Successful management of posterior horseshoe anal fistula with interception of fistulous tract with application of Ksharsutra: A case report

Abstract BACKGROUND: Anal fistula, particularly in its complex forms, is no longer considered a simple surgical entity due to its high recurrence rates and anatomical variability, despite ongoing innovations in management strategies. The majority (~90%) of fistula-in-ano cases are attributed to cryptoglandular infections, while the remainder may arise from underlying systemic conditions or iatrogenic causes. Complex fistulae, such as those with horseshoe or branching tracts, often present with extensive secondary pathways traversing the ischiorectal fossa and deep postanal spaces, making complete eradication challenging and increasing the risk of sphincter injury. This challenge is further compounded in patients with a history of failed prior surgeries. The interception of fistulous tract with application of Ksharasutra (IFTAK) technique is a minimally invasive, sphincter-sparing approach that aims to effectively intercept the primary tract and address secondary extensions, offering a promising option in the management of complex fistula-in-ano. PATIENT INFORMATION: A 39-year-old male with a history of failed fistula surgery 10 years prior presented with multiple external openings and recurrent discharge in the posterior perianal region, suggestive of a horseshoe-shaped complex anal fistula ( Parikshepi Bhagandara ). Magnetic resonance imaging revealed two tracts in the bilateral paramedian gluteal region, extending into the intersphincteric spaces (length 5.2 cm, diameter 5.8 mm), converging at the 6 o’clock position, with adjacent inflammatory changes—confirming a diagnosis of complex fistula-in-ano. INTERVENTION AND RESULT: Given the complex horseshoe configuration and a history of previous surgical failure, the patient was managed using the IFTAK technique. The patient was subsequently monitored for wound healing, symptom resolution, sphincter integrity, and recurrence. Complete clinical healing was achieved within 5 weeks, with no signs of recurrence at follow-up. CONCLUSION: The patient demonstrated good procedural tolerance, minimal discomfort, and good quality of life during the post-treatment period.