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Introduction

A fistula-in-ano is an irregular, chronic, granulation tissue-lined channel that extends from the internal opening of the anorectal lumen to the perineum or other nearby structures [1]. The majority of anal fistulas are the consequence of an infection in the anal glands, which causes an abscess to form in the intersphincteric plane. From there, the sepsis can spread in all four directions, opening either internally or externally or blindly [2]. Fistulas are complex in nature and present treatment challenges due to the expansion of sepsis into deeper or numerous planes and a larger involvement of the sphincter musculature (> 30%) [3]. In the traditional Indian Medicine system of Ayurveda, anal fistula is described as bhagandara, a surgical disease to be treated either by excision or laying open. Sushruta (2 nd cent.BC), the ancient Indian surgeon, in addition, prescribed an alternative, safe, and minimally invasive treatment with the use of a medicated seton known as ksharasutra (kshara -caustic/alkali, sutra - thread; in Sanskrit) [4].

A ksharasutra is prepared by smearing oleoresins of Commiphora mukul(snuhi ksheera) powder of Curcuma longa(haridra) and the alkaline ash (kshara) obtained from Achyranthes aspera(apamarga) on a surgical linen thread no. 20. According to the conventional therapeutic mode, the ksharasutra is applied in the fistulous track from one end (opening) to the other using a probe and is changed weekly by the railroad technique. The drugs coated on the thread gradually dissolve and cause lysis of the unhealthy granulation tissue; the whole track is therefore laid open gradually by chemical fistulectomy as well as by mechanical pressure, with an average cutting and healing rate of 1cm per week [5]. Although the success rate of this conventional mode of ksharasutra therapy has been reported to be as high as 96.5% with a low incidence of incontinence [6], the duration of treatment is 5 to 6 week in low level anal fistulas with patients requiring multiple hospital visits in long fistulas and other complex cases [7].

Case Report

In the present case study, a 35 year old male patient came to our hospital OPD of Shalya Tantra, department in Pa.Pu. Gurumauli Annasaheb More Ayurveda Medical College & Hospital, Malipargaon,tq. Majalgaon Dist.Beed. Maharashtra.431131 Ayurveda Hospital, with a chief complaints of pain and pus discharge from perianal region since last 3 months. perianal region approximately 5-6 cm away from anal verge. on digital per rectal examination & Probing also was done to confirm site of internal opening of bhagandara Internal opening at 1 o’ clock position into the anal canal at dentate line Patient did not have previous H/O any medical and surgical illness with negative family history. Patient was diagnosed a case of anterior low levwl 1 clock position Bhagandara (Fistula-in-ano) on the basis of clinical presentation.

1. Patient name – ABC
2. Age- 35year
3. Gender – male
4. Occupation- private job.
5. Date of admission-5/1/26
6. Date of discharge-7/1/26

1. General Examination
2. GC - Moderate
3.  Pulse - 86/min
4. BP - 140/84 mmhg
5. RS - 16/min
6. Temp - 98.8 F
7. Appetite - Normal
8. Bowel – Normal

Investigations done

1. Complete blood count(CBC)-normal
2. CT, BT, -normal.
3. Random blood sugar -normal
4. HIV I & II, -NEGATIVE
5. HBsAg were non-reactive.
6. Usg report-Subcutaneous low fistila in ano.
7. Physicin fitness taken-fit for surgery.

Surgical Treatment given

Pre-operative procedure

1. Perianal part preparation done.
2. Proctolysis Enema given at before night of operation-bowel will be emptyed.
3. Written consent from patient.
4. NBM-Patient.
5. Xylocaine 2% test dose done. injection tetanus toxoid (TT) -IM given.

Operative procedures

Under low spinal anesthesia (saddle block),all aseptic precaution will be done,part painted with betadine liquid and savlon,track identified and probing done anal dilitation also done,some part of external opening was excisedwith cautery then apamarga Ksharasutra has inserted to fistula track with probe, then ligate the thread,then anal pack with jatyadi taila and yasthimadhu taila keeping, then Sterile pad and ‘T’ bandage were applied and the patients were shifted to the ward in conscious condition.

Postoperative procedures

Patients were kept in head low position and nil by mouth for about 6 hours after surgery. Appropriate antibiotics and analgesics were given for 3 consecutive postoperative days. Patients were advised to start warm water sitz bath with betadine liquid and MGSO4 solution per day for 15 min. from the next day of operation.

Fig 1: Apamrga Kshar Sutra application in Fistula in Ano

FOLLOW UP

Patient was discharged after 3 days and advice for change ksharasutra after every 7 days till cutting of the whole tract. Sitz bath and dressing with jatyadi tail was advised and allowed the patient for his routine work. After 5 setting tract was cut and heal spontaneously.

Table follow ups

Observation

When patient was come to our ayurveda hospital opd in shalya tantra for changing the ksharasutra the following observation was done-1) In 1st and 2nd setting the ksharasutra was in situ condition,the fistula track and wound was in healthy and good condition small pus and oozing was there,while changing the ksharasutra patient feels moderate burning type of pain pain,and subsite after taken sitz bath.2)In 3rd and 4th setting time the fistula track become healthy,there is no pus and oozing or any discharge,3)In 5th setting the fistula track was opened and dressing done with betadine.

