Treatment of Trans-Sphincteric Fistula-In-Ano with Combined Therapy of Laser and Kshara Sutra

Fistula-in-ano is most infectious disease among all the ano-rectal disorders since ancient times. Over the past few decades, various techniques are being evaluated in terms to prevent its recurrence and complications; it is still a challenging surgical disease. The sign and symptoms of fistula in ano resembles with Bhagandar described in Ayurvedic classics. Kshara sutra therapy (medicated thread) practiced in Ayurveda Since ancient time for the management of Naadi Vrana and Bhagandar. Kshara sutra therapy has revolutionized the treatment of fistula-in-ano, as it treat the main culprit of fistula that is cryptoglandular origin but the drawback of Kshara sutra therapy are as it takes more number of hospital visit, long anxiety period and discomfort. In present time LASER therapy is used in various medical surgery and also in proctology like in fistula as FILAC, DLPL etc. Diode LASER 980nm (Radial Fibre) burns unhealthy granulation tissues in 360° manner with less or minimal pain, LASER act as photo evaporation effect and leads to the shrinkage of the fistula tract. But if we do LASER in internal opening of fistula it provides a bare area for microbes and creates a chance to re-infects the crypts and anal glands, which further leads recurrent fistula formation. Therefore a novel technique for sphincter preserving surgery proposed as combined therapy of Kshara sutra ligation for main culprit that is cryptoglandular infection as SMAK (Sub Mucosal Application of Kshara Sutra) and LASER, shrink the remaining fistula tract instantly

Treatment of Fistula in ano by Kshara Sutra

PURPOSE: Sushrutra (BC 5th century) advocated a conservative management by applying Kshara Sutra (phyto-chemically processed thread) for the treatment of anal fistulas in India. In 1965, this technique was introduced by Deshpande and 40 cases were treated on an "outpatient" ambulatory basis. The purpose of this study is to determine the result of Kshara Sutra (KS) in treatment of fistula in ano. METHODS: One hundred and five patients with anal fistula were treated with KS. Excision of the primary lesion and fistula tract was done externally and KS was passed around the tract. Tissue gripped within the thread was the anoderm, mucosa, and sphincter. Finally, the thread encircled the part of the anal wall that needed excision and an additional clamp for loose tying. RESULTS: The range of age was from 21 to 59 years while the sex ratio was 6.5:1 (M:F). In 94 patients, the average cutting time was about two weeks, and the other were three to four weeks. KS thread was applied only once for primary operation in 98 cases, and a successive change was required in 7 cases. The mean hospital stay after operation was 4.2 days. In 76 cases, the mean period of follow up was 23 (range 7~32) months. There were no recurrences, but there were 4 mild deformities of the anus, 2 mild soilings, 1 delayed cutting, and 5 delayed healings. CONCLUSIONS: Kshara Sutra is a technically easy, safe, and simple method and does not require a long hospitalization.