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.

Introduction

I. INTRODUCTION

The Word fistula is derived from a Latin word a reed, pipe or flute. It implies a chronic granulating track connecting two epithelial-lined surfaces. These surfaces may be continuous or mucosal. The anal fistula is a single track with an external opening in the skin of perianal region and an internal opening in the modified skin or mucosa of anal canal or rectum. In Ayurvedic classics, this disease has been described with the name of BHAGANDARA.

Fistula-in ano is one of the most common ailments pertaining to ano-rectal region. This disease causes discomfort and pain to patient, which creates problems in routine work. As the wound is located in anal region which is more prone to infection, thus takes long time to heal and the condition remains troublesome, operative procedures often leads to complications like recurrences and incontinence. Fistula-in-ano not only cause poor prognosis like longer period and recurrence, also need to repeated operation which cause a lot of lost money. Which gives physical, mental and economical burdens and trotting from the suffering humanity. The main principle of the management of the fistula-in –ano are close the internal opening of anal fistula remove unhealthy tissue and eradication of fistulous track and preserve sphincter function. in modern medical science has develop so many various techniques which includes i.e

A. Modified Lift

First the patient is kept in proper lithotomy position and perianal region was cleaned with antiseptic lotions and draped.

According to condition local or spinal anesthesia was used. Thus when the patient was reassured and gloves finger was gently introduced into the rectum. Then a suitable selected probe was passed through the external opening of the fistula to int. opening.

1. A curvilinear incision is made at intersphentiarc groove 1cm from and paraller to the anal canal.
2. The fibers of internal and external sphincter are separated and the intersphincteric groove is entered.
3. The fistula track is identified.
4. The track is isolated, secure and suture ligated at both ends and secure after removal of the fistula probe.
5. And permanted distal part of the track is excised.
6. Know a plain thread (No. 20) are applied from proximally opening to internal opening.
7. External opening is enlarged and left open to drain and heal.

B. IFTAK

First the patient is kept in lithotomy position and perianal region was cleaned with antiseptic lotions and dropped.

After use local or spinal anesthesia –

1. Identification of infected anal crypt and internal opening with digital rectal examination.
2. Assessment of fistulous track and its branching with the help of malleable probe.
3. A 2 to 2.5 cm linear vertical incision made on ant. midline or post midline.
4. Dissection of fistulous track.
5. Interception of fistulous track – Fistulous track is visible as shing whitish structure. The track is intercepted.
6. If any abscess cavity is found dissection in intersphincteric space.
7. Probing through intercepted track to internal opening.
8. Then application of plain surgical linen thread (No. 20).

C. Change of Guggulu Kshar Sutra

Kshar Sutra were changed at weekly interval. The kshar sutara is tied to the previously applied. Kshar Sutra in position toward outer end of the knot. Then   artery forceps applied inner end to the same knot. Then the old thread is cut between the artery forceps and the knot pulling of the artery forceps along with the thread ultimately replaces the old thread by Guggulu Kshar Stura. Then the two ends are ligated.

This procedure is done by Railroad technique. The same procedure is followed for successive change of guggulu kshar sutra at weekly interval. When ext. opening dry and cavity (If present) was heal. Then lay open of the window.

II. 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 sunderlal hospital institute of medical science Banaras Hindu university. from 15 patients were treated with IFTAK and 15 patients were treated with modified LIFT. during period of November 30, 2018 to February 28, 2020.all the patients were examined before surgery including per rectum examination. All routine investigation and fistulograme and CT. scan and MRI as per need.

Age of patients were 12 to 60 years and all gender, previous operated, recurrence. But post operative incontinence of stool, secondary fistula in ano due to crohn’s disease, tuberculosis, carcinoma, ulcerative colitis, uncontrolled diabetes mellitus patients were exclusion.

III. RESULTS

Out of 30 patients most common age 30-39 years and common in male (83.33%) compare to female (16.66%). Mostly people belong to rural compare to urban habitat (36.66%). It is observed that higher percentage (70%) of patients were mixed food habit. Patients had an addiction of tobacco (36.66%) followed by alcohol (26.66%). According to type of previous treatment conservative treatment was taken by (36.66%) while 16.66% patients have history of previous operated fistula in ano. Chronicity of the disease from a few weeks to many year majority of patients (36.66%) belong to the chronicity of >1 year.

Pain was more observed in patients treated with modified LIFT after completed study [10week(70day)] two patients complain of pain treated by modified LIFT bot no patients complain of pain treated with IFTAK. In patients treated with modified LIFT after 10 week wound were healed in 66.7% followed patients treat with IFTAK 60.0%.

IV. DISCUSSION

In ayurvedic texts the description of bhagandar is found as one of the mahagad. It can be correlated with fistula in ano with its sign and symptom. Fistula in ano is very common surgical problems. and a great challenge for surgeons to treat without damage of sphincters and recurrence. There are many treatments available for the treatment of fistula in ano. each procedure has its some complication this study done here compare to modified LIFT and IFTAK.

The incidence of fistula in ano was more in male 4th decades of life. Among all the patient maximum patients have mixed food habit. In maximum patients internal opening of fistula in ano have been found posterior. All patients complain pain in perianal region maximum patient relief from pain treated with IFTAK. Maximum number of patient have wound healed treated with modified LIFT compare to IFTAK.

Conclusion

Modified LIFT has moderate pain complain in post-operative with early healed of the wound. IFTAK has also pain complain but less compare to modified LIFT but wound healing time is taken more compare to modified LIFT.

References

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Copyright

Copyright © 2024 Dr. Manfool Puniya, Prof. Lakshman Singh. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.