What is Kshar Sutra?
Kshar Sutra (KS) is an ancient Ayurvedic treatment used to successfully treat fistulas, first mentioned in Ayurvedic texts dating around 500BC.
KS is an interesting and effective technique whereby a medicated thread is inserted through the fistula tunnel using a malleable probe – NOT to be confused with setons!
The thread undergoes a specific process of coating 21 times. Ayurvedic medications are used, each of which play an important part in the healing process.
Unlike the setons placed at home, this one is changed frequently, a fresh thread is placed, and the medications do their thing. The general idea is to essentially train that fistula out of the body gently from the inside (see below for difference between KS and cutting seton. I’ve also included a video below to show the KS process). The thread is inserted through the tunnel and tied externally. As you move/walk and just in general, it is working internally to gently cut the fistula track, drain it and clean it, and the medications control any infection. As the scar tissue forms internally, it closes the track – leaving no tunnels – one of the reasons why the success rate is so high.
This is KS in simple terms, but of course it is far more intricate than that (see research paper – ‘Fistula in Ano and the vital role of Ayurveda inside and outside India’, and more information below). The number of thread changes varies from person to person, the frequency of visits to the doctor varies from person to person, the medications provided can vary from person to person.
Treatment takes into account the individuals unique mind/body type. The doctor monitors each persons progress, and moves forward based on their personal healing – both physically and mentally. As is the way of Ayurveda, which recognises we are all different.
Most importantly, the main goals of Kshar sutra is no recurrence and no incontinence.
My fistula began due to a fissure and through sheer bad luck an anal gland became infected (or perhaps now I can say it was good luck due to my incredible experience and ability to help others). Another common cause of fistulas is Crohn‘s disease. Whilst KS may be possible for Crohn‘s patients in remission, it may not be successful and fistulas may form again.
‘THE GOAL OF THE PHYSICIAN IS TO REPLACE THE FISTULAR TRACT WITH STRONG, SUPPLE AND PERMANENT SCAR TISSUE. WHEN KSHAR SUTRA IS DONE UNDER A WATCHFUL EYE, THE SCAR TISSUE THAT REPLACES THE FISTULA WILL CONTRACT ALONG WITH THE SPHINCTER, FULLY PRESERVING THE PATIENT’S CONTINENCE’
An animated visual of the process:
* At the 1minute 15 mark you will see the process of the fistula moving to the surface, leaving a superficial wound
THE DIFFERENCE BETWEEN KSHAR STURA AND A CUTTING SETON:
‘KS MOVES THROUGH THE MUSCLE ONLY AS QUICKLY AS THE TISSUE HEALS. THE MEDICINE ON THE THREAD BOTH CAUTERISES AND HEALS THE TISSUE BY USE OF CHEMICAL ACTION. CUTTING SETONS RELY ON MECHANICAL ACTION. THE RATE OF LIFELONG CONTINENCE AFTER KS IS CLOSE TO PERFECT
ANY PHYSICIAN RUSHING THE PROCESS BY TIGHTENING THE THREAD IN THE FISTULA TRACT AND RELYING ON MECHANICAL PRESSURE WILL RISK THE FUNCTIONING OF THE PATIENT’S SPHINCTER, THEREBY HAVING LITTLE ADVANTAGE OVER THE CUTTING SETON IN COMMON ALLOPATHIC USE
DISCERNMENT SHOULD BE USED WHEN SELECTING A PHYSICIAN TO PERFORM KSHAR SUTRA AS STRICT AYURVEDIC PRINCIPLES PROMISE THE BEST RESULTS’
Ksharasutra Therapy is an Ayurvedic Parasurgical Technique. Great Indian Surgeon Sushruta narrated in his teachings the use of Kshara for cure of fistula in ano and other anorectal diseases. The work of Sushruta was later compiled as “Sushrut Samhita” in the 5th century A.D. Acharya Chakrapani Datta (10-11 Century A.D.) and Acharya Bhav Mishra (16-18 century A.D.) have described in their classical Ayurvedic texts, the method of preparation and treatment of fistula in ano by use of Kshara Sutra (K.S.). It is being used for the successful treatment of Anorectal Diseases for over 5000 years.
In this technique, a specially prepared thread (Kshar Sutra) is used to cure diseases. Kshar Sutra acts by “Herbal Chemical Cauterisation” and removes the disease from the body.
How does Kshar Sutra Work?
1. The cut through of fistulous tract is effected by the pressure exerted on anorectal tissue by the moderately tight Kshar Sutra tied in the fistulous tract.
