Given the safety, cost-effectiveness and the success rate of Ksharasutra in the treatment of anal fistula, the Department of AYUSH, in collaboration with the ICMR and the CCRAS, is organizing a National Campaign to promote the use of Ksharasutra in ano-rectal diseases. A National Workshop is being organized on 24-25 August 2007 in the auditorium of the All India Institute of Medical Sciences, New Delhi. Eminent experts in Ksharasutra will be participating in the Workshop. In keeping with the increased interest in Ksharasutra in foreign countries, a renowned Japanese expert Dr. Kenji Tazawa will also be participating in the National Workshop.

Even though there has been a resurgence of interest in Ayurveda in India and abroad on account its proven promotive, preventive and curative aspects, one its major branches - Ayurvedic surgery- has not got much publicity. This is a bit strange considering that Ayurvedic surgery has a long and hoary tradition stretching from Susruta who lived around 1500-1000 BC.

There is one particular Ayurvedic surgical procedure described by Susruta which has been developed and standardized by Ayurvedic researchers and scientifically validated by modern medicine in the 20th century which is providing relief to large numbers of patients of Anal fistula, also known as Bhagandara in Ayurveda. The Ksharasutra procedure is a minimally invasive surgical procedure for the treatment of Anal fistula, a painful condition affecting large numbers of people which is conventionally treated by surgery. Surgery for Anal fistula requires hospitalization and postoperative care, all of which is costly, and there is probability of damage to the tissues around the anal canal. The incidence of recurrence after conventional surgery is also rather high. In comparison, Ksharasutra has much lower recurrence rate and, more importantly, is an ambulatory form of treatment and hospitalization with its attendant expenditure and loss of income is not involved. Ksharasutra is safe and can be used on patients who would otherwise be considered a high risk in conventional surgery. The cost to the patient for the procedure is also quite low.

The Ksharasutra or medicated thread is prepared by repeatedly coating a surgical linen thread with an alkali of the Achyranthes aspera plant, latex of Euphorbia nerifolia and turmeric powder. The coated medicated thread has proteolytic, caustic and antiseptic properties and promotes rapid wound healing. In the Ksharasutra procedure the medicated thread is inserted through the external opening of the fistula and ligated through the anal opening. The procedure is done in an operation theatre under local anesthesia and the patient is able to leave the hospital after 10-15 minutes. The Kshara coated on the thread cuts the fibre tissue in 2-3 days and the healing of the tract occurs within 3-4 days. The thread is replaced after 7 days.  The normal cutting time is 1 cm. per week. This means that if the fistula is 5 cm. long the treatment will take 5 sittings.   The Ksharasutra therapy is unique in that it provides for cutting and healing simultaneously.

Though there are references to Ksharasutra in the Ayurvedic classics, no detailed description of the preparation of the Ksharasutra and the method of application is available.  In 1964, Ksharasutra therapy was developed by the late Dr. P.S. Shankaran in the Department of Shalya Shalaka of the Banaras Hindu University. Subsequently, a great deal of significant clinical and research work was done under the guidance of Prof. P.J. Deshpande in the Department of Shalya Shalaka. More than 15 different types of Ksharasutra were evaluated and techniques for the preparation of the Ksharasutra, the designing of instruments required for its application were developed and standardized by the Department of Shalya Shalaka. The Department also set up an Ano-rectal clinic where more than 20,000 patients have been treated with a success rate of 97 per cent.

The Indian Council of Medical Research (ICMR) conducted randomized, double blind, multi-centric clinical trials on Ksharasutra therapy and it was found that the recurrence of anal fistula was only 4 per cent as compared to the 11 per cent in patients who had undergone conventional surgery.  Ksharasutra therapy is unique in that it is one of the few Ayurvedic therapies which has been rigorously studied, evaluated and accepted by modern medicine. The Central Council for Research in Ayurveda and Siddha (CCRAS) and the Regional Research Laboratory, Jammu also conducted path breaking clinical research and contributed to the standardization of the procedure.

Ksharasutra therapy has become popular not only among Aurvedic surgeons but also among modern medicine surgeons because of its safety, cost-effectiveness, success rate and simplicity.  This therapy is now available in most Ayurvedic medical colleges in the country and also in some modern medicine hospitals.  Ksharasutra has also become popular in countries like Japan, Sri Lanka, Bangladesh and Nepal.  The scope for increasing the use of Ksharasutra in India is immense.  This is a procedure which should be made widely available at district and block level hospitals in the country.

One of the problems faces by patients using Ksharasutra is the mild to moderate pain experienced while the medicated thread is changed.  A great deal of research and clinical trials are going on to minimize the irritation caused by the medicated thread.  Ksharasutra prepared out of guggulu, honey, etc. appears to be a suitable alternative.

Source: PIB

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