Pilonidal Sinus Extended to Create Transsphincteric Anal Fistula Treated by Kshara Sutra (A Medicated Herbal Seton) without Antibiotics

A Rare Case Report

Abstract

Multiple treatments have been described for fistula-in-ano; however, the ideal treatment remains elusive. The treatment of fistula-in-ano is a tightrope walk between preserving continence and preventing recurrence. A 70-year-old male patient from Mumbai (India) was suffering pilonidal sinus along with fistula-in-ano for 3 years. Kshar Sutra thread was used for the treatment. No internal medication was given for wound healing or infection control. There were no complications, such as infection, severe pain, or severe bleeding, and incontinence after the procedure. The patient was completed cured and is disease free for the last 5 years. Kshar Sutra is an effective treatment without any complications with complete healing.

INTRODUCTION

An anal fistula is a common disorder and has a prevalence of about 8.6 cases per 100,000 population.[¹] Its prevalence in men is around 12.3 cases per 100,000 population, and in women, it is approximately 5.6 cases per 100,000 population.[¹] The pilonidal disease is common, with a prevalence rate of about 26 per 100,000 population.[²³] In spite of both the diseases being fairly common, yet there is a scarcity of data demonstrating the coexistence of both the diseases in the same patient. A study reported that of 1284 patients of anal fistula and pilonidal disease who were clinically and radiologically evaluated over the 7-year period, 9 (0.70%) patients had coexisting anal fistula–pilonidal disease.[⁴]

CASE REPORT

A 70-year-old male patient from Mumbai (India) was suffering pilonidal sinus along with fistula-in-ano for 3 years. The patient suffered from abscess many times with pus discharge from the external opening. The abscess was never drained and infection was controlled by antibiotics as and when required. The first checkup was conducted on October 1, 2016, in our clinic in Pune, India. The diagnosis was a pilonidal sinus with a transsphincteric fistula [Figure 1]. The infected track was about 14 cm in length. The internal opening was 1.5 cm inside from the anal opening.

Figure 1: Pilonidal sinus before Kshar Sutra procedure

Kshar Sutra thread was used for the treatment. Kshar Sutra thread is traditionally prepared by coating multiple layers of Snuhi (Euphorbia neriifolia Linn.) latex, Apamarga (Achyranthes aspera Linn.), and turmeric powder on 20 number Barbour surgical linen threads.

Procedure

Kshar Sutra was done as an outpatient procedure. In the knee–chest position, local and surface anesthesia was used inside the infected track and around the anal area. The flexible probe was inserted from the pilonidal sinus opening to the internal opening in the anal canal. Kshar Sutra (medicated thread) was mounted on the probe and inserted through the external opening of the pilonidal sinus to the internal opening inside the anal canal. A knot was placed with both ends of the Kshar Sutra to fix the position. The procedure was completed in 20 min [Figure 2].

Figure 2: Kshar Sutra procedure

Follow-up procedure

On an outpatient department basis, surface and local anesthesia was used in and around the wound. The new Kshar Sutra was tied on the old one. The old one was pulled out and the new Kshar Sutra was inserted in. A knot was placed with both ends of the Kshar Sutra to fix the position. The patient was followed six times and every time new Kshar Sutra was inserted by the same procedure. No medication was given for wound healing or infection control. The nonsteroidal anti-inflammatory drug was given as a pain killer if required along with an antacid. Tablet tranexamic acid + mefenamic acid was given if required for excessive bleeding. There were no complications, such as infection, severe pain, or severe bleeding, and incontinence after the procedure. The patient was under care from November 2016 to April 2017 [Figure 3]. The patient was completed cured and is disease free for the last 5 years [Figure 4].

Figure 3: Follow-up picture (2017)

Figure 4: Follow-up picture (May 2021)

DISCUSSION

Recurrence, incontinence, and nonhealing are the most common outcomes with conventional management. Kshara Sutra treatment for anal fistula has been mentioned in Sushruta Samhita, an ancient Indian surgical textbook.[⁵] The cutting and healing action of the thread during treatment takes care of destroying the remaining tracks. It cuts the fistula track very slowly during the patient's movement. The herbal coating reacts with the infected tissue, and the infected tissue is removed, so walking and daily activities are recommended to continue.

It was reported that the treatment of communicating fistula–pilonidal disease presented a therapeutic challenge. In the majority of these cases, the fistula was high and was thus not suitable for fistulotomy. A sphincter-saving procedure, the transanal opening of intersphincteric space, was done in all these cases.[⁶⁷] It was reported that the treatment of pilonidal disease in communicating fistula–pilonidal disease was quite challenging. As a result of communication of pilonidal sinus with the rectum, an open procedure with minimal morbidity lay open with curettage under local anesthesia was performed along with the sphincter-saving procedure for fistula.[⁸⁹] Accarpio et al. reported that pilonidal cyst was present on the presacral area, but the fistulous tract was found inside the anal canal and the excision of the fistula resolved all the symptoms.[¹⁰]

Sohn and Martz reported that chronic pilonidal disease was associated with sinus tract formation which was almost exclusively limited to the sacrococcygeal region. Excision of the sinuses and associated tracts was performed through incision and curettage of the tracts with or without marsupialization with recurrence rates of up to 19.0%. Wide local excision with primary closure was usually associated with more wound complications and reported recurrence rates of 11.0%–29.0%.[¹¹]

Eberspacher et al. performed a fistulectomy of the anterior tract of the fistula, put a seton in the posterior transsphincteric anal fistula, and drained the abscess. It was further stated that after 40 days of medication and the fall of the seton, there was good healing of posterior perianal fistula and removed the residual pilonidal disease in the sacrococcygeal region, with primary closure and complete recovery in 2 weeks.[¹²]

No systemic side effects are encountered with Kshara Sutra therapy, although transient infection, local burning sensation, mild pain, itching, and slight indurations are observed, which rarely need medication. Postoperative tissue damage and scarring are minimal. The Kshara Sutra therapy, a unique method of drug delivery, most appropriate for healing the fistulous track, offers an effective, ambulatory, and safe alternative treatment in patients with fistula-in-ano.[¹³] Kshar Sutra not only cuts the track but also debrides the fistula through its herbal ingredients effectively. Kshar Sutra treatment is an outpatient procedure and can be done in a minor operation theater.[¹⁴]

CONCLUSIONS

Complex transsphincteric fistula with pilonidal sinus disease is difficult to cure. Kshar Sutra is an effective treatment for fistula-in-ano without any complications with complete healing. This treatment ensures the destruction of fistula structures and removal of infection and helps the body to create healthy tissue without any further complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.