KSHAR-SUTRA (क्षारसूत्र) THERAPY:

“Kshar Sutra” (क्षारसूत्र) is a Sanskrit phrase in which Kshar (क्षार) refers to anything that is corrosive or caustic; while Sutra(सूत्र) means a thread.It is described by many Ayurvedic texts which originated and flourished in India. It is one among popular Ayurvedic treatment modality in the branch of Salyatantra followed by Susruta.
The Ksharsutra was first mentioned by the “Father of Surgery” Sushrut in his text named SUSHRUT – SAMHITA for the treatment of Nadi Vrana(sinus), Bhagandara (fistula- in – ano), arbuda (excision of small benign tumour) etc

Preparation of Ksharsutra and the Drugs Required:

• Apamarg( Achyranthus aspera )
• Burning of Apamarg Plant
• Ashes of Achyranthus aspera
• Dissolving the ashes in water (4 times)
• Decantation and straining of Apamarg Solution
• Filtration
• Boiling the solution to get the Kshar
• Snuhi( Euphorbia Netriifolia )
• Collection of latex by slitting open the Snuhi plant vertically
• Straining of the latex of Snuhi
• Rhizomes of Haridra( Curcuma Lonnga )

Preparation of Ksharsutra:

• Dissected Rhizomes of Haridra showing the orange inner portion
• Powder of dry Haridra Rhizomes
• Thread used for preparing Kshar Sutra
• Tying the thread on the frame
• Coating the thread with latex / Ksheer of Snuhi
• Coating the thread with Snuhi Ksheer prior to Apamarg Kshar Coat
• Coating the thread with Apamarg Kshar
• Coating the thread with Snuhi Ksheer prior to Haridra powder coat
• Coating the thread with powder of Haridra
• Prepared Ksharsutra on the frame
• Packing the Ksharsutra in a glass tube
• Packed and Sealed Ksharsutra

Preparation of Kshar-Sutra is no doubt, 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, Arendakarkataki, Udumbar etc. The Ksharas used are Apamarg Kshar, Ark Kshar, Kadali Kshar etc. We have here used the following drugs.

Drugs Required:

• 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.Any cotton / linen thread of good strength can be used for Kshar-Sutra. In our practice, we generally use Barbour Linen No. 30 and 20. No. 30 is finer compared to No. 20. The tensile strength of No.
20 is reduced to the least extent in comparison to other threads after the complete procedure and hence it is this thread which is usually preferred in the manufacture of Kshar-sutras. The thread is tightly wound around opposite hooks to form rows.
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 above. Apamarg Kshar is coated on it immediately (i. e. when the thread is still wet) so that it sticks to the thread properly. Different practitioners have developed different ways in which to do this. 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.

Before going into the details of the collection and preparation the drugs required, I would like to mention here that though the most widely used Kshar-Sutra are prepared from Snuhi ksheer and Apamarg Kshar and Haridra, we can make a variety of different Kshar-sutra from a combination of ksheer from different ksheeri vrikshas i.e. latex of different trees like Udumber ksheer, Arka ksheer, Aerandkarkati ksheer and Ksharas like Ark Kshar, Kadli Kshar, Nimb Kshar etc.

Collection and preparation of the drugs required in the preparation of Kshar-sutra:

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. With the help of a scalpel, we 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.

Method of preparing Apamarg Kshar :

Water soluble extract of the ash of Achyranthus aspera.

Well grown shrubs are collected in the month of November. These shrubs are dried. 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. 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.

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. They adhere to the sides of the container. Theses should be constantly removed by stirring the boiling solution. When almost all the water is evaporated we get a white substance which settles at the bottom. Minimizing the heat, the process should be continued till all the water evaporates and we get a thick layer of the Kshar at the bottom of the container. This thick layer can be removed on cooling. The substance which we now get is the pure extract of the ash of Apamarg Panchang. This is powdered and packed in air tight container for further use.

The method of preparing the Kshar may be modified when mass production is desired.

Preparation of Haridra Powder:

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. 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 Ksharsootra 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.With the picking up of the Kshar-sutra mode of treatment in Ano-rectal diseases, the requirement and demand for good quality standardized Kshar-sutra is inevitably going to increase and hence Kshar-sutra manufacturing and marketing on both large scale as well as small scale though quite difficult and cumbersome may be a rewarding project.

Indication:

• Fistula in ano (Low anal, high anal, multiple opening fistula)
• Pinonidal Sinus
• Advantages of Kshar Sutra:
• 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
• Non-surgical procedure
• No cut – no stitch
• Less pain – less bleeding
• No incontinence (loss of control on motion)
• No recurrence
• No daily dressing required
• No hospitalization require
• 6 to 12 hours.
• The procedure leaves just a pencil scar at the site.
• 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.

Mode of action of Kshara sutra :

Ksharsutra has both cutting & healing action. Kshara sutra works by 4 ways :

• Pressure necrosis
• Chemical cauterization by kshar (alkali)
• Sloughing of the tissue of the walls of the fistulous track
• Cutting provides adequate drainage. It leads to an easy debridement of unhealthy tissue and pus etc.
• Thus providing a cleaner base for the wound healing of the track. The Kshara-sutra is changed weekly so that an average pace of cutting of about 0.5-0.8 cm/week is maintained along with healing from behind. Finally the whole track is cut through and the fistula / pilonidal sinus gets healed up with minimal scarring and without any other major complication. Infection is not the only cause in fistula. The structure itself is a big cause of recurrence. As kshar-sutra totally distroys the unhealthy tissue & structure, there is no recurrence.

Pathya-Apathya ( Diet and routinely activities) :

From the day of Kshara sutra threading procedure, light diet is advised. Patient is also advised to take plenty of fluids, blend diet, green vegetables, salad and seasonal fruits. Avoid non veg , spicy and fermented food . Do not strain during defecation. Sitz bath is useful for cleaning. Take a walk at least 2 killometers per day

Caution :

Many patients wander here and there in search of any doctor or medicines to cure fistula & pilonidal sinus and often waste their time, money and energy by getting trapped in the misleading advertisements, quacks etc. Remember fistula & pilonidal sinus is curable by ksharsutra treatment. Most of the patients egnore this disease till they feel large abscess & severe pain. Advance medical surgeries & antibiotics don’t assure 100% cure at first surgery. Be aware of quacks and false claims’ advertisements like those of injection treatment, herbal treatment etc. seen commonly in media. Bengali, are also not genuine and legal treatments. They can harm your health and can lead to complications like anal incontinence.