Management of Chronic Complex Anal Fistula (Bhagandara) with Integrated Approach Using Fistulectomy, Fistulotomy and Yava Kshara Sutra: A Case Report

Background: Fistula-in-ano (Bhagandara), chronic ano-rectal condition usually characterized by constant discharge, recurrence and challenges of sphincter injury following conventional surgical practice. Integrated approach of modern surgical intervention along with Ayurveda Kshara Sutra therapy provides a patient centric sphincter saving approach with better wound healing and less recurrence. Clinical presentation: 34-year-old male presented with chief complaints of pain and purulent discharge from perianal region from last 6 months. Per rectal examination shows 2 external openings at 10 o’clock position in perianal region and secondary subscrotal opening at 11 o’clock position. Internal opening at 12 o’clock position. MRI fistulogram showed low anal inter-sphincteric fistula. Intervention: Comprehensive integrated treatment of fistulectomy with primary threading for the main tract and fistulotomy for the secondary tract followed by weekly Yava Kshara Sutra application was carried out. Postoperative internal Ayurvedic medicines and local wound management were carried out and patient was regularly followed up. Outcomes: There was progressive reduction in main complaints of pain and discharge. Fistulous tract healed completely (secondary intention) in 33 days. Postoperative complications and recurrence did not reported during entire follow up period. There was no impairment of sphincter function. Finally, any adverse effects related to intervention were not seen. Conclusion: Low anal inter-sphincteric fistula-in-ano was successfully treated with integrated approach of fistulectomy, fistulotomy with Yava Kshara Sutra coupled with supportive Ayurvedic management. Therapy provided successful healing, preservation of sphincter function and no side effects with recurrence free recovery noted in subsequent follow up period. Further well-designed clinical studies are required to validate these outcomes and to establish standardized integrative treatment protocols for management of Bhagandara.