Journal of Ayurveda and Integrated Medical Sciences

Ksharsutra is prepared by a methodical coating of specific herbs and Kshara over Barbour’s linen no.20 thread. It is a standard surgical practice for the management of fistula in ano as the therapy has revolutionized the treatment of fistula in ano in terms of minimizing re-occurrence and anal incontinence. Although the treatment is popular and effective, it is not devoid of adversities. Disadvantages of Ksharasutra treatment are post procedural pain, mucopurulent discharge, longer duration of treatment and scar. IFTAK (Interception of Fistulous tract with application of Ksharasutra), is a technique based on the concept of intercepting the fistulous tract close to the anal verge and treating the proximal part of the fistulous tract with Ksharasutra. As the primary site of infection involving the anal crypt is constantly treated by the Kshara and drained by Ksharasutra, cure ensues. Distal part of the tract is left untreated and heals eventually as this part of the tract is not in continuity with the infective focus. IFTAK approach with partial fistulotomy was planned in this case as the fistula was complex presenting with two external openings. Result was encouraging with complete healing of the Fistula, short treatment period, reduced discomfort in terms of pain and discharge and an acceptable scar.

Presenting complaints and medical history

A 30 year old male normotensive, non-diabetic patient came to Shalya OPD of Shri Dharmashthala Manjunatheswara Ayurveda Hospital, Udupi, Karnataka, with complaints of pain, itching and discharge from perianal region since 3 months. Patient also c/o pain and burning sensation during defecation since 3 months. History was not significant for any major medical illness, previous surgery and allergy.

Clinical findings

General and systemic examination was not significant for any systemic illness.

On Per Rectal Examination, Two external fistulous openings were noted at 9’O Clock position 5 cm away from anal verge and at 11 O’clock position 4 cm away from anal verge. One Internal opening at 12 O’clock position was found on digital rectal examination and proctoscopy about 1cm proximal to anal verge. Trans-rectal ultrasound clearly depicted the direction of the fistulous tract with its openings.

(Fig. 3, 4) Partial fistulotomy was carried out on the primary tract at 9 o’clock, secondary tract at 11 o’ clock position was left as such (Fig. 5). Antiseptic dressing and packing was done with Jatyadi Taila. Patient was advised for regular Sitz bath with warm water from the next day and daily dressing with Jatyadi Taila until the fistulotomy wound healed. A short course of antibiotic was prescribed for 5 days.

Patient was prescribed with,

1. Kaishora Guggulu 750mg 1 tab TDS after food
2. Gandhak Rasayan 750mg 1 tab TDS after food
3. Swadishta Virechan Churna 50 gm + Swarna Makshika 1 gm + Pravala Bhasma 5 gm} 5gm HS with luke warm water 
4. Panchtikta Kashaya 20 ml BD after food
5. Jatyadi Taila for local application.

Follow-up and Outcomes

Ksharasutra was changed once a week on OPD basis. Pus discharge was fluent in the first week through fistulotomy wound which gradually changed to serous and became scanty and then completely disappeared after two weeks. Pain was moderate in the first week and later on gradually subsided. The discharge from external opening at 11 o’ clock position reduced gradually within 4 to 5 days and totally dried up in one week (Fig. 6). Ksharasutra completely cut through fistulous tract in three weeks after the first Ksharsutra change and complete healing of wound was achieved with a scar in 10 days after cut through. Patient was advised application of Jatyadi Taila. The fistulous tract was cut through and healed simultaneously by 4^th week with acceptable scar (Fig. 7). There was no complication seen during and after treatment and patient got relief from all symptoms. After 6 months of follow-up, no recurrence was noted, patient was cured completely (Fig. 8).

Figure 1: Pre-Operative image

Figure 6: 2nd week: follow-up

Figure 7: 4th Week: After Complete Cut through by Ksharasutra

Figure 8: After 6 Months

Discussion

Ksharasuta treatment is an effective treatment modality for fistula in ano. Ksharsutra treatment has high success rate^[7] and least recurrence rate (3.33%).^[8] When compared to standard treatment modalities, which call for hospitalization, regional or general anesthesia, and consistent post-operative care, it is a very simple, cost-effective, and a low-complication procedure. Conventional surgical treatments are associated with a significant risk of recurrence (0.7-26.5%) and high risk of impaired continence (5-40%).^[9]

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