Over all on observation of this study when Kshara sutra was changed every week that time it causes burning pain in ano only for one day and it subsides after sitz bath, After the cutting of whole fistulas track patient were observed 15 days and one month followed up. The track was initially 5-6 cm long, and it was cut in 5 - 6 settings. Unit cutting length of track was 1.33 cm per week. No sign and symptoms of recurrence were observed.

Discussion

Ksharsutra in ano-rectal disorders has shown miraculous results. The ingredients of apamarga kshara sutra are Snuhi ksheera, Apamarga Kshara and Haridra Powder. Snuhi ksheera having shodhana as well as Ropana properties along with Katu, Tikta Rasa & UshnaVirya thus improve process of healing. Its cures infection and inflammation Apamarga Kshara has properties of Kshara i.e. Chhedana (excision), Bhedana (incision), Lekhana (scrapping) and Tridoshaghna (alleviating all Dosha). Apamarga Ksharasootra cauterize the tissue of mass indirectly by its Ksharana Guna (Corrosive properties) Haridra powder has the properties like Rakta Shodhana (blood purifing), Twaka Doshahara, Shothahara (anti-inflammatory), Vatahara (allivate vata), Vishaghna (antimicrobial) and it is useful in Vrana Ropana (wound healing). The action of turmeric powder provides the effect of bactericidal action with healing properties.

Apamarga Kshar Sutra is having the ability to perform chemical and mechanical cutting action with simultaneous healing effects on fistulous track. Recently ICMR WHO, CSIR proposed a plan or the setup of kshar sootra centres that will exclusively work on ano rectal diseases on the national basis. Ksharasutra has got validation in the modern books also and is a successful proven method for treating fistula in ano and other ano rectal disorders.

Conclusion

1. According to maharshi susruta -mentioned in his susruta samhita the importance of Para-surgical procedures and its importance, which are Agni Karma, Kshara Karma, Raktamokshana, Jalaukavacharana and Siravedha. The sole purpose of describing Para-surgical procedures was to provide effective treatment modality in the diseases, that cannot be cured by medication and or where surgery was not possible to treat that very condition or there may be great chance of recurrence. Advantages of using these Para-surgical procedures are numerous; ranging from these are easy to perform, less chances of recurrence of disease, least or minimal chances of post-operative hemorrhage or other complications, non-invasive, cost-effective, less painful and can be done on day-care basis.

2. According to modern science Surgery is usually needed to treat an anal fistula. Sometimes parasurgical treatments may be an option, presents challenges because to its recurrence, particularly in high-level and remote communications. In India, ksharasutra therapy, also known as medicated seton therapy is used to treat difficult anal fistulas with a high success rate (recurrence rate of 3.33%). in the present article detail description about A- 35 year male patient diagnosed with anterior fistula in ano at 1clock position treated well with Apamarga ksharasutra treatment is given.

3. Ksharasutra therapy is a very affordable, risk-free procedure when carried out by a qualified surgeon. Ksharasutra is a very successful minimally invasive surgical method for the treatment of fistula-in-ano, or Bhagandara. This is a simple and effective treatment that saves the anal sphincter mucle of the anal canal.

4. Ksharasutra helps cutting the fistulas track, curetting, scrapping, draining and healing of the fistulous track. It destroys and removes unhealthy tissue and promotes healing of the fistulous track due to its caustic action, ontrols infection by the microbicidal action. Separation of debris and cleaning the wound. Facilitate in drainage of pus in fistulous tract and help in healing. Cutting through the tissues and laying the track open.

5. Ksharasutra helps in debridement and prevent bacterial infection.it is very cost effective, ambulatory.minimum tissue loss, minimal recurrence rate,minimal hospital stay, minimal bleeding. Cost-effective and Minimal recurrence rate. Systemic diseases are also undergoing this procedure.No surgical complications like incontinence, stenosis and stricture

6. Comparative Studies and Scientific Validation Recent clinical trials and meta-analyses comparing Ksharasutra therapy with modern surgical interventionshave highlighted its advantages: Lower Recurrence Rate: Unlike conventional methods, which report recurrence rates of up to30%, Ksharasutra therapy has shown rates as low as3–5%.

7. Minimal Incontinence Risk: The preservation of sphincteric function ensures better post-treatment quality of life. Cost-Effectiveness: As a minimally invasive outpatient procedure, it reduces hospitalization and surgical costs. Studies published in various Ayurvedic and modern

8. Advantages of Kshara Sutra Therapy Simple and safe parasurgical procedure, recurrence rate is minimal, Systemic diseases are also undergoing this procedure, No surgical complications like incontinence, stenosis and stricture. medical journals validate the efficacy of Ksharasutra in fistula management, making it an integrative approach to proctology. Ksharasutra therapy, with its unique blend of mechanical and chemical action, serves as an effective, minimally invasive, and recurrence-free treatment for fistula-in-ano. Its incorporation into modern proctology can bridge the gap between traditional wisdom and contemporary medical advancements, offering a holistic approach to anorectal disorders. So, we conclude that in case of fistula in Ano Ksharasutra ligation is best option.