The main limitation of treatment of Fistula-in-Ano by conventional surgery is that even after surgical excision of the tract the recurrence rate still remains between 20-30%. Hence this disease even today stands as a challenge in front of the medical world.

Susruta’s method of thread treatment is known as Kshara-sutra treatment as mentioned above and even today it is quite successful method in treating this difficult disease.  Hippocrates named the procedure of passing the ligature along the fistulous tract as Appolinose. Chandsi and Madrasi treatments are known by their names only and much detail are not known about them. However it was Prof. P. J. Deshpandey at Banaras Hindu University, who took the lead after ancient Acharyas for exploring the technique, and modified and standardized it with the help of modern science and technology. The treatment was put to clinical trials in patient of Bhagandara and many scientific papers published. Apart from that, at the Department of Shalya Shalakya, Gujrat Ayurved University, Jamnagar many works done on Kshara-sutra treatment for the disease Bhagandara under the guidance of Prof. Kulwant Singh. Later on various other places in India and abroad started Kshara-sutra treatment in Bhagandara (Fistula-in-Ano) and piles patients. The Kshara-sutra treatment is now a well accepted Ayurvedic technique for treating the ano-rectal diseases viz. Fistula-in-Ano, Arshas (Piles), Parikartika (Fissures with tags) etc.

APPLICATION OF KSHARA-SUTRA IN A PATIENT OF BHAGANDARA (FISTULA-IN-ANO):

Pre Kshara sutra (Pre-operative):

a.      The patient should be admitted in the hospital a day before operation.

b.      Laxative like Panchsakara churana is given at previous night

c.       Shave and part preparation done.

d.      Patient is kept fasting for at least 8 hours

e.      Consent of the patient in written

f.        Proctoclysis enema 2-4 hours before the procedure

g.      Inj. Xylocaine sensitivity test

h.      Inj. Tetenus toxoid 1 Amp. I/M stat.

EQUIPMENTS AND OTHER REQUIREMENTS:

POSITION: All the patients were given lithotomy position for the  procedure.

Kshara sutra threading procedure (Operative procedure):

Post Kshara sutra threading management (Post operative):

1.       Nil orally for 4 hours

2.       Give liquid diet after that to avoid any type of inconvenience.

3.       Monitor the vitals

4. If operation is done under spinal anaesthesia, to avoid   complication give head-low position for 12 hours.

5.       Jatyadi oil P/R OD

6.       Hot sitz bath with panchvalkal kwath 8 hourly

7.       To avoid hard stool, give mild laxative to the patient

8.       If pain is excessive, urinary retention occurred, it is managed accordingly.

Post Kshara sutra threading complications:

1.   Retention of urine – it has been observed that within 8 to 10 hours after ligation, some of the patients complain of retention of urine which can be tackled by frequent sitz bath in lukewarm panchvalkala kwatha or simple warm water. Catheterization is seldom required.

2.  Local irritation – In some of the patients local i.e. perianal irritation is seen which needs frequent use of oil application and hot sitz bath etc.

3. Abscess formation – In some of the patients (especially who was suffered from interno-external piles), abscess formation takes place which was managed with local application of Dashang lepa with Goghrita.

4.  Haemorrhage – Alarming type of haemorrhage is not a rule with Kshara sutra treatment. However in some of the cases slight oozing may be seen which need no special care except the usual routine line of management, viz. avoidance of hard stool and much straining during defecation.

Weekly change of the sutra: – Kshara-sutra applied initially is kept for 7 days after which it is replaced by a fresh Kshara-sutra by Rail Road Technique. This procedure is repeated every week till the track completely cut through and if there is any unhealthy granulous tissue, it is scrapped-off during this weekly follow-up to promote a better healing.

Mode of action of Kshara sutra:

Kshara sutra works by pressure necrosis, chemical cauterization by kshar (alkali) and sloughing of the tissue of the walls of the fistulous track along with adequate drainage. It leads to an easy debridement of unhealthy tissue and pus etc. and thus providing a cleaner base for the wound healing of the fistulous track. The Kshara-sutra is changed weekly so that an average pace of cutting of about 0.5-0.8 cm/week is maintained along with healing from behind. Finally the whole track is cut through and the fistula gets healed up with minimal scarring and without any other major complication.

Pathya-apathya (Diet and routinely activities):

From the very first day of Kshara sutra threading procedure, light diet like Khichri is advised. Patient is also advised to take plenty of fluids, blend diet, green vegetables, salad and seasonal fruits. Patient is further advised to avoid spicy and fried food and not to strain during defecation.