Ano-Rectal Fistula is a common disease of anal canal and rectum. It affects gastrointestinal, skin and exocrine systems of all ages. The annoying symptoms are:
(a) tender firm lump which bursts out to purulent bloody discharge
(b) pain during and after defecation
(c) anal bleeding with possible fever.

It glooms one's pleasure and makes life miserable with cancerous phobia even as the complications superven. Most of the fistula cases originate spontaneous or secondarily from the anal crypts situated at the ano-rectal juncture or during protracted labour as in Ethiopian ladies (Addis Ababa Fistula Hospital). It is best defined as the "Inflammatory track with internal opening in the anal canal and external opening in the periaxal skin". The male/female ratio is about 5:1 and 75% of the cases are reported between 30 and 60 years of either sexes. The general causes of this condition are:
(a) constipation
(b) trauma
(c) haemorroids
(d) inflammatory bowel disease
(e) inadequate proctological managements
(f) sexual perversion
(g) extensive E. coli infection of the anal canal tear.

The case is generally diagnosed by gentle probing from the external opening to the internal ones. In complicated cases, fistulogram or ballon fistulogram or sigmoidoscopy is considered. Sphincteric, intersphincteric, trans-sphincteric, or extras-phincteric (SITE) fistula is ascertained from retrorectal tumors, carcinoma, crohn’s disease, rectovaginal or vesicovaginal conditions.

Fistulotomy, fistulectomy, and sphinterotomy are standard available proctological operations done under general or regional anaesthesia. Unfortunately, most of the post operative results are almost notorious due to their constant risks to sphincter function, stenosis and painful dressings and defecation. More cases of recurrences occur even from expert hands simply due to anatomy and physiology of the region. Low grade carcinoma may develop in long standing cases due to delay in wound healing.

Bhagandar, a tubular communication formed between anal canal and external surface of the skin is the Ayurvedic synonym to this disorder. The cause of this tube is due to vitiation of the apana vayu, responsible for the equilibrium of the tri-dosha of the pelvic region. Sushruta, father of modern surgery, has advocated five types of bhagandar. Vagbhatta has contributed three more varieties.

Kshara sutra happens to be an ayurvedic device for the management of fistula. It is prepared by impregnating linen suture with several coatings of:
(a) Euphorbia neriifolia latex
(b) Ash of achyranthus aspera
(c) Powder of curcuma longa.

The alkalinity of kshara sutra is 9.7 pH and the tensile strength of this thread is between 7 and 9 kg. Kshara sutra therapy technique is the time tested oriental procedure since vedic period. This technique is more reliable, safe, effective and simple for the benefit of patients with fistula disabilitTherapy Brief- Every detail of the patient’s activities, mode of transport, diet and bowel habits are recorded along with past surgical interventions. Any co-existent anaemia, hepatitis, amoebiasis and helminthic infestation are included under clinical survey. The fistulous track is determined by probing with pradhan’s probe under ice cube analgesia on lithotomy position. The track is primarily threaded with plain suture which is replaced by the alkaline thread after twenty four hours. Subsequent changes are done every week by rail road technique. The length of the thread is noted in cm. The healing is indicated from the decrease of the length of the thread. UCT, unit cutting time is the time taken to cut one cm of the length, which is one week in most of the cases. The number of sittings to cut the entire length of the track depend on age, sex, diet, physical activity and nature of the patient in general. Kshara sutra acts as a curette for the fibrous lining and slough. Curettage is due to proteolytic enzyme present in the thread and also because of the irritant action of the caustics. The chances of recurrence is almost nil because cutting and healing is simultaneous.ies.

Glittering actions of the alkaline thread and ninty eight percentage cure rates of this appealing therapy proved itself that kshara sutra therapy is an ideal procedure for every type of fistula-in-ano cases because
(a) it is safe without any adverse effects
(b) reliable to any patient associated with cardiac, respiratory or endocrine problems
(c) equally effective to any group of patients
(d) cost effective and non recurrent. Above all, this method has been supported by hundreds of clinical research reports from Nepal, India and Sri Lanka.

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