ksharsutra therapy in various surgical disorders
TRANSCRIPT
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Kshar-sutra therapy in various
Anal and other disorders
Dr. Praveen Kumar Choudhary
M.S. (Shalya), B.H.U.
Associate Professor, Deptt. of Shalya Tantra
A&U Tibbia College (Govt. of Delhi), New Delhi
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Modalities of Kshar-karma
Kshar-sutra
Kshar-varti
Kshar-gauze
Kshar injections
Kshar solutions
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Subjects of Kshar-sutra therapy
Anal fistula
Pilo-nidal sinus
Fissure in ano
Haemorrhoids
Sinuses
Warts
Rectovaginal fistula
Injection abscess and stitch abscess
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Kshar-sutra in anal fistula
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Why Kshar-sutra therapy is
superior to surgery?
Slow cutting of the track by pressure
necrosis caused by thread.
Debridment of the infected material by
Kshar including infected anal glands.
Formation of healthy granulation tissue
leads to good healing.
Minimal sphincteric mechanism
disturbance. Nil recurrence.
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Does Kshar sutra heal all Anal
Fistula?
No , there are certain contraindications?
Osteomyelitis of Pelvic bones, Femur.
Tuberculosis of Hip joint, spine, cold
abscess.
Ulcerative colitis, Crohn’s disease,
Venerial diseases.
Intestinal and pelvic malignancies.
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Other conditions
Kshar-sutra may be applied after treating
the following diseases such as:
Tuberculosis, Diabetes mallitus, Chronic
amoebiasis, Anaemia, B.P.H.
If these diseses are not treated, the
recurrence will be there even after
healing of the wound.
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Preparation of the Kshar-sutra
The description of the preparation of
Kshar-sutra is mentioned in Chakradutta
& Rasa-tarangini.
Charaka has described the use of Kshar-
sutra in Bhagandara in Chapter of
Shotha chikitsa. But he has not
mentioned preparation. Sushruta has
also not been mentioned the preparation.
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Standard Apamarga Kshar-sutra
Snuhi Latex
Apamarga Kshar
Haridra Powder
The Kshar-sutra was standardised in the
Deptt of Shalya-Shalakya at the B.H.U.
and approved by the I.C.M.R.
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Snuhi Plant
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Collection of Latex
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Materials & Method
Apamarga Kshar: Prepared by usual
method of Pratisarniya Kshar
preparation.
Snuhi latex: Collected from the stem of
the Snuhi.
Haridra powder: From the dry rhizomes.
Surgical thread no- 20
Kshar-sutra cabinet
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Preparation
11 coatings of the Snuhi latex on surgical
thread for 11 consecutive days.
7 coatings of Snuhi latex and Apamarga
Kshar for 7 consecutive days.
3 coatings of Snuhi latex and Haridra
powder for 3 consecutive days.
A total of 21 coatings are required to
achieve adequate thickness.
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Advancements
1. Udumber Kshir sutra: M.K.Jalan, P.J.
Deshpande
Prepared by applying 11 coatings of
Udumber Ksheer on Surgical thread.
It was a good thread, less irritant, well
tolerated by the patients.
Disadvantage was that the cutting time
was less and sticking of latex on the
thread was less. Making knot was also
difficult.
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Pappaya sutra
Prepared by Papaya pulp, Papain
powder (dried unripe fruit juice) and
Haridra powder.
Papaya fruit pulp and papain powder -
11 coatings.
Papaya fruit pulp and Haridra powder - 3
coatings. Total 13 coatings.
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Snuhi Svarasa Kshar sutra
In this kshar sutra snuhi svarasa was
used in place of Snuhi latex. The
qualities are more or less same except
that slight more coatring are required to
achieve adequate thickness.
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Yavaksar coated sutra
In this thread Yavakshar was used in
place of Apamarga Kshar sutra. The
thread is in use and is good except that
Unit Cutting Time is less in comparison
to Standard kshar sutra.
Ghritkumari based sutra: In this thread
Ghritkumari was used in place of Snuhi
latex. It is also a good thread.
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Tankana ksharsutra
The Tankana was used in place of
Apamarga Kshar.
Gandhaphiroja based Kshar-sutra: In
this thread Gandhaphiroja was used in
place of Snuhi latex.
Aragvadhadi sutra: This thread was
based on the Aragvadhadi varti
mentioned in Sushruta Samhita.
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Guggulu based Kshar sutra
In this thread Guggulu solution prepared
in alcohal was used in the place of snuhi
latex. The rest of the preparation is same
as that of Standard Apamarga Kshar-
sutra.
It is a good thread and it is in use in the
B.H.U and it has good results in
complicated Fistula-in-ano.
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Application of Kshar-sutra
Materials:
Minor Operation theatre
Lithotomy table
Spot light
Kshar-sutra dressing trolley
Instrument box
Ushnodaka avagaha Yantra
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Bhagandara: Treat root of the
disease
As you know that Fistula in ano arises from the infected anal glands; therefore, in order to eradicate the disease, the root cause i.e. anal glands should be taken care of.
