal region may give some indication of the possible course of the track. Horse shoe fistulas however are usually impalpable in the perianal region because of their high position relative to the anal canal. Now, a per/rectal digital examination (P/R) is performed. Palpation of the anal canal may reveal an area of induration or the actual internal opening. P/R is of prime importance in diagnosing a horse shoe fistula. The track of a posterior horse shoe fistula lies close along the Puborectalis sling and hence is felt very distinctly as a thick horizontal rod of induration on one or the both sides (as the case may be) and posteriorly at or just above the level of the anorectal ring. This can be palpated and distinguished more perfectly when the horse shoe fistula is unilateral i.e. incomplete, because the palpation of the two sides reveals a striking difference. Sometimes in inexperienced hands a complete horse shoe fistula, is missed as the symmetrical posterior and lateral induration gives a feeling similar to that of an abnormally prominent and firm Puborectalis sling.
An internal opening is generally in the midline of the posterior wall of the canal at the level of the anal crypt or even up to or above the anorectal ring is frequently (not always) detected in such fistulas.
It is also very important to access the amount of sphincter musculature that has remained if the patient has undergone previous Ano-rectal procedures.
Probing is advisable only after proper inspection and palpation. Also, probing should be done following the Goodsall’s rule to minimize the risk of hurting the patient by 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 a slight curve as required to probe a horse shoe fistula. When the probe is passed as far as possible into the fistula, hold it in the position. Now the forefinger of the other hand is inserted into the anal canal.
The examiner will be able to feel the tip of the probe emerging through the internal opening into the anal canal or it may be palpable through the anal or rectal wall separated 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 the guidance of the finger inside the canal. However the examiner should be very careful not to create an artificial opening by force.
Proctoscopy may reveal an internal opening which may not have been detected by palpation or by passing the probe. Proctoscopy is also useful in determining weather the opening is in the anal canal or above the anorectal ring in the rectum. Besides this, Proctoscopy shows us the state of the rectal mucosa and helps us to decide if any other underlying factors like proctocolitis are present.
Radiological examination: -
Radiological examination of the fistulous track after injecting Conery Dye is useful in the course of the track is doubtful or when a track is suspected to lead to more than one opening i.e. if the track is suspected to bifurcate. This is of value only for high anorectal fistulas or fistulas with one or multiple tracks and one or more opening. As MRI or CT scan of the fistula is more helpful in complex cases.
Radiological examination of chest: -
Anal fistulas especially long standing ones with complex tracks are sometimes associated with active pulmonary tuberculosis. A radiological examination of the chest should be performed. The pulmonary disease must be controlled before the fistula is operated upon.
A full radiological investigation of both small and large bowl should be undertaken if there is any suggestion of Chrohn’s disease. Any other abdominal symptoms particularly diarrhoea should be investigated. Sigmoidoscopy is also necessary to exclude any rectal tumor or inflammatory bowel disease involving the rectum.
Pre operative preparation:-
The lower bowel should be emptied by an enema about an hour before the operation. Sterilization of the bowel is not necessary as routine measure.
General or low spinal anesthesia is necessary.
Position of the patient:-
The patient should be in the lithotomy position with buttocks pulled down over the edge of the table. The procedure can also be performed in Jack knife position.
A pre operative examination should be performed.
The main procedure:-
Proper extensive shaving and painting of the perianal region should be performed.
A gentle and controlled dilatation procedure is carried out. The degree of dilatation varies and 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 to facilitate pulling it out when the procedure is completed. It is now introduced in the rectal canal to absorb any discharge or blood so that it does not flow out during the procedure.
The external opening is located and a probe is passed into it. It will enter deeply parallel to the anal canal and the tip of the probe can be palpated through the rectal wall at a level usually above the Ano rectal ring. It must never be forced through because the real internal opening is nearly always below the Ano-rectal ring, still following the under surface of the Puborectalis. The probe is brought out from the internal opening with the help to the index finger inside the canal leaving the probe in place. We now begin to cut the track with a scalpel. Starting from the external opening we move towards the internal opening, but we do not cut and lay open the whole track. Only the external and lateral part of the track is laid open. Dissection is performed only up to the sphincteric muscles. We stop as soon as we reach this point. The remaining track entering the bowel is not dissected. Now a Kshar-Sutra is passed from the new external opening (within the dissected part) to the internal opening with the help of probe and tied loosely around the remaining sphincteric fibers. The part of the track which is laid open does not require meticulous curetting and scraping out since this work is gradually done by the drugs coated on the thread. Minimal or no excision of the sides of the wound is needed and hence instead of a big deep wound as in the case of conventional Fistulectomy. We make a comparatively smaller wound. Flat gauze dressing moistened with any antiseptic Ayurvedic formula is applied lightly (gently pushed in to wound) to keep the edges of the wound apart and ensure the healing of the wound inside outwards.
The Kshar-Sutra is periodically changed as per the requirement; it gradually cuts the 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 and wide wound which takes weeks to heal. Days of painful dressings follow the main procedure, rendering the patient unable to carry out his routine work for days.
· The procedure many times needs to be completed in two steps and hence the patient has to be operated twice. Naturally an Anesthesia too has to be administered twice. The patient has to go through the whole ordeal twice.
· The post operative dressings require more detailed attention and have to be carried out by qualified nurses. In some cases the first few post operative dressings have to be carried out under general anesthesia.
· There is some tendency for the large deep wounds to form pockets which delay healing. Hence the patient should be examined at least once a week by the surgeon and any pockets of the track that may have been overlooked should be laid open.
· In spite of such extensive postoperative care recurrences are very common.
· One more very important negative aspect of Fistulectomy is that in many such cases division of the greater part of the anal sphincter is necessary leading to partial incontinence which is a very uncomfortable and stress rendering condition for the patient.
· We can claim without any exaggeration that all these negative aspects of Fistulectomy can be avoided to a very great extent in the procedure mentioned above.
· As we have already seen the wound left after the procedure are very small in comparison to the wounds left after conventional Fistulectomy.
· The post operative days of the patient are much more comfortable.
· Dressings are sometimes needed for just a few days in place of weeks and even these post operative dressings do not need very extensive cleaning or irrigating of the wounds.
· The sphincteric muscles are not dissected and hence the possibility of incontinence is ruled out.
· The drugs coated on the Kshar-Sutra are slowly and gradually released into the track and the wound, leaving no pockets overseen. These pockets are drained out by the action of the drugs.
· And last but not the least, the cosmetic aspect of the procedures should not be neglected just because the region involved does not usually come in view. As the late professor Dr. P K Zaver (Ex President, Colorectal Surgeon Society of India) used to state, ‘An anorectal and perianal surgery should be performed as precisely as Maxilo-Facial cosmetic surgery’. The appearance of the perianal part, after complete healing has occurred should be as near normal as possible. Clearly, this is more possible when minimum dissection and extension of the wounds is performed. The wounds after a partial Fistulectomy with Kshar-Sutra are much smaller and hence leave a better appearance after healing.
The combination procedure has befits over 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 will have two or sometimes three different threads in the track. Changing three different threads at a sitting (during dressing) may be very painful and inconvenient to the patient.
The gradual cutting of the track takes a very long time which is significantly shortened by combining the procedures.
In some cases it is not possible to provide adequate drainage without laying a part of the track open.
I hope, the benefits of combining two methods judiciously have been made clear.
DR MEDHA PATEL M.D. Ayu
DR MUKUL PATEL M.D. Ayu