2. The presence of Kshar Sutra in the fistulous tract does not allow the cavity to close down from either ends and there is a continuous drainage of pus along the Kshar Sutra itself.
3. The Kshar Sutra slowly and gradually cuts through the fistulous tract from apex to the periphery. There is an ideal simultaneous cutting and healing of the tract and no pocket of pus is allowed to stay back.
4. The Kshara (Caustics) applied on the thread are anti-inflammatory, antislough agents and in addition, have property of chemical curetting. The Kshar Sutra remains in direct contact of the tract and therefore, it chemically curettes out the tract and sloughs out the epithelial lining, thereby allowing the fistulous tract to collapse and heal.
5. The Kshar Sutra, due to its antibacterial property, does not allow bacteria to multiply in its presence.
6. The pH of Kshar Sutra was towards the alkaline side and therefore it did not allow rectal pathogens to invade the cavity
7. Kshar Sutra totally destroys the unhealthy tissue & structure of the fistula, significantly lessening the chance of recurrence.
What are potential benefits of Kshar Sutra?
1. It is generally an out patient treatment.
2. Performed mostly under local anesthesia.
3. The recurrence is negligible after Ksharsutra ligation procedure.
4. Success rates are in the high 90’s (97% or more according to many sources).
5. Most important benefit of Kshar Sutra therapy over modern surgeries is that the muscles that supports 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.
The medicated thread
The thread undergoes a specific, meticulous process whereby it is coated in Ayurvedic medicines. 21 layers in total.
These medicines consist of:
Commiphora mukul/Guggulu – used for anti inflammatory and anti bacterial properties which aids in wound healing.
Kshara – used for anti-inflammatory and anti-microbial properties. The alkaline nature of Kshara cauterises dead tissue which aids in cutting the tract.
Curcuma longa/turmeric – minimises the reaction to caustics and aids in healing the tract.
The combination of these three herbal drugs are a unique formulation for cutting and healing fistulous tracts.
The process undertaken to create the thread is very specific and intricate. You can see information about it here: Thread preparation explained
A moving video created by patients whilst in Bangalore:
How long does treatment take?
Treatment duration varies from person to person for various reasons. Complexity, length, track location, underlying health conditions…to name a few.
My fistula took about 4.5 months to heal due to it’s complexity, but I was one of the longest standing patients at that time and had a couple of delays. The shortest treatment I witnessed occurred in 3 weeks and the longest in 5.5 months. The average treatment time for most patients I encountered was between 1-2 months.
Dr Bhat would provide his patients with a time frame in the initial phase, and in most instances this was accurate. Often treatment would finish earlier than expected, but occasionally there would be delays for whatever reason. This can be difficult for many patients, especially after leaving loved ones and employment.
Does it hurt?
Yes, there is pain at times. Fistulas are painful and the treatment is not an overnight fix. As for how frequent the pain is and the intensity – this once again depends on the individual.
Most report the first couple of weeks healing from the initial surgery as the most painful. Thread changes varied in severity. But overall, the pain would decrease relatively quickly. Most patients note that the extreme pain decreases between 20-60 minutes after thread change.
Interestingly, during my first couple of weeks, the main pain I was feeling was from the cut/wound on my butt. The internal pain was an ache and unpleasant, but the external one was cutting and worse. Plus movement makes it take longer to heal cause you really do use your butt far more than you realise.
When I first arrived in Bangalore, Dr Bhat completed a partial fistulotomy (no muscle is dissected) and inserted the first medicated thread. In most cases an epidural is used. For the initial 1-2 weeks I would attend the clinic daily to have the wound monitored and cleaned. Once the doctor deemed it ready, he completed the first thread change. The anticipation of the thread change was worse than the reality. The pain of the change was short lived. Definitely intense but short lived. Tensing or clenching during the change did amplify the pain, but I am yet to meet someone who isn’t tense through that process! Dr Bhat does utilise different methods of pain relief where needed (eg, external anaesthetic spray, internal numbing suppository, local anaesthetic).
From the moment I stepped into the clinic, I let Dr Bhat work his magic and went with the flow. I had full confidence in his skill and handed myself over to the treatment and happily accepted whatever amount of time would be needed.
I saw much trauma and fear from other patients, and this is completely understandable, but I was 100% confident I was doing the right thing and that any pain I felt was one step closer to being free. I knew that this pain signified healing. Having said that, I did have some very tough moments. Very. Mainly early on in the piece. It‘s a challenging treatment – but so is treatment at home. At least I knew that the struggle was going to end and never return…
‘NOTABLE FOR MANY PATIENTS IS THE SENSATION IN THE FISTULAR TRACT SWITCHING FROM A DISCOMFORT OF DISEASE TO A DISCOMFORT OF HEALING’
During treatment
During treatment, the doctor will provide appropriate Ayurvedic medications which can vary depending on the patient, and give instructions around wound care and diet.
