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Abstract

SPHINCTER TONE OF PATIENTS WITH FISTULA-IN-ANO TREATED BY KSHARASUTRA THERAPY WITH THE HELP OF HIGH RESOLUTION ANAL MANOMETRY: A CLINICAL STUDY

Deep Chand Goan*

Abstract

The anal fistula has been a common surgical ailment reported since the time of Hippocrates (460-356 BC) but little systematic evidence exists on its management. This disease is not life threatening but caused discomfort and pain to patient which create problem in routine work. Many surgical procedure available for the treatment of fistula in ano but the results of these procedures are not very satisfactory especially for the treatment of complex and recurrent fistula in ano. Even so many advancement in surgery there is still a big challenge to surgeons for the management of fistula in ano. As many surgical procedure frequently leads to complication like recurrence, incontinence, delayed healing which creates psychological troublesome along with discomfort. The main objective of management of fistula is the cure of the disease, preserving the anal sphincter, preventing recurrence, and allowing an early return to normal activity of the patient. Recurrence and feacal incontinence is the major problem in surgical treatment of fistulae which can worse the previous condition. Reported recurrence and incontinence range from 0 to 32% and from 0 to 63% respectively during various surgical treatment.[1] Background: Anal manometry is an important investigation in anorectal disorders. It can detect pathologies that are difficult to detect with physical examination. Maintenance of continence is directly related to the integrity of sphincter muscles of the anal canal. The clinical utility of manometry ultimately depends on its power to discriminate between the normal and abnormal function. Therefore it becomes mandatory to assess the sphincter functions before the Ksharsutra treatment as well as after the treatment. This will improve the quality of life after the therapy as well as it will refine the whole treatment procedure. At present only one study had been done for assessment of sphincter tone after Ksharsutra therapy with single channel self made anal manometry on department of Shalya Tantra, SCPM Ayurvedic Medical College and Hospital, Gonda, U.P. So the aim of this study is to assess the continence status before and after Ksharasutra therapy in patient of fistula in ano with the help of High Resolution 16 channel Anal manometry along with questionnaire. Results: In this study, of low anal fistula treated with ksharasutra therapy, Mean  SD of resting anal pressure before and after therapy was (72.414.73 mmHg) and (70.9512.3 mmHg) respectively showing no significant reduction (p=0.5) in resting anal pressure. On the other hand there was statistically significant reduction was noted in squeeze anal pressure (17424.92, to 164.6524.167 mmHg) (p=0.001) after ksharasutra therapy. This statistical reduction in squeeze anal pressure was noted because the range of normal squeeze anal pressure is enough wide(i.e. 80-170mmHg). On wexner scoring system zero incontinence score was found in all patients. The study shows no signficaint reduction in anal canal length after therapy in the cases of low anal fistula in ano. Conclusions: The present study included 60 patients of fistula in ano treated with Ksharasutra therapy. They were divided into three group having 20 patient in each. Group I included low anal fistula. We are taken patients suffering from complex fistula in group II and recurrent complex fistula in group III. Assessment of incontinence done by a Water Perfusion System 16 channel anorectal manometry along with wexner scoring system. Ksharasutra appears to be the best option for the management of high anal fistula and recurrent fistula where there were no post treatment major incontinence and least recurrence rate (5 percent). Further there was no significant reduction of resting or squeezes pressure at the time of follow up.

Keywords: Transrectal Ultrasonography, Anal Endosonography, Electromyography, Ligation of Intersphincteric Fistula Tract, Digital rectal examination, Endoanal ultrasound, External Anal Sphincter, Internal Anal Sphincter.


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