Article by Dr Raghuram Y.S. MD (Ay) and Dr Manasa, BAMS
Advantages of Kshara Sutra
The procedure is safe, simple and effective para-surgical procedure
It doesn’t require hospitalization for more than 3-4 hours, it can be done as an out-patient procedure without admitting the patient for many hours (patient can be discharged few hours after the procedure)
- Kshara sutra is performed under local anaesthesia. The whole procedure will be dealt within 30-45 minutes.
- The kshara sutra procedure doesn’t leave big scars, small scar may be left over
- Minimal bed rest needed
- Patient can resume daily routine activities within 3-5 days
- Freedom from painful dressings
- There are hardly any complications after the procedure
- Minimal recurrence rate – The rate of recurrence of ano-rectal disorders after kshara sutra is minimum, it depends how good the follow up care by the patient was!! The recurrence rate is usually high after fistulectomy but is less than 2% with kshara 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 un-drained.
- No chances of incontinence, stenosis, stricture or any other complications
- It is cost-effective and ambulatory
- The most important benefit of kshara sutra treatment procedure over the modern surgical procedures is that the muscles that support the anus and helps in controlling the bowel movements are not dissected and hence the possibility of anal incontinence (loss of power to hold stools) is not there.
- Read related: KsharaSutra Treatment: Introduction, Indication, Contra Indications
Kshara Sutra standardization
Standardization of Kshara-Sutra
Standardization of Kshara Sutra (and its raw materials) has been done on the basis of analysis of various physical and chemical parameters of the ingredients so as to ensure the quality control with cost effectiveness at the clinical level. This analysis was done at Chandigarh and Lucknow laboratories. Various characteristics of an ideal ksharasutra are as follows:
- pH = 10.1
- Length of the Ksharasutra = 30±1cm
- Diameter of the thread = 1.9mm
- Minimum breaking load = 5.83kg
- Weight of coating = 0.83gm
- Thickness of thread after coating = 2.10+0.11mm
pH of individual ingredients:
– Snuhi Ksheera – 5.6
– Haridra – 6.2
– Apamarga Kshara – 10.2
Advances in Kshara Sutra
Research works have led to recent advances in innovative approach towards Ksharasutra administration.
Read related: KsharaSutra Pradhana Karma – Main Procedure
In this instead of snuhi, the latex of Udumbara or Ficus glomerulata is used. It carries a comparably cold potency (sheeta veerya) and a pH of 8.5. This has been tried in dushta vranas (contaminated wounds). It was found well tolerated and less irritant than the traditional Apamarga kshara sutra, doesn’t produce much pain, heals wound. But the unit cutting time was seen to be less in comparison to the standard thread. The sticking ability of the latex on the thread was also less. Knotting after application was difficult as seen in the studies.
Papaya Kshara Sutra
In this, instead of snuhi kshara, the fruit pulp of papaya fruit is used i.e. papain powder (obtained by drying unripe fruit juice). Papain is said to consist of strong proteolytic enzymes which lead to debridement of necrosed tissue, very early after application. It facilitates early wound healing and could be easily prepared in short time. It was found that it went well with the tolerance of the patient and but the disadvantage was that its unit cutting time was very less.
Read related: Ksharasutra Preparation Method: Detailed Explanation
Guggulu based Kshara Sutra
In this form of preparation, solution of Guggulu (Commiphora mukul) was used in place of latex of Snuhi. Guggulu is used due to its analgesic, debridement and healing properties, good binding action on the sutra or thread and its anti-inflammatory activities. Guggulu is easily available and its solution can be readily prepared either in water or alcohol. This kshara sutra was well tolerated by patients. Owing to its non-bleeding nature and analgesic role, pain and anxiety during and after application of kshara sutra are minimal. In comparison to the other threads, pain, discharges, indurations were seen to reduce in quick time. Wound healing was also good. Disadvantages included softening and loosening of ksharasutra due to soapy nature of the medicine.
Yava Kshara Sutra
In this, Yava kshara or the alkali obtained after burning the whole plant of barley is used. Its property of scrapping is well known. It comprises of fibrolytic, hygroscopic and anti-inflammatory actions. Pain and agony was less and the thread was well tolerated.
Aloe vera Kshara Sutra
Aloe vera Ghritakumari Kshar Sutra – In this preparation, Ghrita kumari pulp or pulp of Aloe vera was used in place of latex of snuhi. It possesses local anaesthetic property and is not as caustic as Snuhi. Its pulp has binding action. It is easily available and preserved, causes good healing of wound and is well toelrated. There are no associated allergic reactions. The disadvantages of the thread were that the sticking of kumari pulp neither was nor uniform. The thread was beaded and thus caused pain during application.
Need for experimentation
Need for extensive study and experimentation related to use of Kshar Sutra –
Though Apamarga Kshara Sutra is the classic form of Kshara Sutra which has been used as an unparalleled remedy in treating ano-rectal conditions, it has its own disadvantages and drawbacks. To overcome these disadvantages (limitations), newer methods of preparation of kshara sutras using different combinations of medicaments while preserving the sanctity of original preparations have come into quest. Some of the limitations of apamarga kshara sutra are as below mentioned –
– Snuhi latex, one of the chief ingredients of kshara sutra preparation creates lot of problems during preparation of the thread. A very little amount of latex is collected after the incision of the stem. It coagulates if not used early.
– Collection of latex becomes difficult in summer. Thus its preparations are possible only in some seasons.
– Severe pain is felt by most patients during the application of kshara sutra thread. In few cases the intensity of pain is so severe that the patients tend to discontinue the therapy haphazardly.
– Certain allergic reactions are also noted, though not in all the patients.
Expiry date of Ksar Sutra –
Kshara sutra expires 6 months from the date of manufacture. They shall not be used and be discarded after the mentioned time.
History of KsharSutra –
The credit of mentioning and describing Kshara sutra for the first time ever goes to Acharya Sushruta, the pioneer and father of Ayurvedic surgery. He mentions it as an effective treatment for Nadi Vrana (sinus), Bhagandara (fistula in ano), Arbuda (benign tumours) etc conditions but Sushruta has not emphasised on its preparation.
Chakrapani Dutta was the first person to mention the method of preparation of kshara sutra with its indication in Bhagandara (fistula-in-ano) and Arshas (Haemorrhoids, Piles). He described the method of preparation of kshara sutra as ‘smearing a thread repeatedly in the snuhi ksheera (latex of Euphorbia meriifolia) and Haridra churna (powder of Turmeric). The later authors too explained kshara sutra on almost similar lines. But because of complexities surrounding the preparation of kshara sutra and inadequate method of procedure of application, it lost its popularity among Ayurvedic surgeons over a period of time.
Rasatarangini (published later to Chakradutta) came up with a bettor method of kshara sutra preparation.
In the later period, kshara sutra became an important strategy and remedy in combating ano-rectal disorders, with the procedure gaining immense popularity among the surgeons.
Even today, Kshara Sutra is being practiced by a big group of doctors and surgeons belonging to Ayurveda. It has become an unparalleled specialization in effectively combating disease pertaining to anal and rectal origin.
The credit of standardization and development of kshara sutra for practical use mainly goes to Prof. P.J.Deshpande, Dr S.R. Gupta in the present era.
Many variants of kshara sutra have been introduced into the Ayurvedic practice, thanks to constant research process.
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