PREPARATION OF KSHARA AND KSHARSUTRA

Dr. Joban ModhaDr. Mukul Patel

Advantages of Kshar Sutra

Choice of treatment for Fistula in ano. The procedure does not require

hospitalization for more than 3 to 4 hours. The patient requires no bed rest & can

resume his/her daily routine within 6 to 12 hours.

The procedure leaves just a pencil scar at the site.

Advantages of Kshar Sutra

Freedom from painful dressings. There are no chances of incontinence and

the recurrence rate which is usually found to be quite high after Fistulectomy is less than 2% with Kshar - Sutra treatment.

This is because the medicines on the thread gradually and continuously curate the pyogenic membrane and fibrous tissue and thus leave no pus pockets undrained.

Ksharsutra preparation

There is not a single reference in the Brihattrayee or even in the Laghutrayee, of the method of preparation of Kshar Sutra as it is used today.

There are some references indicating the use of medicated thread in the treatment of Arsha and Bhagandara in Sushruta and Bhavprakasha.

Ksharsutra preparation

In the recent past, the late Dr. P. J. Deshpande had done extensive research and had come forward with a scientific and standard method of preparing the Kshar Sutra.

This method of preparation of Kshar Sutra has been adopted widely by institutes of Ayurveda and by ayurvedists in general.

Not only the clinical efficacy but many other aspects are also considered in the standardization of the Ksharsutra.

Ksharsutra preparation

Standard method developed by C.C.R.A.S. (Ref.: Management of Bhagandara with Ksharsutra by Dr P. J. Deshpande, Dr K. R. Sharma, Dr S. K. Sharma).

Preparation of Ksharsutra and the Drugs Required Preparation of Kshar-Sutra is a lengthy

and difficult task and the collection and preparation of required drugs is still more cumbersome.

A number of different drugs are used in various combinations for the preparation of the Kshar-Sutra.

The Ksheer (latex) generally used are of Snuhi, Ark, Udumbar etc.

The Ksharas used are Apamarg Kshar, Ark Kshar, Kadali Kshar etc.

Requirements

Snuhi Ksheer Apamarg Kshar Haridra powder Thread,-Linen Barbour No.-20. Aluminium or steel frames are drilled with

small hooks for holding threads in place at an interval of about 1 1/2". The size of the frame may vary to suit specific needs.

Requirements

Any cotton / linen thread of good strength can be used for Kshar-Sutra.

Generally Barbour Linen No. 30 and 20. threads are used. No. 30 is finer compared to No. 20.

1. Method of preparing Apamarg Kshar :

1. Method of preparing Apamarg Kshar :

Well grown shrubs are collected in the month of November.

These shrubs are dried.

Acyranthus Aspera

When dry, they are burned down to ash in a clean open space or in a big container.

The ashes of the Panchang (whole plant) of the shrubs are collected on cooling.

The ash itself can be preserved in airtight containers and may be used to prepare the Kshar at convenience.

The ash is stirred in pure soft water 4 times the ash (Rastarangini).Here the ratio of ash to water is in reference to its volume and not weight.

The water soluble constituents of the ash are dissolved in the water.

The mixture is stirred for a few minutes and then allowed to stand for a few hours. This process is repeated 4 to 5 times.

The mixture is then allowed to stand for a period of a few hours again.

The ash settles down and we get a clear yellowish liquid solution on top which now contains all the water soluble constituents of the Apamarg ash. The solution is carefully decanted into another container and strained.

Filtration

The clear yellowish solution may still contain minute insoluble parts of the ash.

To get pure Kshar it is advisable to further purify this solution by filtering so that the remaining minute insoluble particles are removed.

This process is repeated 4 to 5 times. The mixture is then allowed to stand for a

period of a few hours again. The ash settles down and we get a clear

yellowish liquid solution on top which now contains all the water soluble constituents of the Apamarg ash.

The solution is carefully decanted into another container and strained.

To get pure Kshar it is advisable to further purify this solution by filtering so that the remaining minute insoluble particles are removed.

The solution is now kept to boil in a thick preferably stainless steel container. As the water evaporates, we start getting crystals of Apamarg Kshar.

APAMARGA KSHARA

When almost all the water is evaporated we get a white substance which settles at the bottom.

This is powdered and packed in air tight container for further use.

> Collection of Snuhi Ksheer : - Latex of Euphorbia neriifolia The Ksheer from Snuhi

is collected best, early in the morning, before sunrise.

