Kshar-sutra therapy in various

Anal and other disorders

Dr. Praveen Kumar Choudhary

M.S. (Shalya), B.H.U.

Associate Professor, Deptt. of Shalya Tantra

A&U Tibbia College (Govt. of Delhi), New Delhi

Modalities of Kshar-karma

Kshar-sutra

Kshar-varti

Kshar-gauze

Kshar injections

Kshar solutions

Subjects of Kshar-sutra therapy

Anal fistula

Pilo-nidal sinus

Fissure in ano

Haemorrhoids

Sinuses

Warts

Rectovaginal fistula

Injection abscess and stitch abscess

Kshar-sutra in anal fistula

Why Kshar-sutra therapy is

superior to surgery?

Slow cutting of the track by pressure

necrosis caused by thread.

Debridment of the infected material by

Kshar including infected anal glands.

Formation of healthy granulation tissue

leads to good healing.

Minimal sphincteric mechanism

disturbance. Nil recurrence.

Does Kshar sutra heal all Anal

Fistula?

No , there are certain contraindications?

Osteomyelitis of Pelvic bones, Femur.

Tuberculosis of Hip joint, spine, cold

abscess.

Ulcerative colitis, Crohn’s disease,

Venerial diseases.

Intestinal and pelvic malignancies.

Other conditions

Kshar-sutra may be applied after treating

the following diseases such as:

Tuberculosis, Diabetes mallitus, Chronic

amoebiasis, Anaemia, B.P.H.

If these diseses are not treated, the

recurrence will be there even after

healing of the wound.

Preparation of the Kshar-sutra

The description of the preparation of

Kshar-sutra is mentioned in Chakradutta

& Rasa-tarangini.

Charaka has described the use of Kshar-

sutra in Bhagandara in Chapter of

Shotha chikitsa. But he has not

mentioned preparation. Sushruta has

also not been mentioned the preparation.

Standard Apamarga Kshar-sutra

Snuhi Latex

Apamarga Kshar

Haridra Powder

The Kshar-sutra was standardised in the

Deptt of Shalya-Shalakya at the B.H.U.

and approved by the I.C.M.R.

Snuhi Plant

Collection of Latex

Materials & Method

Apamarga Kshar: Prepared by usual

method of Pratisarniya Kshar

preparation.

Snuhi latex: Collected from the stem of

the Snuhi.

Haridra powder: From the dry rhizomes.

Surgical thread no- 20

Kshar-sutra cabinet

Preparation

11 coatings of the Snuhi latex on surgical

thread for 11 consecutive days.

7 coatings of Snuhi latex and Apamarga

Kshar for 7 consecutive days.

3 coatings of Snuhi latex and Haridra

powder for 3 consecutive days.

A total of 21 coatings are required to

achieve adequate thickness.

Advancements

1. Udumber Kshir sutra: M.K.Jalan, P.J.

Deshpande

Prepared by applying 11 coatings of

Udumber Ksheer on Surgical thread.

It was a good thread, less irritant, well

tolerated by the patients.

Disadvantage was that the cutting time

was less and sticking of latex on the

thread was less. Making knot was also

difficult.

Pappaya sutra

Prepared by Papaya pulp, Papain

powder (dried unripe fruit juice) and

Haridra powder.

Papaya fruit pulp and papain powder -

11 coatings.

Papaya fruit pulp and Haridra powder - 3

coatings. Total 13 coatings.

Snuhi Svarasa Kshar sutra

In this kshar sutra snuhi svarasa was

used in place of Snuhi latex. The

qualities are more or less same except

that slight more coatring are required to

achieve adequate thickness.

Yavaksar coated sutra

In this thread Yavakshar was used in

place of Apamarga Kshar sutra. The

thread is in use and is good except that

Unit Cutting Time is less in comparison

to Standard kshar sutra.

Ghritkumari based sutra: In this thread

Ghritkumari was used in place of Snuhi

latex. It is also a good thread.

Tankana ksharsutra

The Tankana was used in place of

Apamarga Kshar.

Gandhaphiroja based Kshar-sutra: In

this thread Gandhaphiroja was used in

place of Snuhi latex.

Aragvadhadi sutra: This thread was

based on the Aragvadhadi varti

mentioned in Sushruta Samhita.

Guggulu based Kshar sutra

In this thread Guggulu solution prepared

in alcohal was used in the place of snuhi

latex. The rest of the preparation is same

as that of Standard Apamarga Kshar-

sutra.

It is a good thread and it is in use in the

B.H.U and it has good results in

complicated Fistula-in-ano.

Application of Kshar-sutra

Materials:

Minor Operation theatre

Lithotomy table

Spot light

Kshar-sutra dressing trolley

Instrument box

Ushnodaka avagaha Yantra

Bhagandara: Treat root of the

disease

As you know that Fistula in ano arises from the infected anal glands; therefore, in order to eradicate the disease, the root cause i.e. anal glands should be taken care of.

