KSHARA SUTRA IN FISTULA-IN-ANO: A REVIEW OF CLASSICAL BASIS, TECHNIQUE AND CLINICAL EVIDENCE
Background: Fistula-in-ano (Bhagandara) is a common anorectal condition with high recurrence and a risk of faecal incontinence after surgery. Kshara Sutra, a thread coated with alkaline and herbal preparations described by Sushruta, is a minimally invasive Ayurvedic seton technique that cuts and heals the fistula tract gradually. Objective: To review the classical basis, preparation and technique of Kshara Sutra and the clinical evidence comparing it with conventional surgery. Methods: Narrative review of Sushruta Samhita and of clinical trials, a meta-analysis and surgical guidelines identified through PubMed, Google Scholar and Indian databases. Results: Sushruta described the use of Kshara-coated thread for Nadi Vrana (sinus) and Bhagandara. The modern standardised Kshara Sutra, developed at Banaras Hindu University, is coated 21 times with Snuhi latex, Apamarga Kshara and Haridra. A multicentric randomised trial by the Indian Council of Medical Research reported lower recurrence with Kshara Sutra than with conventional surgery. In a Singapore trial, Kshara Sutra produced more early postoperative pain but similar healing and continence to fistulotomy. An Indian randomised trial found less severe pain, shorter hospital stay, earlier return to work and lower cost with Kshara Sutra, but longer healing time. A 2024 meta-analysis of seven studies reported high cure rates and negligible incontinence. Conclusion: Kshara Sutra is a safe, low-cost, sphincter-preserving option for fistula-in-ano, particularly for low and simple fistulas, with recurrence rates comparable to or lower than fistulotomy. Larger trials in complex fistulas, with standardised outcome reporting and long follow-up, are needed.
KEYWORDS: Kshara Sutra; Bhagandara; fistula-in-ano; seton; Apamarga Kshara; Snuhi; Sushruta; anorectal surgery