Journal of Ayurveda and Integrated Medical Sciences

Introduction

Ano-rectal disorders present with a variety of symptoms and result from either structural or functional dysfunction. A fistula-in-ano is an irregular, chronic, granulation tissue-lined channel that extends from the internal opening of the anorectal lumen to the perineum or other nearby structures. The majority of anal fistulas are the consequence of an infection in the anal glands, which causes an abscess to form in the intersphincteric plane. From there, the sepsis can spread in all four directions, opening either internally or externally or blindly. In Ayurveda it is mentioned that certain clinical condition requires surgical intervention for better cure.^[1] Sushruta has discussed in the detail about various Shastra Karma along with Anushastra Karma which includes Agnikarma, Jalaukavcharana and Ksharakarma. Kshara is considered as one of the most important parasurgical procedure as it can produce excision, incision, scrapping and can pacify all three Doshas. Kshara application in the form of Ksharasutra, in anorectal diseases has become more popular due to its easy approach and low rate of recurrence. It has been accepted by WHO as treatment modality for management of Fistula-in-ano. Ksharasutra induces both mechanical and chemical cutting by virtue of the Kshara and also helps in doing Shodhana and Ropana of the Tract leading to early healing of the tract. Direct reference of Ksharasutra is found in Sushruta Samhitha for the treatment of Nadivrana.

Chakradatta has referred to a medicated thread coated with Snuhi and Haridra powder in treatment of Arsha and Bhagandar. But the modified Ksharasutra available now a day is reestablished and standardised by the Dept. of Shalya Tantra, Banaras Hindu University. The standard Ksharasutra is prepared by 11 coatings of Snuhi Ksheera then 7 coatings of Snuhi Ksheera and Apamarga Kshara and then again 3 coatings of Snuhi Ksheera and Haridra Churna.^[2] This Kshara Sutra is used in treatment of fistula in ano due to its cutting, curetting and healing effect as well as it controls the infection. Although the success rate of this conventional mode of Ksharasutra therapy has been reported to be as high as 96.5% with a low incidence of incontinence, the duration of treatment has been long, with patients requiring multiple hospital visits in long fistulas and other complex cases.^[2]

CVS: S1 S2 Normal, no cardiac murmurs

RS: Chest clears on both sides.

Digestive System: Appetite - normal, Bowel - constipated.

P/A: No Abnormality detected, no organomegaly. No previous surgical scar marks.

Inverted Umbilicus and normal scaphoid shape was noted

Pulse: 86/min,

BP: 130/90 mm Hg,

Local Examination

In lithotomy position of patient, the findings observed on Inspection were, Single external opening noted in perianal region approximately 5-6 cm away from anal verge at 5’o Clock Position with pus discharge noted. Internal opening noted at 3 o’ clock position inside the anal canal above the dentate line proctoscopic examination. Probing was done to confirm site of internal opening of Bhagandara. On proctoscopic examination no any other anal pathology like Haemprrhoids / Fissure in ano noted. After complete examination the diagnosis was confirmed as Transphincteric Fistula in Ano i.e., Bhagandara. In this patient perianal skin was normal with no dermatitis or skin excoriation.

Investigations

Complete blood count, CT, BT, random blood sugar was normal and HIV I & II, and HBsAg were non-reactive.

Treatment given

Following the preliminary assessment, the patient was explained about the Kshara Sutra procedure and informed consent taken from the patient. Patient was posted for OT and under Spinal Anaesthesia, pt was given lithotomy position and part painted with Betadine 5% solution. Lords anal dilatation was done and four finger dilatation achieved.

Probing done and Fistulous tract identified in at 5’0 clock position about 6cms from the anal verge. Internal opening identified 3’0 clock position above the dentate line. Apamarga Kshara Sutra placed in situ of fistulous tract. Perfect haemostasis achieved and anal packing done and Patient was shifted to recovery room post catheterisation.

Kshara is considered superior to all surgical and Para surgical measures 6, because they perform the work of incision, puncture, and scarification to relive derangements of the Tridosha 7 and uniformly affect the diseased part to which they are applied. As per Sushruta, Kshara possess the following qualities, Tridoshaghna – because of different types of drugs it can pacify all the humours, Saumyata – owing Pachana, Katuka, Vilayana, Shodhana, Ropana, Stambhana, Lekhana, Krimighna, It normalizes Aama, Kapha, Visha, Medo Dhatu and also cures Kushtha when given in proper doses⁴. Kshara Sutra means thread made up of caustic material which destroys or cleans the devitalized tissue and to disintegrate the skin or other tissues1. Pioneer of Ayurvedic surgery Acharya Sushruta first mentioned Ksharasutra in the treatment of Nadi Vrana (sinus), Bhagandara (fistula in ano), Arbuda (Benign tumor)^[2] etc.

But does not emphasis upon its preparation. Chakrapani Dutta was the first person to mention the method of preparation with its indication in Bhagandara (fistula-in-ano) and Arsha (hemorrhoid). He described method of preparation as smearing a thread repeatedly in latex of Snuhi (Euphorbia neriifolia) and Haridra (turmeric) powder.^[4] After Chakrapani Dutta almost all the later author described same method of preparation of Kshara Sutra. To their white color qualities of Kshara helping Inchedhana and Bhedana of the fistula tract, Kshara Sutra by virtue of its Kshariya Guna and Dravyas used, it helps in cutting the tract in phased manner followed by healing of the cut tract.^[5] Apamarga has Katu Tiktha Rasa, Lagu Ruksha Guna and Tikshna Guna, Ushna Virya, and its Karma is Kaphavatahara,^[6] so Aparmarga Kshara is used in this case, The patient endured mild pain during the Kshara Sutra changing period but it was managed with Symptomatic treatment for the same. Patient withstood the procedure well during the entire treatment course and also the patient was able to carry out his minimum basic everyday activities. Pus discharge was noticed during first 2 weeks followed by which there was no discharge seen from the external opening.

Conclusion

Kshar Sutra procedure has been the gold standard therapy in the management of Fistula In ano with least recurrence rates and good patient compliance with the treatment modality where it overshines

7. cSusruta Samhita, Chikitsa Sthan, Kaviraj Ambika Dutta Shastri, Chaukhamba Sanskrit Samsthan.

8. Despande P.J, Pathak S.N, The Treatment of Fistula in Ano with Kshara Sutra Treatment