What is the role of Kshar Sutra in treating a type 2 perianal fistula with an intersphincteric abscess?

Role of Kshar Sutra in Type 2 Perianal Fistula with Intersphincteric Abscess

Kshar Sutra (medicated seton) can be considered as an alternative treatment option for type 2 perianal fistula with intersphincteric abscess after initial surgical drainage of the abscess, with evidence showing lower recurrence rates compared to conventional surgery despite longer healing times. 1

Initial Management

• The first step in managing a type 2 perianal fistula with intersphincteric abscess must be surgical drainage of the abscess to control sepsis before any definitive treatment 2, 3
• Examination under anesthesia (EUA) is essential for proper diagnosis and classification of the fistula, and should be performed by an experienced surgeon 4
• Placement of a non-cutting (loose) seton during the initial procedure is recommended to maintain drainage and prevent recurrent abscess formation 2, 3
• Antibiotics should be used as adjunctive therapy after surgical drainage but are insufficient alone for treating the abscess 3, 4

Role of Kshar Sutra

• Kshar Sutra is a medicated thread coated with Ayurvedic medicines that acts as a cutting seton while promoting healing of the fistula tract 1, 5
• Randomized controlled trials have shown complete healing with Kshar Sutra in all treated patients, with a significantly lower recurrence rate (4%) compared to conventional surgery (11%) 1
• The healing time with Kshar Sutra is longer (median 8 weeks) compared to conventional surgery (median 4 weeks), but patients experience less disruption to their routine work (2.7 vs 15.5 days work off) 1, 6
• Kshar Sutra has shown an average Unit Cutting Time and Healing (UCTH) of approximately 7-8 days/cm of fistula tract 5, 7

Advantages of Kshar Sutra Over Conventional Surgery

• Lower recurrence rates (4% vs 11%) make it particularly valuable for complex fistulas 1
• Lower incidence of anal incontinence compared to conventional surgery 1, 6
• Ambulatory procedure with minimal disruption to patient's daily activities 1, 7
• Cost-effective compared to conventional surgical approaches 6
• No open wound unlike fistulotomy, resulting in better patient comfort 6

Limitations and Side Effects

• Longer healing time (median 8 weeks vs 4 weeks for conventional surgery) 1
• Transient local burning sensation and increased discharge from the fistulous opening in most patients during the first 48-72 hours 1, 7
• Weekly follow-up required for changing the Kshar Sutra until complete cutting of the tract 7
• Local induration may develop in some patients (approximately 15%) 7

Treatment Algorithm

1. Initial management:

   • Surgical drainage of the intersphincteric abscess 3
   • Placement of a loose, non-cutting seton to maintain drainage 2, 3
   • Adjunctive antibiotic therapy 3, 4

2. After resolution of acute infection:

   • For low fistulas not involving significant sphincter muscle:

     • Option 1: Fistulotomy if sphincter involvement is minimal 2
     • Option 2: Kshar Sutra placement with weekly changes until complete cutting of the tract 1, 7

   • For high or complex fistulas involving significant sphincter muscle:

     • Kshar Sutra is preferred over fistulotomy to preserve sphincter function 1, 6
     • Alternative options include advancement flap, LIFT procedure, or fibrin glue 2

3. For recurrent or refractory cases:

   • Consider diverting stoma as a temporary measure 2
   • Proctectomy as the last resort for severe, therapy-refractory disease 2

Monitoring and Follow-up

• Weekly follow-up for Kshar Sutra changes until complete cutting of the tract 7
• Clinical assessment of decreased drainage is usually sufficient to evaluate response 2, 4
• MRI or anal endosonography can be used to evaluate improvement of fistula track inflammation 2, 4
• Long-term follow-up (at least 12 months) is recommended to monitor for recurrence 5

Kshar Sutra represents a valuable treatment option that balances efficacy with sphincter preservation, particularly beneficial for complex fistulas where conventional surgery carries higher risks of incontinence and recurrence.