Warm sitz baths are essential (not in the initial days after surgery, and not usually on the same day as a thread change). They will help alleviate pressure/discomfort/pain after bowel movements, as well as help clean the area. Bowel movements can be very painful depending on where the thread is situated, so where needed, a diet high in fiber will help minimise this.
It is highly recommended that the patient will have a diet that excludes spicy foods and meat. Meat can cause constipation and inflammation (last thing you want during treatment) and spicy foods can irritate the bowels and may cause diarrhea. (Also the last thing you want during treatment!).
Resting when needed is essential of course, but movement/walking is very helpful. It aids the thread in gently cleaning and cutting the track, as well as provides exercise which is great for obvious reasons.
Equal to all of these requirements is the mindset of the patient. There’s a reason Dr Bhat repeatedly tells his patient’s to ‘be happy’ or ‘don’t worry’. It’s not just small talk. It’s a psychological tactic used to aid or train the patient to actually be happy! This in turn aids in healing.
After treatment
It’s important to note that just because the fistula is dead, healing is still a long process.
Once the fistula has been trained out of the body, the patient is left with a superficial wound that will require care, often for months after. Cleanliness is essential and can be bothersome due to the location of the wound.
Once the wound is healed, the new scar tissue can form creases or crevices that can collect debris after a bowel movement. Extra care is needed when cleaning.
The scar tissue can take up to 12 months to mature. As the tissue development occurs, many experience itchiness, burning and moisture in the area in the first period after treatment. As well as possible surface swelling and sensations.
It’s also common for a patient to experience gas incontinence in the early stages of healing. It is recommended to do clenching exercises to assist in managing this.
Most patients report that these symptoms cease within the first year.
For me, I did experience gas incontinence which took 4-5 months to stop. I believe this would have ended sooner but I did not exercise the area enough. This gas would mainly occur when coughing, sneezing or laughing. I also have to spend additional time cleaning after bowel movements as my wound is quite large and squishy. This has now filled out considerably, but not completely (as I write this, it has been 10 months since I was declared fistula free).
It is in these immediate months following that patients experience doubt and fear around the treatment being successful. How could they not after the trauma experienced and failed surgeries at home? Thankfully I was aware of what to expect and was able to reassure myself whenever I felt glitches or pangs in the area. Many other patients I met were not as confident as myself and were only reassured months after, when these symptoms subsided. Trauma from a fistula can run very deep.
Dr Bhat remains available to this day for all of his patients.
On top of these symptoms, I also had to re-learn how to sit and walk properly as I had adapted my movements to accommodate the pain of the fistula. My knee hurt due to curling my leg under me when I sat, my posture suffered as I would lean forward to alleviate pressure from my butt, I had taken to walking slowly and with short steps…the fistula physically affected more than just my butt. I became so much more unfit than I already was.
Research paper
Special mention to Moira who has kindly shared her extremely helpful research paper to help others and allowed me to reference her work here.
A previous fistula fighter herself, Moira is an invaluable member of the Facebook support group Kshar Sutra for fistulas.
You can read her paper here (PDF link). A MUST read if considering KS:
FISTULA IN ANO AND THE VITAL ROLE OF AYURVEDA INSIDE AND OUTSIDE INDIA
Why isn’t Kshar Sutra available anywhere else?
There are many reasons I guess – mainly due to lack of research. In addition to that, the lack of acceptance of ‘alternative’ medicine. (I truly dislike the term ‘alternative medicine’ as, for me, it implies that anything outside of Western medicine is not the norm. With many successful systems of medicine in the world – most, if not all, outdating Western medicine – and with how complex we are as humans, how can anyone say there is only one ‘correct’ way? Ludicrous! Nonsense! Dr Bhat utilises both West and Ayurvedic medicine during his treatment which speaks volumes about him as a physician). I also think that there is a stigma around India due to it being a developing country….there are many reasons we can only assume at.
KS is a very specific skill that takes years and patience to master. Additionally, the frequent – sometimes daily – visits to the physician are difficult to access in the West. I saw Dr Bhat in Bangalore 101 times for my fistula. I cannot imagine having this much access in Australia, and can’t even begin to imagine the cost if it was available via specialists, even when compared to the total cost of travelling to India.
Pilonidal Sinus
KS is also utilised to treat Pilonidal Sinus. Below is a video of Dr Bhat explaining what Pilonidal Sinus is, and how the KS method is used to heal it.