IFTAK technique: An advanced Ksharsutra technique for management of fistula in ano.

Fistula in ano is mostnotorious disease among all the ano-rectal disorders since antiquity. Over the past few decades, various techniques are being evaluated in terms to prevent its recurrence and complications, but despite more than two millennia of efforts, fistula in ano still remains a perplexing surgical disease. The sign and symptoms of fistula in ano resembles with Bhagandara described in Ayurveda classics. For the management of this painful disease many treatment modalities are enumerated in Ayurveda classics and Ksharsutra therapy is one among them which is proved to be gold standard. Though Ksharsutra therapy is big revolution in the field of fistula in ano, but it has some disadvantages like it is time consuming process, severe post-procedural pain, big scar mark. So, in present era IFTAK is emerging as an advanced innovative technique for the management of fistula in ano along with betterment in the consequences of conventional method of Ksharsutra therapy. In the present case report, IFTAK (Interception of Fistulous tract and application of Ksharsutra) technique is used in trans sphincteric fistula in ano which showed a great potential in management by minimizing the duration of treatment, mild post procedural pain and minimum scar mark.

Efficacy of Guggulu and Shallaki based Ksharasutra with Triphala Guggulu orally in the management of Bhagandara w.s.r. to fistula-in-ano: A open labelled randomized comparative clinical study.

Background: Bhagandara is a disease of ano-rectal region and can be correlated with fistula-in-ano. Ksharasutra (application of medicated thread) is being practiced for ano-rectal disorders, particularly in Bhagandara. Guggulu-based Ksharasutra has shown good results in previous studies. Literatures and experiments of Shallaki showed anti-inflammatory, antifungal, analgesic, wound healing properties and Shallaki Niryasa (resin of Boswellia serrate Roxb.) is also having binding effect. Here, Shallaki-based Ksharasutra is used in comparison of Guggulu-based Ksharasutra with Triphala Guggulu orally for better outcome in the management of Bhagandara. Aim: The aim of this study was to evaluate and compare the efficacy of Guggulu and Shallaki based Ksharasutra with Triphala Guggulu orally in the management of Bhagandara. Materials and methods: Total 46 patients were registered and randomly allocated by computer generated chart by into three groups. In group A (n = 15), Guggulu-based Ksharasutra was applied in fistula-in-ano without any oral medication; in group B (n = 16), Guggulu-based Ksharasutra was applied with Triphala Guggulu orally; and in group C (n = 15), Shallaki-based Ksharasutra was applied with Triphala Guggulu orally. Patients were assessed for pain, discharge, itching and swelling in the affected region and unit cutting time (UCT) of fistulous tract. Ksharasutra was changed by railroad technique on weekly based follow-up till complete healing of the tract occurred. Results: In group A, relief in pain, discharge, and swelling was found and was statistically highly significant while insignificant result was found in itching after cut through of the fistulous tract and the same results were found in group B (n = 14) and group C (n = 15). The mean UCT was higher in group A (8.94 days/cm) than in group C (8.43 days/cm) and in group B (8.59 days/cm). Conclusion: Shallaki based Ksharasutra is more effective in cutting of fistula track while Guggulu based Ksharasutra is more effective in pain relief in the treatment of Bhagandara, along with oral Triphala Guggulu as compared to Guggulu based Ksharasutra with and without Triphala Guggulu orally.

Comparative clinical study of Guggulu-based Ksharasutra in Bhagandara (fistula-in-ano) with or without partial fistulectomy.

BACKGROUND: In Ayurveda, Bhagandara is considered as one of the grave disease by Sushruta due to more recurrence rate. Ksharasutra is para-surgical procedure which is found more effective in the management of fistula-in-ano. Ksharasutra is routinely prepared with Snuhi Ksheera (latex), Haridra powder and Apamarga Kshara. In conventional method collection of Snuhi latex is time consuming and laborious. Guggulu was selected as an alternative for preparation of Ksharasutra having similar binding property as Snuhi latex, and has antiseptic, anti-inflammatory and wound-healing properties. That is why, here, in this trial, the Snuhi latex was replaced by Guggulu. AIM: To evaluate the efficacy of Guggulu based Ksharasutra with and without partial fistulectomy in the management of Bhagandara. MATERIALS AND METHODS: In this research study, 42 patients of Bhagandara (fistula-in-ano) were selected and randomly divided into two groups. In group-A (n = 22), patients were treated only with application of Guggulu-based Ksharasutra and in group-B (n = 20), partial fistulectomy was done and then Guggulu-based Ksharasutra was applied in remaining fistulous tract. After Ksharasutra application, patients were assessed for relief in symptoms such as pain, discharge, itching and swelling as subjective parameters and unit cutting time (UCT) as an objective parameter, on weekly follow-up basis and Ksharasutra was changed by railroad technique up to complete cut through of the tract. RESULTS: In patients of group-A (plain Guggulu-based Ksharasutra), highly significant relief was seen in pain and discharge. The significant result was seen in itching while insignificant relief in swelling. In patients of group-B (partial fistulectomy with Guggulu-based Ksharasutra), relief in symptoms such as pain, discharge, and itching was statistically highly significant. The relief in swelling in this group was found statistically significant. The mean UCT was 8.85 days/cm in group-A, whereas the mean UCT was 8.19 days/cm in group-B. CONCLUSION: Partial fistulectomy with Guggulu-based Ksharasutra is better as compared to plain Guggulu-based Ksharasutra application in cases of Bhagandara (fistula-in-ano).

