Management of complex fistula-in-ano by interception of fistula track with application of ksharasutra (IFTAK): a novel technique

Objective: Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods: In the present prospective study, 300 patients with complex fistula-inano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results: There were 227 transsphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion: The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage. (AU)

A prospective study on tubercular fistula in ano and its management / Estudo prospectivo sobre a fístula anal tuberculosa e seu tratamento

Abstract Objective Tuberculosis fistula in ano, though less encountered, is an important clinical entity in developing countries like India. Diagnosis of TB fistula is a challenge despite of advances in diagnostic modalities and it depends upon both local and systemic clinical presentation. This prospective study aimed at to substantiate the importance of clinical diagnosis as well as medical management of tubercular fistula by antitubercular drugs. Methods and results 25 patients of fistula in ano suspected to be of tubercular origin underwent histopathology of fistulous tracks and an 8 week therapeutic trial of antitubercular treatment after getting an informed consent. Though biopsy showed positive evidence of tubercular pathology only in 52% cases, therapeutic trial showed improvement in local and systemic features in 23 (92%) cases. Of these 23 cases, 3 were cured after 18 months of anti tubercular treatment and 18 showed cure after 24 months of anti tubercular treatment while 2 cases withdrew from the study at 12 and 14 months respectively due to adverse drug reactions though their fistulous symptoms were relieved. Conclusion Meticulous clinical evaluation plays a vital role in diagnosis of tubercular fistula in addition to other diagnostic methods. Anti tubercular treatment is the mainstay of treatment in tubercular fistula with a minimum duration of 18-24 months owing to the recurrent and relapsing nature of disease.

Resumo Objetivo A fístula anal da tuberculose (TB), embora menos observada, constitui entidade clínica importante em países em desenvolvimento, como a Índia. O diagnóstico de fístula TB é tarefa desafiadora, apesar dos avanços nas modalidades diagnósticas; seu estabelecimento depende tanto da apresentação clínica local, como da apresentação sistêmica. Esse estudo prospectivo teve por objetivo consubstanciar a importância do diagnóstico clínico e também do tratamento clínico da fístula TB com medicamentos contra tuberculose. Métodos e resultados Foi realizado estudo histopatológico de tratos fistulosos em 25 pacientes com fístula anal com suspeita de origem tuberculosa; depois de obtido o consentimento livre e informado, esses pacientes foram submetidos a tratamento anti-tuberculose (TAT) durante 8 semanas. Embora a biópsia tenha revelado evidência positiva de patologia tuberculosa em apenas 52% dos casos, o curso terapêutico resultou em melhora nos aspectos local e sistêmico em 23 (92%) pacientes. Desses 23 casos, 3 e 18 casos estavam curados após 18 e 24 meses de TAT, respectivamente, enquanto que 2 pacientes desistiram do estudo após 12 e 14 meses, respectivamente, em decorrência de reações farmacológicas adversas, mesmo diante do alívio de seus sintomas fistulosos. Conclusão Juntamente com outros métodos diagnósticos, uma avaliação clínica meticulosa desempenha papel vital no diagnóstico da fístula TB. TAT é o principal procedimento terapêutico em pacientes com fístula TB, com duração mínima de 18-24 meses devido à natureza recorrente e recidivante da doença.