Different treatment options in patients of anal Fistula!!!

Different treatment options in patients of anal Fistula!!!

Till date many treatments have been tried to cure Anal Fistula with different effectiveness.Most common treatment options are as below:

1. 1. Lay-open of fistula-in- ano: In this procedure; an operation is carried to cut the fistula open.After that it is regularly packed on daily basis to ensure proper healing of wound. It lefts behind a scar tissue and depending upon location of Fistula in relation to sphincter muscles there might be some risk of stool incontinence and if it is not healed properly; there are chances of recurrence.
2. Cutting seton: This treatment involves inserting a tube in fistula tract and tying it outside the body. Seton is tightened on regular basis to ensure cutting the fistula tract. So it is the tightened seton which causes cutting of tract. This procedure might involve too much pain and in some cases there might be incontinence especially of flatus.
3. Fistulectomy: It is surgical procedure where whole Fistula tract is excised (cut out). In certain cases; there might be more than 1 surgery. Recurrence of fistula and stool incontinence are the possible post treatment complications.
4. Colostomy: In this procedure an opening is made by drawing part of colon through an opening to anterior wall of abdomen. A Stoma appliance is fixed to this opening to make an alternate way for stool to leave the body.This procedure is done to avoid contact of fecal matter with Fistula assuming that it will lessen the chances of infection and fistula will heal easily. Along with recurrence of fistula and incontinence there are certain other complications in this procedure like formation of hernia near Stoma opening,Stomal blockage; another fistula formation near Stomal opening etc.
5. Fibrin glue injection: In this procedure; bio degradable glue is injected in the fistula tract which is supposed to close the fistula and let it heal naturally.Recurrence rate in Fibrin glue injection is as high as 30-35%.
6. Fistula plug: This treatment involves plugging the fistula tract from inside with a plug made up of intestinal tissue. Complicationin this treatment involves treatment failure, plug extrusion, abscess at the site of plug etc. 
7. Endorectal advancement flap: In this procedure; internal opening of Fistula is identified and a mucosal flap is cut around the opening and opening is closed with this flap. After that external opening is cleaned and sutured. The main complications in this treatment are failure of treatment and recurrence of fistula.
8. LIFT Technique: Ligation of Intersphincteric Fistula tract procedure; involves closure of internal opening of Fistula tract and removal of infected tissue. Recurrence of Fistula is the main complication in LIFT procedure.
9. VAAFT: Video Assisted Anal Fistula Treatment; with fistuloscope fistula tract is visualized and location of internal opening is confirmed.After that internal opening is closed using stapler or flap made from a layer of skin and internal layer of intestine. Disadvantages of VAAFT include reopening of internal opening leading to failure of treatment and recurrence of fistula.
10. Kshar Sutra Treatment: It has been proved to be highly effective treatment for Anal fistula. Clinical trials were conducted by Indian Council of Medical Research (ICMR) in 1991 at various medical institute including All India Institute of Medical Sciences (AIIMS) New Delhi and PGI Chandigarh etc. to see the effectiveness of Ksharsutra Treatment. It was concluded that Ksharsutra treatment is more effective and more convenient as compared to surgery in the patient of Anal Fistula. 

With the latest concept of Graded Ksharsutra (Sushruta Ano Rectal Institute; New Delhi) the chances of recurrence after Kshar Sutra treatment are predictably zero. 

Kshar Sutra is a medicated thread which is prepared by coating of certain herbal latex with herbomineral powders. The thread is alkaline in nature and it has highly selective debridement property. The fistulous tract is properly defined using MRI fistulogram or clinical probing and then with the help of certain instruments; the thread is placed in the fistulous tract. The medicine is gradually released in the tract from the thread and do the necessary debridement of fistulous tract. The thread is changed at weekly interval till there is a final cut through and the tract has healed. So here it is the medicine which debrides the fistula and ensure healing. Thread is just working as a vehicle for drug delivery in Fistula Tract. 

The anal fistula patient in whom fistula has recurred after Fistulectomy/ Colostomy/ Glue/ MAFT/ VAAFT these patients have been successfully treated by Graded Ksharsutra. The treatment is equally effective in the case of complex high anal fistula (Supra levator/ trans sphincteric/ horse shoe shaped multiple tracts).

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