How does kshar sutra compare to fistulectomy in treating type 2 perianal fistula?

Comparison of Kshar Sutra and Fistulectomy for Type 2 Perianal Fistula

Kshar sutra is superior to fistulectomy for type 2 perianal fistula due to lower recurrence rates (4% vs 11%), reduced risk of anal incontinence, and minimal disruption to patients' daily activities despite longer healing time. 1

Efficacy Comparison

• Kshar sutra demonstrates complete healing in all patients, similar to fistulectomy, but with significantly lower recurrence rates (4% vs 11%) in long-term follow-up 1
• Fistulectomy offers faster healing (mean: 35.7 days) compared to kshar sutra (mean: 53 days), but this comes at the cost of higher recurrence rates 2
• Ligation of intersphincteric fistula tract (LIFT) procedure shows lower recurrence rates compared to both fistulectomy and kshar sutra at 18 months (15% vs 20% vs 45% respectively), though this difference was not statistically significant 3

Post-Operative Complications

• Severe post-operative pain is significantly less common with kshar sutra (7.7%) compared to fistulectomy (25%), making it more tolerable for patients 2
• Fistulectomy is associated with higher risk of anal incontinence compared to kshar sutra (13 vs 8 patients in a multicentric trial) 1
• Wound discharge is more common with kshar sutra (15.3% vs 8.3%), but this is generally manageable and resolves with healing 2
• Post-operative bleeding complications are more common with fistulectomy compared to other techniques 4

Patient Quality of Life Considerations

• Patients treated with kshar sutra experience significantly less disruption to their daily activities (2.7 days work off vs 15.5 days with fistulectomy) 2
• Kshar sutra is significantly more cost-effective than fistulectomy (approximately 1/3 the cost), making it more accessible to patients 2
• Kshar sutra can be performed as an ambulatory procedure, reducing hospitalization requirements 1

Treatment Algorithm Based on Fistula Characteristics

• For simple, low anal fistulas without proctitis:

  • Fistulotomy can be considered with healing rates approaching 100% in carefully selected patients 5, 6
  • Kshar sutra is preferred when sphincter preservation is a concern due to lower incontinence rates 1

• For complex perianal fistulas:

  • Initial seton placement followed by definitive treatment is recommended 5
  • Kshar sutra offers better long-term outcomes with lower recurrence rates compared to fistulectomy 1
  • LIFT procedure may be considered as it shows promising results with lower post-operative morbidity 3

Important Caveats and Considerations

• Fistulotomy or fistulectomy should be avoided in patients with proctitis due to higher risk of complications and recurrence 5
• Cutting setons (including improperly applied kshar sutra) can result in high incontinence rates (up to 57%) and should be used with caution 5
• Anterior fistulas in female patients should not undergo fistulotomy due to high risk of incontinence 5
• Combined medical and surgical approaches offer better outcomes than either approach alone, particularly in complex cases 6