Transrectal Ultra Sonography based evidence of Ksharasutra therapy for Fistula-in-ano - A case series.

Ksharasutra (parasurgical procedure using a thread treated by alkalies) is being practiced in Indian system of medicine since ancient time for management of ano-rectal disorders; particularly for Bhagandara, (fistula in ano), and generally difficult to treat. In this case series, standard Ksharasutra was prepared as per the Ayurvedic Pharmacopeia of India and used to treat the different cases of Bhagandara. In this case series total 6 patients of Bhagandara were treated with Ksharasutra and partial fistulectomy. The average Unit Cutting Time and healing (UCTH) was observed 7.86 days/cm. During treatment Panchawalkala Kwatha (decoction of five medicinal plant's bark), Shatdhautaghrita, Jatyaditaila and Erandabhrishtaharitaki Churna were used as adjuvant drugs. To generate quality evidence Transrectal Ultra Sonography (TRUS) was used in pre as well as post-treatment and showed remarkable tool to assess effect of treatment. Substantial clinical result was observed at the end of treatment and all the patients were free of fistula. No recurrence was observed in any case during the 12 follow up of 12 months. The treatment was reported safe and well tolerated in all the patients.

Innovative approach in the management of horse-shoe fistula-in-ano with Ksarasutra.

Fistula-in-ano is a common surgical problem. Horse-shoe fistulas usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep potential space. The "Sambukavarta Bhagandara" described by Susruta can be correlated with the horse-shoe type of fistula. In this condition, neither fistulotomy nor "Ksarasutra" treatment alone, are useful hence there is a need for newer innovative surgical techniques to tackle this challenging disease. An integral approach of incision and drainage of both the abscess on the arms of the horse-shoe fistula with Ksarasutra ligation at 6 o' clock position proves to be successful. We have tried the same technique with good results. No recurrence was found in the patients during the follow-up period of 6 months. A 45-year-old female with a known case of diabetes mellitus and hypertension approached with both right and left ischiorectal fossa inflammatory swelling. An innovative approach was used to manage horse-shoe fistula by making an additional opening below the anus at 6 o'clock position. Apamarga Ksarasutra (medicated thread made using apamarga) was ligated through the additional opening to the internal opening at 6 o'clock position for draining through both the cavities. Ksarasutra was changed weekly and the fistula healed completely by 3 months.

Wound healing potential of Pañcavalkala formulations in a postfistulectomy wound.

Sushruta mentioned sixty measures for management of wounds. Panchavalkal is the combination of five herbs having properties like Shodhana (cleaning) and Ropana (healing) of wounds. Individual drugs and in combination have Kashaya rasa (astringent) dominant and useful in the management of Vrana (wounds) as well as Shotha (inflammations). A 35 years old male patient consulted in Shalya OPD with complaints like discharge per anum, induration and intermittent pain at perianal region since last five years. On inspection external opening was observed at anterior portion 1 O' clock position which was four centimeter away from anal verge. That case was diagnosed as Bhagandara (fistula-in-ano) and was treated with partial fistulectomy and application of Guggulu based Ksharasutra in the remaining tract. The big fistulectomy wound was treated with local application of Panchavalkal ointment daily and simultaneous change of Ksharasutra. The wound was assessed daily for pain, swelling, discharge, size, and shape. The wound healed completely within two and half month with normal scar having good tissue strength. This case demonstrated that post fistulectomy wound can be treated with Panchavalkal ointment.

Management of rare, low anal anterior fistula exception to Goodsall's rule with Ksarasutra.

