Introduction
(History of Kshar Sutra Therapy)

Ksharasutra Therapy is an Ayurvedic Parasurgical Technique. Great Indian Surgeon Sushruta narrated in his teachings the use of Kshara for cure of fistula in ano and other anorectal diseases. The work of Sushruta was later compiled as "Sushrut Samhita" in the 5th century A.D. Acharya Chakrapani Datta (10-11 Century A.D.) and Acharya Bhav Mishra (16-18 century A.D.) have described in their classical Ayurvedic texts, the method of preparation and treatment of fistula in ano by use of Kshara Sutra (K.S.). It is being used for the successful treatment of Anorectal Diseases from many years.

In this technique, a specially prepared thread (Kshar Sutra) is used to cure diseases. Kshar Sutra acts by "Herbal Chemical Cauterisation" and removes the disease from the body.

Many studies have been published by Ayurvedic doctors recently with encouraging results for treatment of fistula in ano and other anorectal diseases by use of Kshara Sutra.

Requirements:

1. Thread : Surgical Linen thread of size 20.
2. Latex of Euphorbia neriifolia
3. Haridra (Curcuma longa)
4. Apamarg Kshar (Achyranthus aspera)

Method of Preparation:

For the preparation of thread, surgical linen thread gauge number 20 was manually coated eleven times with the latex of Euphorbia neriifolia, followed by seven coatings of the latex and the alkaline powder of Achyranthus aspera alternatively, and dried. In the final phase, three coatings of latex and powder of Curcuma longa were given alternatively.

The thread thus prepared was sterilized by ultra violet radiation and placed in a polythene bag or glass tube.

1. The cut through of fistulous tract is effected by the pressure exerted on anorectal tissue by the moderately tight Kshar Sutra tied in the fistulous tract.
2. The presence of Kshar Sutra in the fistulous tract does not allow the cavity to close down from either ends and there is a continuous drainage of pus along the Kshar Sutra itself.
3. The Kshar Sutra slowly and gradually cuts through the fistulous tract from apex to the periphery. There is an ideal simultaneous cutting and healing of the tract and no pocket of pus is allowed to stay back.
4. The Kshara (Caustics) applied on the thread are anti-inflammatory, antislough agents and in addition, have property of chemical curetting. The Kshar Sutra remains in direct contact of the tract and therefore, it chemically curettes out the tract and sloughs out the epithelial lining, thereby allowing the fistulous tract to collapse and heal.
5. The Kshar Sutra, due to its antibacterial property, does not allow bacteria to multiply in its presence.
6. The pH of Kshar Sutra was towards the alkaline side and therefore it did not allow rectal pathogens to invade the cavity.

1. Patients are allowed to take orally only liquid diet before six hours of operation.
2. From next morning, warm Pancha Valkal Kwath sitz bath are advised to take at least thrice a day adding 5gm Sphatikadi yog for a minimum period of 3 weeks.
3. Semi solid diet is allowed after 3-4 hours of the procedure.
4. Tab. Triphala Guggulu – 500 mg TDS Haritaki Churna - 5-10 gm. once at bed time followed by warm water were prescribed.
5. Jatyadi Tail Matrabasti (10 ml.) was prescribed twice a day for another two weeks.
6. If the pain is there, some suitable analgesic was prescribed.
7. Antibiotics were generally avoided.

Patients are advised strictly:-

1. To be ambulated (stay active like walking) during the period of treatment.
2. To take normal food daily and avoid irritant spicy food.
3. To take fibre containing diet & vegetables with plenty of water.
4. To avoid such types of foods which cause constipation.
5. To keep the bowel clear regularly by taking suitable and mild laxatives.
6. To avoid prolonged sitting as well as standing during the treatment.
7. To avoid long distance travelling and driving.
8. To keep the anal region clean and do proper dressing

Patients are advised strictly:-

1. It is an Out Patient Treatment.
2. Performed mostly under Local anesthesia.
3. Only 30- 45 minutes is required for the procedure
4. Hospital stay is usually minimum (5-6 hrs).
5. Minimal bed rest is required after the procedure.
6. Patient can resume his / her daily routine within 3 to 5 days.
7. The recurrence rate is very less after Ksharsutra ligation procedure
8. Most important benefit of Kshar Sutra Therapy over Modern Surgeries is that the muscles that supports the Anus and helps in controlling the bowel movements are not dissected and hence the possibility of Anal Incontinence (loss of power to hold stools) is not there.