Fistula-in-ano and Ayurveda Kshar-sutra therapy

The history of medical literature available today very clearly speaks that the disease Fistula-in-Ano (Bhagandara) affects more reputations of surgeons who deals with it. There is a saying in medical world "the best way to take revenge of a surgeon is to refer him a patient of Fistula-in-Ano". Thus, it is a well known fact that in spite of the tremendous developments of modern medical science especially of surgery, the disease Fistula-in-Ano still remains a challenging problem to the medical world.

The ano-rectal disorders and their management has established a separate surgico-dynamic  speciality among the various surgical disorders. The ano-rectal disorders have been known form the very early period of evolution to the medical science. The disease Bhagandara (Fistula-in-Ano) is said to have existed about four thousand years according to Wilson (1963) as mentioned by Khurana et al (1972). Furstenbergh et al (1964) have mentioned the method of Apolinose by which Hippocratus, the Father of modern medicine (460 BC) treated Fistula-in-Ano.

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. IM stat.

EQUIPMENTS AND OTHER REQUIREMENTS

Proctoscope	Probes of different sizes
Artery foreceps both Staight & curved	Sponge holding foreceps
Surgical gloves assorted size and pair	Scissiors
Towel clips	Syringes
Swabs	Linens
Kshara sutra	Jatyadi oil

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

Kshara sutra threading procedure (Operative procedure):

1. Spinal anesthesia is induced by the Anesthetist.
2. The patient is made to lie on the operation table in Lithotomy position.
3. The perianal area is cleaned with Savlon and spirit followed by Betadine painting.
4. The outer area is covered with sterile cloth, leaving the anal area open.
5. Digital examination done to locate any induration, internal opening and to exclude other lesions.
6. Probing is done through a malleable probe to locate the internal opening with the index finger of other hand inside the anus. If internal opening is located, the probe is pushed out through the anal verge and the track is threaded loosely by Kshara sutra. However if internal opening couldn’t be located it is made inside the anal canal at a point which offer least resistance to the tip of the probe. Again Kshara sutra threading of the track is done loosely.
7.  10 ml. of Jatyadi oil is pushed inside the rectum and sterilized gauze is applied on the anus covering the external opening.
8.  T-bandage is tied to keep the dressing in proper position.
9.  Thereafter the patient is shifted to the ward.

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.

Picture 1: A case of multiple Fistula-in-ano, with kshar-sutra threading done in all the 3 tracks separately.

Picture 2: A completely healed case of Fistula-in-ano after kshar sutra treatment. In this case there was done fistulectomy which was not successful and fistula recurred. Thereafter the threading of the track was done by kshar sutra and the fistula healed successfully in about 4 months without any recurrence. 

NOTE: The procedure can also be performed under local anaesthesia or without anaesthesia at all if the patient is co-operative. However  if the patient is sensitive (Vata dominant prakriti), spinal anaesthesia is the best choice.