A Novel Application of the IMPAKT Technique with Kadali Ksharasutra for Multiple-Opening Fistula-in-Ano: A Case Report”

Abstract

Fistula-in-ano is a chronic condition with an abnormal communicating tract between the anus, rectum, and perianal 
skin lined by unhealthy granulation tissue. Ayurveda describes a similar condition as Bhagandara, with available 
treatment options being Ksharasutra therapy. IFTAK and MIKST are advanced ksharasutra techniques that require 
specialization, whereas the IMPAKT technique is a newer approach that combines fistulotomy with Ksharasutra 
therapy. This case report aims to look into the effect of IMPAKT with Kadali Ksharasutra in a patient with a complex, 
multiple-opening fistula-in-ano. A 27-year-old male from East Khasi Hills, Meghalaya, presented to the Shalya Tantra 
outpatient department with recurrent pus discharge, pain and three small external openings. On examination, a cord
like tract was felt extending radially from the external opening at the 2 o’clock position and opening at the 2 o’clock 
position internally. Magnetic resonance imaging fistulogram showed a left-sided complex trans-sphincteric fistulous 
tract with multiple extensions. Under local anesthesia, the fistulous tract from the external opening was partially laid 
open and curetted, and a plain linen thread was placed through the remaining tract, which was replaced by Kadali 
Ksharasutra on the 5th post-operative day. Ksharasutra was changed at regular 7-day intervals. After healing of the 
laid-open portion, the remaining tract was again laid open under local anesthesia. The patient continued the prescribed 
medication and local care. At follow-up, the wound showed complete contraction and healing. This case suggests that 
the IMPAKT technique may be a useful approach for managing complex, multiple-opening fistula-in-ano, resulting in 
healing of the fistulous tract without reported sphincter damage or recurrence during follow-up.