If you could remove the pathological anal glands, branches will heal automatically.

Therefore, keep watch on anal glands at the pectinate line.

Anal glands

Chronicity of Fistula in ano is due to persistence of anal gland epithelium in the internal opening of the track. This keeps the opening patent.

Anal glands provide a channel between lumen of anus and connective tissue encircling the terminal bowel.

Anal gland is just like a diverticulum –stasis and infection may occur.

What is interceptive kshar-sutra

technique

Emphasis is made on the internal opening and area of fibrosis.

The track is threaded somewhere in the middle nearer to anal canal by making an artificial opening.

No need to thread the external opening.

The secretions become dry on destruction of anal gland by chemical cauterization of thread.

Surgical spaces around anus

Examination of Bhagandara (Fistula

in ano)

Symptoms: Pain, Swelling, Discharge

Examination: Local Eamination

P/R Examination, Probing

Radiological : Fistulography

Imaging: Trans rectal USG, MRI

Other investigations: Blood Sugar, Elisa

for Tuberculosis, Rule out Carcinoma of

rectum and Inflammatory bowel diseases

Fistulography

Materials:

Malecot catheter 32 Fr size fitted with a

condom at one end and inflation bulb at

another end to push air in it. It is introduced

into the rectum to know its boundary.

Infant feeding tubes of various sizes for

introduction into the fistulous opening. The

contrast is injected into opening through this

tube. The X-rays are taken AP/LAT VIEW.

AP View

The contrast injected

in external opening

may be seen.

It is better to put a

condom fitted with

malecot in rectum to

mary its boundry.

Lateral view: Digital enhancement

Track can be seen

as black line on

digital radiogram.

Lateral X-ray cannot

reveal good findings

on analogue films.

Causes of recurrence after

surgery

Inadequate excision

inadequate removal

of anal glands

Deep pus pockets

are not curreted.

False assessment of

internal opening.

Primary disease

untreated.

Presence of Fecal

matter in the wound.

Moisture in the

wound leads to

bacterial infection.

Bridge formation

during healing of

wound.

Primary threading

Feel internal opening

It you are not able to

locate internal

opening, never try to

thread.

Goodsall’s rule

No need to pressure

Rotatory movement

Shataponak Bhagandara

Shambukavarta Bhagandara

Multiple fistula

Difficult to treat

Extensive branching

causes difficulty

Judicious use of

surgery and kshar-

sutra.

Surgery is horrible

This patient is operated

at Balaji Action Institute

twice. Even colostomy

was performed but of no

avail.

Extensive damage to

anal musculature leads

to incontinance. Treated

by kshar-varti.

Could not tolerate K.S.

Complications of surgery

Faulty diagnosis.

Operated somewhere in U.P. for Fistula.

The actual diagnosis was Ulcerative colitis.

The infection travelled to abdominal wall.

Contd.

The same case as

described earlier.

Scrotal fistula

The patient was

presented with balanitis

and orchitis.

On careful examination

an opening at anterior

aspect of scrotum was

noticed.

Another opening was

present lateral to

scrotum.

Surgery and KS therapy.

Contd.

The patient was

operated for fistula at

Jaipur SMS hospital

and later received

KS therapy.

Put on ATT.

What is interceptive approach

The track is

intercepted on the

way to either

opening.

Considerable time is

saved in this

approach.

Scrotal fistula

Multiple opening in

the scrotum.

Later diagnosed as a

case of tubercular

epididymitis.

Not any

communication with

anus or urethra was

noticed.

Skin to skin threading – No

No useful purpose

has been solved by

threading skin to skin

openings.

After several case

studies, it was found

a time consuming

procedure with no

extra benefits.

KS with Surgery

Thread causes

sterilization of

track by

destroying anal

glands.

We can cut

remaining track

surgically in order

to save time.

Complicated Fistula

Extensive superficial cutaneous gangrene was seen. Debrided surgically.

The patient was a known Diabetes patient.

No complication was noticed in last six months.

Fistula: Drainage

Drainage

towards

anus.

For

subsequent

threading.

Investigate thoroughly

Long standing cases

Patients of older age

groups.

Unusual

presentation of

fistula.

Colonoscopy in

unusual mass in

rectum.

Long standing cases

There is

extensive

fibrosis in this

IR fistula.

The patient

has been

suffering from

10 years.

Tubercular FIA

Multiple Fistula

No need to put

thread in all tracts.

Start from the most

presenting one.

Malignancies

Extensive ulceration

Bleed to touch

Confirmation by colonoscopy

Haemorrhoids

Application of K.S. in haemorrhoids

K.S. on niddle

K.S. in Pilonidal sinus

KS in other sinus

And many more to come

Thank you