If you could remove the pathological anal glands, branches will heal automatically.
Therefore, keep watch on anal glands at the pectinate line.
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Anal glands
Chronicity of Fistula in ano is due to persistence of anal gland epithelium in the internal opening of the track. This keeps the opening patent.
Anal glands provide a channel between lumen of anus and connective tissue encircling the terminal bowel.
Anal gland is just like a diverticulum –stasis and infection may occur.
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What is interceptive kshar-sutra
technique
Emphasis is made on the internal opening and area of fibrosis.
The track is threaded somewhere in the middle nearer to anal canal by making an artificial opening.
No need to thread the external opening.
The secretions become dry on destruction of anal gland by chemical cauterization of thread.
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Surgical spaces around anus
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Examination of Bhagandara (Fistula
in ano)
Symptoms: Pain, Swelling, Discharge
Examination: Local Eamination
P/R Examination, Probing
Radiological : Fistulography
Imaging: Trans rectal USG, MRI
Other investigations: Blood Sugar, Elisa
for Tuberculosis, Rule out Carcinoma of
rectum and Inflammatory bowel diseases
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Fistulography
Materials:
Malecot catheter 32 Fr size fitted with a
condom at one end and inflation bulb at
another end to push air in it. It is introduced
into the rectum to know its boundary.
Infant feeding tubes of various sizes for
introduction into the fistulous opening. The
contrast is injected into opening through this
tube. The X-rays are taken AP/LAT VIEW.
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AP View
The contrast injected
in external opening
may be seen.
It is better to put a
condom fitted with
malecot in rectum to
mary its boundry.
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Lateral view: Digital enhancement
Track can be seen
as black line on
digital radiogram.
Lateral X-ray cannot
reveal good findings
on analogue films.
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Causes of recurrence after
surgery
Inadequate excision
inadequate removal
of anal glands
Deep pus pockets
are not curreted.
False assessment of
internal opening.
Primary disease
untreated.
Presence of Fecal
matter in the wound.
Moisture in the
wound leads to
bacterial infection.
Bridge formation
during healing of
wound.
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Primary threading
Feel internal opening
It you are not able to
locate internal
opening, never try to
thread.
Goodsall’s rule
No need to pressure
Rotatory movement
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Shataponak Bhagandara
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Shambukavarta Bhagandara
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Multiple fistula
Difficult to treat
Extensive branching
causes difficulty
Judicious use of
surgery and kshar-
sutra.
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Surgery is horrible
This patient is operated
at Balaji Action Institute
twice. Even colostomy
was performed but of no
avail.
Extensive damage to
anal musculature leads
to incontinance. Treated
by kshar-varti.
Could not tolerate K.S.
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Complications of surgery
Faulty diagnosis.
Operated somewhere in U.P. for Fistula.
The actual diagnosis was Ulcerative colitis.
The infection travelled to abdominal wall.
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Contd.
The same case as
described earlier.
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Scrotal fistula
The patient was
presented with balanitis
and orchitis.
On careful examination
an opening at anterior
aspect of scrotum was
noticed.
Another opening was
present lateral to
scrotum.
Surgery and KS therapy.
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Contd.
The patient was
operated for fistula at
Jaipur SMS hospital
and later received
KS therapy.
Put on ATT.
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What is interceptive approach
The track is
intercepted on the
way to either
opening.
Considerable time is
saved in this
approach.
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Scrotal fistula
Multiple opening in
the scrotum.
Later diagnosed as a
case of tubercular
epididymitis.
Not any
communication with
anus or urethra was
noticed.
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Skin to skin threading – No
No useful purpose
has been solved by
threading skin to skin
openings.
After several case
studies, it was found
a time consuming
procedure with no
extra benefits.
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KS with Surgery
Thread causes
sterilization of
track by
destroying anal
glands.
We can cut
remaining track
surgically in order
to save time.
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Complicated Fistula
Extensive superficial cutaneous gangrene was seen. Debrided surgically.
The patient was a known Diabetes patient.
No complication was noticed in last six months.
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Fistula: Drainage
Drainage
towards
anus.
For
subsequent
threading.
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Investigate thoroughly
Long standing cases
Patients of older age
groups.
Unusual
presentation of
fistula.
Colonoscopy in
unusual mass in
rectum.
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Long standing cases
There is
extensive
fibrosis in this
IR fistula.
The patient
has been
suffering from
10 years.
Tubercular FIA
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Multiple Fistula
No need to put
thread in all tracts.
Start from the most
presenting one.
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Malignancies
Extensive ulceration
Bleed to touch
Confirmation by colonoscopy
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Haemorrhoids
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Application of K.S. in haemorrhoids
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K.S. on niddle
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K.S. in Pilonidal sinus
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KS in other sinus
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And many more to come
Thank you