The management of fistula-in-ano by Setons is the contribution of Hippocrates
(460-356 BC) but the idea of the setons is derived from the K.S
. treatment which is being used for treating the disease Bhagandara, since the period of Sushruta.[8
] Sushruta and Vagbhata have told Asthi Shalya
as one of the causative factors of fistula-in-ano and this holds true even today i.e., by impaction of foreign body in the terminal part of the Guda
either causes an abscess in the vicinity of the anal canal which ultimately develops the Bhagandara
/Fistula in ano.[9
] Goligher in his text book of Surgery of the anus, rectum and colon mentions that “Occasionally a foreign body, such as a rabbit or fish-bone or particle of egg-shell may be lodged in the anorectal region, helping to cause the chronic infective process and as a formation of fistula.”[10
] The description of Bhagandara Pidakaa
(fistulous abscess) clearly shows that Sushruta had an idea regarding the occurrence of a fistulous abscess and he was also well aware that, not all abscesses in this region lead to the causation of fistula-in-ano but only Bhagandara Pidika
] (fistulous abscess) is converted in to Bhagandara
(Fistula in ano). The description of blind internal, blind external fistula, the detailed techniques of surgery i.e., excision or fistulectomy, are available in detail and it shows the advancements that had taken place for the management of Bhagandara
at the time of Sushruta. In fact it may be remarked that the present day modern techniques are just a reflection of his principles.
The art of probing i.e., ‘Eshana Karma
’ was well mastered by Sushruta owing to which he classified Bhagandara
and has given a very scientific classification into Antarmukha
varieties of Bhagandara
] Sushruta was practising more than 10 types of incisions especially in Shataponaka
types of Bhagandara
] The incisions are indicated on the basis of the course of tracts. The character of Kharjura Patra
or date palm leaf consists of central axis on which the leaves are arranged, probably the nature of incision looks like the main incision along with small branched incision. But when individual date palm leaf is considered which looks like V-shape, indicates laying open of the fistulous tract as done in fistulectomy. Vagbhata[14
] gives importance to the anatomical relation of Bhagandara
and says that, the Bhagandara
localised in Pravahini
and Samvarani Vali
should be refused to treat. The explanation about the Bhagandara
treatment in relation to the Guda Valis
shows the height of knowledge of Ayurvedic scientists about the consequences of surgical management of fistula in ano and the deformities occurs thereafter.[15
The incidence of Bhagandara
was commonly seen in the age group of 20-40 years with peak incidence of 63.60% . It is the active period of a person's life and there will be many social assignments in this stage of life. The persons are casual to this problem because it starts with a minimal discomfort in anal region. In this study, 87.88% patients were males, which go hand in hand with a study conducted in a large population which concluded that the prevalence rate is double in males compared to female.[2
] 48.49% patients were from rural areas and 51.51% patients were from Urban Areas which showed almost equal prevalence rate in the rural as well as urban populations. 72.73% patients were vegetarians in this study. The high percentage of disease occurrence in vegetarian populations suggested their dominance in the Gujarat state and may be due to the oily and spic y vegetarian dominated diet of the locality. 63.64% patients had the habit of tobacco chewing, a common habit observed among the people of Saurashtra region. 51.52% of the patients had the habit of consuming Viruddahara
as they consumed salted Khichadi
with milk. 57.56% patients had Madhyama Koshtha
this factor cannot be ignored because the nature of Koshtha
depends on the nature of Agni Bala
which may play an important role to disturb the Dosha
and its related disorders .
In preoperative assessment one patient was found HIV-positive and two patients were found to be HBsAg positive and they were excluded from the study. This showed the importance of preoperative screening before K.S. treatment. In this study it was observed that 30.31% patients had the chronicity of 1-2 years and 20.20% patients were afflicted from the disease for 2-3 years. The shyness of the patient delays the consultation and treatment particularly in cases of anorectal disorders.The disease in initial stage presents only with mild aching pain with some discharge and if neglected at this stage, it may turn to be high anal fistula with multiple tracts. 64.70% patients were diagnosed as low anal fistula and 35.30% patients were of high anal category. Maximum number of patients i.e., about 70% had the external openings at the posterior perineal triangle (5, 6, and 7’o clock), as gravity causes the pus to get collected in the most dependent area, which in turn leads to the formation of abscess and ultimate fistulous opening at that particular region.
The adjuvant drugs were prescribed to achieve better outcome of the surgical management in all the groups. Triphala Guggulu
helps in the post operative wound healing.[16
] During the entire trial period maximum for 5 months use of Triphala Guggulu
was recorded and did not cause any adverse effect. Gandhaka Rasayana
] was found equally effective in preventing the infection as the chances of infection is high because there is presence of discharge from the tract till the thread is in situ. The specially designed Ano rectal chair was used for Avagaha Sveda
(Sitz Bath). Avagaha Sveda
] using Sphatikadi Yoga
helped in maintaining the hygiene of the perineal part and reduced the Shotha
(inflammation) as well as pain. Matra Basti
] of 10 ml Jaati Kalpa Taila
, daily helped in Shamana
of the aggravated Vata
and provided soothing effect to ano rectum from pain with easy evacuation of stools.
Discussion on results
There are several factors, which affect the Unit Cutting Time (UCT) as follows:
- UCT is less in submucosal, subcutaneous and low anal fistulae.
- UCT is high in cases of fibrosed/tough scar tissue which generally created after the previous operation done for fistulae in ano and in cases of high rectal fistulae and trans-sphincteric fistulae.
- Presence of infection and inflammation delays the UCT.
When the UCT of all three groups were evaluated, the UCT of Ksheera Sutra was comparatively lower (7.42 days) to standard Apamarga group i.e., 8.82 days. But abscess was formed at the 2nd week in four patients of this group. The patients of this group also complained of burning sensation in the post operative period and successive change of the thread for few hours. The Snuhi Ksheera Sutra (Group-A) can be effectively used in the cases of fibrosed and recurrent cases of fistula as the tough scar of the previous operation is likely to offer resistance in the process of cutting and delay the process of healing as well. Snuhi Ksheera Sutra was not found much effective in reducing the pain scores compared to the standard group whereas, Snuhi Ksheera Sutra (Group-A) produced much discharge in the postoperative period compared to the other two groups i.e., Group-B and Group-C.
. (Group-B) showed a comparatively higher UCT of 9.76 days but it did not produce any complications like burning sensation and abscess in the postoperative period. Although Kshara
and due to Visheshakriyaavacharanaat
] the Tilanala K.S
. can also be used in Pittaja Prakriti
patients effectively. Tilanala K.S
. (Group-B) reduced the pain scores effectively compared to Snuhi Ksheera Sutra
(Group-A). E. coli
was found responsible for the infection which was proved in the pus culture report of the majority of patients and was effectively controlled by Tilanala K.S
The K.S. threading is a minor procedure and could be carried out at OPD level. The expenses required for this modality are quite low and there is no need to hospitalize the patient for longer duration. It is a boon to the sufferer of this notorious disease ‘Bhagandara’ particularly who may not be able to access high-tech hospitals which requires much expenses.