Frequency of Kshar Sutra Replacement in Fistula Track Healing
Weekly replacement of kshar sutra (medicated seton) is recommended for optimal healing of fistula tracks with an average cutting rate of approximately 1 cm per week.
Mechanism and Efficacy of Kshar Sutra
Kshar sutra is a medicated thread used in the management of fistula-in-ano, particularly for complex fistulae. The treatment involves:
- Initial placement of the kshar sutra through the fistula track
- Regular replacement of the thread to maintain its therapeutic effect
- Gradual cutting and healing of the fistula track simultaneously
Evidence for Weekly Replacement
Research demonstrates that weekly replacement of kshar sutra is the standard protocol for effective fistula management:
- Studies show that the average cutting rate is approximately 1 cm per week 1
- The mean cut-out time across patients is 8.3 weeks (range 3-18 weeks) 1
- Non-medicated setons do not show effective cutting action, highlighting the importance of the medicated kshar sutra 1
Treatment Duration and Healing Time
The total duration of treatment depends on:
- Length and complexity of the fistula track
- Patient's healing response
- Presence of secondary tracts or abscesses
A recent study using Transrectal Ultra Sonography (TRUS) to evaluate kshar sutra therapy found an average Unit Cutting Time and Healing (UCTH) of 7.86 days/cm 2. This provides objective evidence for the cutting and healing rate.
Monitoring and Follow-up Protocol
Regular follow-up is essential during kshar sutra therapy:
- Weekly assessment and replacement of the thread
- Monitoring for complications such as local induration or abscess formation
- Assessment of cutting rate and healing progress
- Continued follow-up for at least 6-12 months after treatment completion to monitor for recurrence
Comparative Efficacy and Outcomes
When compared to other treatment modalities for fistula-in-ano:
- Kshar sutra shows lower recurrence rates compared to conventional surgical techniques 3
- In a comparative study with LIFT procedure and fistulectomy, kshar sutra had higher recurrence rates at 6 months (30%) and 18 months (45%), though the difference was not statistically significant 4
- Postoperative pain may be higher with kshar sutra compared to LIFT procedure 4
Adjunctive Therapies
To enhance the efficacy of kshar sutra treatment, adjunctive therapies may include:
- Panchawalkala Kwatha (decoction of five medicinal plant's bark)
- Shatdhautaghrita
- Jatyaditaila
- Erandabhrishtaharitaki Churna 2
Complications and Management
Potential complications during kshar sutra therapy include:
- Anal discharge and burning pain in the first 48-72 hours (common) 1
- Local induration (approximately 15% of cases) 1
- Abscess formation (approximately 3.5% of cases) 1
Conclusion
Weekly replacement of kshar sutra is the standard protocol for fistula-in-ano treatment, with an average cutting rate of 1 cm per week. The complete healing time depends on the length and complexity of the fistula track, typically ranging from 3-18 weeks. Regular follow-up and appropriate adjunctive therapies can enhance outcomes and minimize complications.