Introduction :

Kshara is a caustic chemical, alkaline in nature obtained from the ashes of medicinal plants. It is a milder procedure compared to surgery and thermal cautery. It is the superior most among the sharp and subsidiary instruments because of performing excision, incision and scraping.

Importance

It is versatile, because even such places that are difficult in approach by ordinary measures can be treated by Kshara Karma. It is more effective than the other modalities of treatment, because they can be administered both internally and externally. Kshara Karma is useful as the substitute of surgical instruments, because they can be used safely on the patients who are afraid of surgery.

Classification

On the basis of Administration –

Pratisaaraneeya Kshara – External application

Paneeya Kshara – Internal application

On the basis of Concentration –

Mild, Moderate and Highly

Method of Preparation of Pratisaraneeya Teekshana Kshara

Utility / Properties of Kshara

• Prepared Kshara, being a composite of many drugs, alleviates three doshas.
• Being white in colour it is plain.
• As it is made of drugs having pungent, hot, sharp, digestive property, it does cauterizing, digesting and splitting actions.
• If used in excess it can result in impotency.
• Externally it has: Cleansing, Heating, Absorbent and Scraping properties
• Internally it destroys: Worms, Amadosha, Kapha dosha, Skin diseases, Poison and Obesity.

Indications of Pratisaraneeya Teekshna Kshara –

• Internal Haemorrhoids
• After Fistulectomy
• Rectal prolapse
• After excision of pilonidal sinus
• After Incision and drainage of Anorectal abscess.

Application of Pratisaraneeya Kshara in Internal Piles

I. Pre-operative –

First the required instruments like Proctoscopes, Kshara, Lemon juice, Yastimadhu Taila, Allis tissue forceps, Artery forceps, etc. are kept ready with proper sterilization. The night prior to procedure, the patient is usually had light diet afterwards nil orally. The part is prepared well and gives soap water enema 2 to 4 hours prior to procedure.

II. Operative procedure –

The patient is in lithotomy position, the part is cleaned with aseptic solutions and draping was done after Local Anaesthesia / Spinal Anaesthesia. Lubricated Slit Proctoscope is to be introduced into the anus and internal piles bulges in. Then the pile mass should be rubbed and cleaned with cloth or a cotton swab with warm water. Then the Kshara applied over the pile mass and wait for 2 minutes or until the pile mass turns to the colour of Reddish black (Pakwa Jambu Phala Varna). After this process, the pile mass must be washed with Lemon juice to neutralize the Kshara after proper burning of piles. The same procedure should be followed in other piles also. Later the rectal pack with Yashtimadhu Taila is applied and bandaging was done and shifted to the postoperative ward.

III. Post operative

Patient is allowed to orally with sips of liquids and liquid diet after 4 to 6 hours of procedure. Later Patient is advised for Pancha Valkala Kwatha / Triphala Kwatha Sitz bath for 10- 15 minutes to relieve the pain and swelling. Triphala Guggulu & Gandhaka Rasayana 2 BDS for 10 days. Analgesics and Antibiotics if necessary. Histopathological examination of slough material in blackish brown discharge reveals the presence of necrosed haemorrhoidal tissue.

Mode of Action of Pratisaraneeya Kshara in Internal piles

Pratisaraneeya Kshara acts on haemorrhoids in two ways

(1)It cauterizes the pile mass directly because of its corrosive nature. (2) It coagulates protein in haemorrhoidal plexus. The coagulation of protein leads to disintegration of haemoglobin into haem and globin. Synergy of these actions results in decreasing the size of the pile mass. Further, necrosis of the tissue in the haemorrhoidal vein will occur. This necrosed tissue slough out as blackish brown discharge for 3 to 7 days. The haem present in the slough gives the discharge its colour. The tissue becomes fibrosed and scar formation seen. The haemorrhoidal vein obliterates permanently and there is no recurrence of haemorrhoids.

APPLICATION OF KSHARA IN INTERNAL HAEMORRHOIDS

Application of Pratisaraneeya Kshara in after fistulectomy

In small low anal fistulas, first excise the fistula tract followed by application of Kshara and wait for 2 minutes. Later neutralize with Lemon juice and pack with Yastimadhu Taila. It is helpful for quick healing and avoids recurrence of fistula tract.

In high level fistulas, excision of fistulous tract was done partially followed by application of Kshara. Later Kshara Sutra is applied in remaining fistulous tract at anal sphincteric area. The excised fistulous tract heals completely with help of Kshara and remaining fistulous tract was cut by Kshara Sutra ligation. So that patient can be cured at less time and pain.

In this technique, after excision of fistulous tract and applying Kshara, leads to debridement of the fibrous tissue and at the same time remaining wound will be healed by its Scraping and Healing property of Kshara. In the mean time the Kshara sutra ligation at sphincteric area of fistulous tract leads to cutting and debridement and drainage of fistulous tract at the same time preserving continence of anal canal.

Application of Pratisaraneeya Kshara in Rectal Prolapse

The patient is in lithotomy position, the part is cleaned with aseptic solutions and draping was done after Local Anaesthesia / Spinal Anaesthesia. Lubricated Slit Proctoscope is to be introduced and Kshara applied at lower most all around healthy mucosa of 3 cm area of anal canal and wait for 2 minutes or until it turns to the colour of Reddish black. After this process, the mucosa must be washed with Lemon juice to neutralize the Kshara after proper burning of mucosa. Later the rectal pack with Yashtimadhu Taila is applied and bandaging was done and shifted to the postoperative ward.

After Kshara application in rectal prolapse, the burned part heals and anal canal become fibrosed and narrowed. Then prolapse of rectum is stopped completely.

Application of Pratisaraneeya Kshara in Pilonidal Sinus

EXCISED PILONIDAL SINUS

Advantages of Kshara Therapy

• Postoperative pain is mild in intensity.
• No bleeding
• Minimum hospitalization – one day care
• No scope for recurrence
• No stricture formation (if correct procedure is followed)

Complications of Kshara Therapy

• Bleeding – Negligible
• Pain – Mild to moderate pain – relieved by hot sitz bath and oil enema.
• Discharge – Blackish brown discharge will be occur 5 to 7 days postoperatively.
• Anal stricture – Improper technique
• Recurrence – Improper technique