If collection of Ksheer is tried after sunrise, we can get just a few drops of Ksheer from a Snuhi branch.

> Collection of Snuhi Ksheer : - Latex of Euphorbia neriifolia

With the help of a scalpel, slit the Snuhi branch vertically from down upwards (5mm deep) keeping a collection jar under the slit.

As soon as the cut is made, a milky substance (ksheer) starts dripping down.

This ksheer is collected in the jar.

The amount to be collected depends upon the threads to be coated.

After collection the Ksheer, jar is to be packed so that no air enters it because Ksheer if kept in contact with air, starts to coagulate and turns into a chewing-gum like sticky semisolid substance.

Before coating the threads, the ksheer is to be strained from a wire strainer or with the help of a double folded gauze piece. The ksheer is now ready for use. Snuhiksheer should be always used fresh.

Preparation of Haridra Powder - Curcuma Longa The third drug required

for the last three coatings is Haridra powder. Haridra is known to most of us as turmeric.

The well developed dry rhizomes of Curcuma longa are used to prepare the powder.

Haridra plant

Dissected Rhizomes

Powder of dry Haridra

The combination of the three above mentioned drugs does the work of cutting, curetting and healing the fistula.

The multiple coats on the threads probably make the effect of the drugs gradual and continuous.

The drugs keep on dissolving and being released gradually for a couple of days, after which the Ksharsutra is changed if and when required.

The thread itself acts as a vehicle for the drugs to reach the sight and the coating on the thread probably renders a sort of a sustained release effect of the drugs in the track.

KSHARSUTRA

The thread is given 21 coatings out of which the first 10 coating are given only the fresh Snuhi Ksheer.

The next 7 with Snuhi Ksheer and Apamarg Kshar and the last 4 with Snuhi Ksheer and Haridra.

A piece of gauze is taken and folded into a small square.

It is then dipped in the fresh Snuhi Ksheer (latex of Euphorbia neriifolia) and the thread is coated (i.e. a Bhavna is given) with the ksheer from down upwards.

When all the threads are coated in this manner, the frame is kept to dry in a specially made chamber.

The second coating (Bhavna) is given only when the first one dries.

The thread is coated 10 times in this way; one after the other after the previous coating of the Ksheer dries completely.

The frames are placed in a special chamber for drying.

The temperature inside the chamber may be increased by passing hot dry air with the help of a fan.

The air inside the chamber should be kept circulating to facilitate quicker drying of the threads.

The process of drying is best performed when the level of Humidity is lower.

After completing the first 10 coatings of Snuhi ksheer, we now proceed to coat the thread with both Snuhi Ksheer and Apamarg Kshar.

The thread is coated with fresh Snuhi ksheer in the way described before.

Apamarg Kshar is coated on it immediately (i. e. when the thread is still wet) so that it sticks to the thread properly.

With experience we have found that the best way to do it is to coat only 3 or 4 threads at a time with Snuhi ksheer and then pass them through a pile of Apamarg Kshar on a flat plate.

This is done by sliding the frame over the pile of Kshar in such a way that the threads pass through the pile of Kshar and the Kshar sticks on the wet thread. When all threads of a frame are coated in this way, the frame is again kept for drying in the chamber.

The thread is coated in this way 7 times. The thread is coated only when the previous coat is completely dry. Hence 10+7= 17 coats are completed.

The last four coats are to be given with Snuhi ksheer and Haridra. This is done in the same way as the previous 7 coats substituting Haridra powder in place of Apamarg Kshar.

While applying every coat, care should be taken that the drug spreads evenly on all the sides of the thread and does not aggregate at one spot to make a knot like appearance.

The thread should be smooth and even, having the same thickness through out the length. Care should be taken to carry out the procedure in a dry atmosphere.

A specially prepared chamber is used for drying the threads so that it can be dried in a dust free atmosphere.

In the absence of a chamber the threads may be dried in the open under direct sun rays in a dry and dust free atmosphere.

After we finish coating the threads 21 times and they are totally dry the threads are cut to size and then packed in capillary like glass test tubes.

These tubes are cut to size, cleaned, dried, and sterilized. One or two threads are packed in each tube. The tube is packed/ sealed over a burner so that the Kshar-Sutra in it remains dry and sterile.

These tubes are sent for Gama radiation after being packed & sealed. The tube is broken and the Kshar-Sutra removed for use when required.