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Fistula in ano

Fistula in ano (bhagandar) and piles from the greatest percentage of diseases pertaining to the ano-rectal region. Of them, the farmer is a disagreeable condition for the patient often creates problems which become the source his restlessness the disease has not been known to have any particular racial affinity and has a uniform distribution throughout the world.

History suggests that the condition fistula in ano is an age-old problem and that the operations for this disease were designed from time to time to suit the needs of the days. However, an earliest systematic treatise on this subject has been written by John Ardernae in 1339 who recounted systematically the steps of the operation. It was he who first took recourse to the knife and believed laying the tract open with a director and a bistury. In the 14th Century, the surgical treatment for fistula was popularized as fashion of the day in France after the successful treatment of fistula-in-ano of King Luis XIV by surgeon Charles Felix, who was a barber surgeon to the court of the king and received a huge sum from him as a reward for operation. This made operative treatment the treatment of choice and 14th century was regarded as the golden age of rectal surgery.

Later in the 18th century, percival Pott in his book on fistula-in-ano emphasized the need for exposing the fistulous tract by incision as mentioned by Arderne. Still later, for some time, the operative treatment was replaced by ligaturing the fistulous tract with strong silk or with India rubber ligatures. In the later part of the last century and also in the early part of this century, fistula was treated by the injections of irritant chemicals into the tract such as 3-4% silver nitrate, bismuth paste and a combination of quinine and urethane. None of these procedures were satisfactory and could not stand the test of the time, & Fredrick Salmon soon came with his modicafication of the classical incision of fistulae, claiming better results. Further modifications to this technique were added by Salmon and his successor Lockhart-Mummery, Milligan, Morgan and Gabriel, at the St. Mark's Hospital.

Changing trends in the treatments is due to the fact that none of the methods proved satisfactory and recurrence of the disease was rather a rule. This mainly being due to site and the frequency of combination of the disease-bearing area. In spite of the best efforts even today, the main problems faced in the treatment of this disease, are :

(i) Extensive mutilation of the ano-rectal and ischio-rectal area which is a prerequisite for redical cure,

(ii) Prolonged hospitalization,

(iii) High rate of recurrence.

The present trend in the treatment of fistula-in-ano (bhagander) lies in redical excision of the tract with removal of a major portion of the surrounding tissue. This is a very bold step and unfortunately the poor patient has to be victim of the widespread surgical wound which poses various problems in healing in comparison to other wounds. The dressings in the post-operative period are painful and have to be meticulous to avoid recurrence. It is probably for this reason that the frequency of recurrence in spite of the radical excision, rates pretty high in this disease. Jackman in 1944, reported a study of five hundred cases of fistula-in-ano from the Mayo clinic. 215 patients in the above study(i.e. 43 percent) had to be subjected to repeated surgery while some of these had to be operated on as many as fourteen times. The gravity of the problem of the operative treatment is best judged from the conclusion of John McGivney that "the operative procedures for ano-rectal fistula can be a challenge to the most ingenious surgeons". Further he mentions the high frequency of failure of surgical treatment in this disease. It will not be an exaggeration to comment that the chances for permanent cure in the case of fistula-in-ano after surgery do not exceed fifty percent even with the most conservative estimate.

Besides high rates of recurrence, the operation of fistula-in-ano is usually followed by an unusually long period of convalescence during which the patient has to stay in this hospital and undergo a painful of surgical dressing once or twice every day. While the dressing itself offers an ordeal for him and scares him, the patient also has to suffer economic loss as he has to be away from his job and the society as a result of prolonged hospitalization. It is true that attempts are being made to minimize the period of convalescence by primary closure of the wound and by skin grafts etc; but the result of these techniques are still controversial.

Extensive excision of tissues essential to achieve radical cure is again a point of vital importance which goes against the choice of operative treatment of fistula-in-ano. Even for the small tract, the extent of the excision of tissues has to be sufficiently wide in order to let the wound heal from the apex to avoid the formation of any pocket inside. If the fistulae are multiple, the extents of the wound excision even beyond limits and a major portion of the buttock has to be removed. This mutilating surgery not only produces an ugly appearance of the part, but also results into a number of post-operative complications. Some of these complications like sphincteric incontinence, stenosis, proctitis and fissure-in-ano have a difficult course and make the life of patient worse than it was before the operation. Thus , the surgical treatment of fistula-in-ano still presents a number of practical problems which stand as a challenge to the modern medical world. No doubt some fistulae respond to surgery satisfactorily, but the overall picture of response is highly disappointing. Hence, it leaves a scope to devise a technique which would ideally offer the cure of this disease in reasonably shorter time, avoid recurrences and extensive mutilating surgery and would prove economically better.

The present work is an attempt to fulfill these ideal requirements. The technique adopted in this is the revival of an age-old procedure practiced by "Sushruta" , the eminent Indian Surgeon, who lived sometime between 1000 to 800 B.C., with necessary modifications based on the knowledge of recent surgical developments. The method is non-operative and belongs to the Para surgical group of measures. It involves the application of a specially prepared medicated thread processed with certain vegetable caustics. The thread is passed into the fistulous tract, tied outside the anal aperture and left in situ for seven days after which it is changed and retied. The patient is sent home after every sitting and is advised to continue his routine work as usual. In due course of time , the thread falls out spontaneously and the fistulous track is simultaneously healed. The resultant scar formation is very minimal and the method is safe and free from any complications.