Modified Conventional Ksharasutra Therapy (MC-KST) for Grade III Trans-Sphincteric Fistula-in-Ano: A Case Report

Abstract

Acharya Sushruta described Chedana Karma (excision) and Ksharasutra therapy (medicated seton technique) for managing Bhagandara (fistulas of pelvic, Ano-rectal, and perineal regions). Modified Conventional Ksharasutra Therapy (MC-KST) was introduced at the All India Institute of Ayurveda (AIIA), New Delhi, in 2018 for complex trans-sphincteric fistula-in-ano. The technique combines coring of the fistulous tract up to the external anal sphincter (EAS), interception, and staged Ksharasutra therapy to eradicate anal gland infection and healing of fistulous tract while minimizing sphincter injury, and preserving continence. In this case report, a 20-year-old male CA student presented with pus discharge from the right sub-scrotal region and irregular bowel habits for two months. Local perianal examination in lithotomy position revealed a single external opening at the 11 o’clock position at the base of the right side of scrotum, approximately 6 cm from the anal verge. Digital rectal examination revealed induration and tenderness at the 12 o’clock position above the dentate line. MRI fistulogram demonstrated a St. James’s University Hospital Grade III trans-sphincteric fistula-in-ano, with an internal opening at 12 o’clock, approximately 2.8 cm from the anal verge. The tract extended to the base of the scrotum, without supra-levator extension. The patient underwent MC-KST under saddle block. Complete cut-through of the fistulous tract by Ksharasutra was achieved after 39 days of regular treatment, followed by complete wound healing within an additional 20 days. No complications were reported during treatment. The patient remained free from recurrence throughout six months of follow-up. Study concluded that MC-KST demonstrated a favourable outcome in this case of Grade-III trans-sphincteric fistula-in-ano, with complete tract cut-through and subsequent wound healing within 59 days. The absence of reported complications and recurrence during six months of follow-up suggests that MC-KST may be a promising approach for managing complex trans-sphincteric fistula-in-ano.