Anal fistula (bhagandara) is a chronic inflammatory condition, a tubular structure opening in the ano-rectal canal at one end and surface of perineum/peri-anal skin on the other end. Typically, fistula has two openings, one internal and other external associated with chronic on/off pus discharge on/off pain, pruritis and sometimes passing of stool from external opening. This affects predominantly male patients due to various etiologies viz., repeated peri-anal infections, Crohn's disease, HIV infection, etc., Complex and atypical variety is encountered in very few patients, which require special treatment for cure. The condition poses difficulty for a surgeon in treating due to issues like patient hesitation, trouble in preparing ksarasutra, natural and routine infection with urine, stool etc., and dearth of surgical experts and technique. We would like to report a complex and atypical, single case of anterior, low anal fistula with tract reaching to median raphe of scrotum, which was managed successfully by limited application of ksarasutra.

A comparative clinical study of Snuhi Ksheera Sutra, Tilanala Kshara Sutra and Apamarga Kshara Sutra in Bhagandara (Fistula in Ano).

Bhagandara (Fistula in Ano) at modern parlance is a common anorectal condition prevalent in the populations worldwide and its prevalence is second highest after Arsha (hemorrhoids). Kshara Sutra (K.S.) is one of the chief modality in the treatment of Bhagandara in Ayurvedic science. Exploration of the new plants for the preparation of Kshara as a better substitute to Apamarga Kshara is the need of the hour. To find out an effective alternative to Apamarga K.S. in view of easy processing, a Snuhi Ksheera Sutra without any Kshara and the Tilanala K.S. were opted for their clinical evaluation. Total 33 cases of Bhagandara were divided randomly into 3 groups, having 11 patients in each group. In Group A, Snuhi Ksheera Sutra; in Group B, Tilanala K.S. and in Group C, Apamarga K.S. were used. Assessment was done on objective (Unit Cutting Time - UCT) and subjective parameters. Statistically insignificant difference was observed in the efficacy of treatment by subjective parameters like pain, discharge, etc. between the three groups. It was found that Tilanala K.S. showed higher UCT (9.76 days) while lower in Snuhi Ksheera Sutra (7.42 days) as compared to Apamarga K.S. (8.82 days). Thus Tilanala K.S. can be used as a substitute for Apamarga K.S. and Snuhi Ksheera Sutra can be employed in the recurrent fibrosed cases of Bhagandara.

Modified ksharasutra chikitsa for 'shambukawarta bhagandara'.

Horse-shoe Fistula is a big challenge for both Modern and Ayurvedic Surgeons. We can correlate this with 'Shambukawarta Bhagandara' described by Sushruta. Here, fistula forms secondary to an ischiorectal abscess and both the ischiorectal fossae are involved. Also, they open posteriorly into the anal canal, at the 6 o'clock position, and are associated with a big cavity lying superior (above the levatorani). Therefore, in such a clinical feature neither Fistulotomy ('Wanley operation') nor 'Ksharasutra' treatment alone, prove useful. After going through this, we can say that there is a definite need for newer surgical innovative techniques, to tackle this challenging disease. An integral approach of 'Fistulectomy along the arms of the Horse-shoe fistula with Ksharasutra ligation' in the remaining track connected to the anal canal, and drainage of the postanal space abscess, proved to be very successful. We have tried the same technique with very good results. No recurrence was found in the patients during the follow-up period of three years. The given diagrammatic presentation of the plan of surgery will help to understand the procedure.

Clinical Evaluation of Kshara sutra Therapy in the management of Bhagandara( Fistula- in-Ano)- A prospective study.

STUDY DESIGN: A prospective study of 50 patients suffering from Bhagandara(Fistula in Ano) (age ranging from 18-54years) treated by Kshara sutra therapy PLACE: Kshara sutra unit, Central research Unit, Punjabi bagh, New Delhi DURATION: January 2007 to July 2008. OBJECTIVES: To determine the incidence of low or high anal fistula, recurrence rate following Kshara sutra therapy and effect of Ksharasutra therapy on the Bhagandara. MATERIAL AND METHODS: The fifty patients (50) were selected randomly in the Out Patient Department. STUDY DESIGN: Uncontrolled open level Study. RESULTS: Patients were followed to see the incidence of recurrence, effect of Kshara Sutra Therapy on incontinence. Overall recurrence rate was only 5.88 %. Minor incontinence was observed only following Kshara sutra Therapy for high variety for which no treatment was given. No such complication occurred in low variety. CONCLUSION: Bhagandara (Fistula in Ano) can be treated by Kshara Sutra Therapy with minimal loss of sphincter muscle and low reoccurrence rate.