Dr Arnab Ray 
MS (Ayurveda), PhD
Ayurvedic Proctologist

Complex anal fistulas are characterized by a fistula tract that traverses more than 30-50% of the external anal sphincter. This category includes suprasphincteric, high transsphincteric, and extrasphincteric fistulas. Additionally, recurrent fistulas with multiple tracts or branches, anterior fistulas in female patients, and fistulas resulting from colonic diseases like Crohn's disease are also classified as complex. Minimally invasive procedures, such as seton placement or Ksharasutra treatment, have demonstrated good success rates in managing complex anal fistulas.

The anal sphincters, comprised of the external and internal anal sphincter muscles, are crucial for maintaining continence—the ability to control bowel movements. Preserving sphincter function is paramount during anal fistula surgery. Minimizing trauma to these muscles is the primary focus. Repeated fistulectomies can cause irreversible damage to the sphincters. Sphincter-sparing procedures like Ksharasutra treatment, two-stage seton fistulotomy, and laser surgery are preferred options.

High anal fistulas, often involving levator ani or the pelvirectal muscle, are complex and challenging conditions. They are frequently associated with inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. Managing these fistulas is considerably more complicated than managing low anal fistulas. Surgery is reserved for select cases, and minimally invasive techniques using ksharabasti or ksharasutra are often beneficial.

Minimally invasive procedures are now the preferred treatment approach for many anorectal conditions, including hemorrhoids and fistulas. The era of extensive surgical excisions has passed. Modern surgical practice prioritizes preserving the delicate anatomy of the anal canal to maintain its normal physiological functions. Important considerations, often overlooked in more invasive procedures, include the sensation of complete evacuation, preventing leakage, and the ability to control the urge to defecate. Compromising these functions can significantly impact an individual's quality of life. Several minimally invasive techniques are available, including Ksharasutra ligation for internal hemorrhoids, Ksharasutra treatment for anal fistulas, SLOFT, IFTAK, laser fistula ablation, and laser hemorrhoidopexy. These procedures are chosen selectively based on the individual patient's condition.

Ksharasutra is a medicated thread used to treat various anorectal conditions, including complex, high anal, and recurrent fistulas; selected cases of internal hemorrhoids; rectal polyps; and pilonidal sinus. The Ksharasutra procedure is minimally invasive, minimizing damage to the perianal sphincter complex and other delicate tissues of the anal canal. It involves minimal blood loss and boasts a high success rate. Qualified Ayurvedic surgeons receive extensive training in this specialized technique.

Hemorrhoids, also known as piles, are normal anatomical structures within the anal canal. They only become a medical concern when they cause symptoms. Non-surgical treatments, such as medication, ksharakarma (chemical cauterization), sclerotherapy (injection of a hardening agent), banding, and laser therapy, are effective for first, second, and third-degree hemorrhoids. While numerous Ayurvedic medications are available for managing hemorrhoids, they should always be used under the guidance of a qualified medical professional.

Third and fourth-degree hemorrhoids typically require surgical intervention. Minimally invasive procedures like Ksharasutra ligation of internal piles, hemorrhoidal artery ligation, and laser hemorrhoidopexy are increasingly popular due to their reduced invasiveness.

Early-stage anal fissures often respond well to conservative treatment and are usually reversible. Ayurvedic medicines offer a safe, effective, and reliable approach for managing these fissures. While medical management can improve symptoms in chronic anal fissures, surgical intervention may ultimately be necessary.

Surgery offers the quickest relief for patients with anal fissures. Several day-care procedures are available for busy individuals who cannot commit to extended medical management. Chronic anal fissures, especially those accompanied by a sentinel tag, are best treated surgically to prevent complications such as retrofissure abscess and fissure-fistula complex.