NT2 - Case series presentation of a medicated Cutting Seton (Ksharasutra) in the management of Fistula in Ano

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Purpose/Background: Fistula in Ano is a commonly encountered condition requiring surgical intervention, which may have varied outcomes with high degree of recurrence and complications commonly, incontinence. Traditional Ayurveda system of medicine mentions this condition as Bhagandara and suggests effective methods for its treatment including Kshaar Sutra (medicated alkaline surgical thread). The primary aim of management is to eradicate fistula without disturbing or minimally disturbing the anal sphincter mechanism.


Objective: The objective of this study is to present results of case series of Fistula in Ano (Perianal) patients managed with Ksharasutra over the last 15 years.

Methods/Interventions: A total of 751 surgical cases managed with the use of Ksharasutra over the last 15 years (2009-2024) were assessed primarily for relapse, incontinence and UCT (Unit cutting time). The procedure involves cleaning of the area followed by insertion of eye probe through the external fistula opening (or creating one) to place the Ksharasutra and tied it end to end. Partial fistulectomy is done in cases of large fistula. Changing of the Ksharasutra was done at weekly intervals till complete excision and healing. All participants were followed regularly for 12 months and again were called telephonically every year for the next 5 years.

Results/Outcomes: A total of 601 males (80.02%) and 150 females (19.98%) between the age of 5-80 years (mean age 40.21 ±10.28 years) suffering from Fistula in Ano for an average duration of 7.56 ±4.23 months were considered for assessment. 11 patients had fistula due to tuberculosis while 3 patients had Crohn’s disease and 15 patients had PNS. There were 85.08% fistulas with single opening, while 14.92% had more than one opening. The average length of the fistula tract was 5.65-±3.21 cm. There were 10.50% Inter sphincteric fistulas, 50.25% trans sphincteric, 36.25% low and 3% high. Blind external fistula constituted 7.98 % and 92.01 % had external opening. Fistula treated with Ksharasutra healed within the period 70.98 ± 15.92 days. With regards to UCT the average UCT was observed to be 8.75 ±2.90 days. UCT was observed to be high in operated cases while it was low in non-operated cases. UCT also varied in the type of fistula with the lowest in low anal type. Relapse of fistula was observed in 1.99 % (15 cases) while incontinence was observed in only 2.50% of patients of which 60% got resolved within the 3.10 ± 1.32 months and the others resolved in 6.50 ± 2.32 months. UCT was observed to be 7.05 days. 5 patients dropped out of the study due to non-responsive treatment.

Conclusion/Discussion: The study concludes that Kshaarsutra method using medicated Cutting Setone helps in faster recovery with minimal complications of incontinence and recurrence rates.

Key-Words: Kasharasutra, Fistula in Ano