Management of a Complex Trans-Sphincteric Horseshoe Fistula-in-Ano Using Apamarg Ksharsutra

Abstract

Complex fistula-in-ano, particularly trans-sphincteric horseshoe variants, present significant therapeutic challenges due to high recurrence rates and risk of fecal incontinence following conventional surgery. Ksharsutra therapy, an Ayurvedic para-surgical technique, has shown promising outcomes in such cases. Present a detailed case of a middle-aged male with a chronic complex perianal fistula that recurred despite multiple surgeries and Kshar Sutra therapy. Over 8-10 months the patient had persistent purulent anal discharge, pain on sitting, and itching. Clinical exam and imaging (endoanal ultrasound, MRI) confirmed an intersphincteric/ transsphincteric fistula. Treatment options considered included repeat seton placement (possibly Kshar Sutra), fistulotomy, LIFT, advancement flap, plugs, and fibrin glue. We describe the diagnostic workup, surgical planning, and evidence-based management. An evidence table compares fistula treatments. Figures include diagnostic imaging and procedural schematics. An appendix maps provided patient data to case statements for validation.