International Surgery Journal

Akhtar M et al. Int Surg J. 2017 Feb;4(2):834-837

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20170247
Case Report

Kshar sutra in Pilonidal sinus: a minimal invasive modality of

management
Murtaza Akhtar*, Himanshu Gupta, Sunil Mishra,
Murtuza Rangwala, Anil Kad

Department of Surgery, NKPSIMS and LMH, Hingna Road, Nagpur, Maharashtra, India

Received: 04 November 2016

Accepted: 03 December 2016

*Correspondence:
Dr. Murtaza Akhtar,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Pilonidal sinus is an infective condition between the natal cleft in young males. Chronic Pilonidal disease normally
needs a surgical treatment for eradication of septic focus, which ranges from cutting of the tract to complex rotation
flap. Kshar sutra is an age old treatment modality practiced since times of Sushruta. Lack of established evidence in
the evidence based scenario is the rationale for current study. It is a tertiary care hospital based case series with
inclusion criteria of pain and discharge in and around the natal cleft. Clinically diagnosed as Pilonidal sinus with two
openings one in natal cleft and other outside the natal cleft. The patients with multiple sinuses, previous treatment and
co-morbid conditions are excluded. The study factor was of Kshar sutra threading of Pilonidal Sinus done under local
infiltration of anaesthesia around the tract and changed 2-3 times during entire treatment period on clinical judgement.
The outcome factors were duration of cutting open of tract and duration for total healing, number of times Kshar sutra
was changed and local complications. A total of 5 cases, all males with median age of 21 years and median
presentation duration of 8 months were recruited. The median cutting duration of the tract was 23 days and total tract
healing time was 29 days. Kshar sutra was changed 2-3 times during the entire duration of treatment. There was no
post-operative complication and recurrence after 20.4 months of follow up. Kshar sutra is a minimal invasive
procedure in Pilonidal sinus which has encouraging results but need large sample and an RCT to provide quality
evidence.

Keywords: Kshar sutra, Medicated seton, Pilonidal sinus

INTRODUCTION injection, lancing, excision of tract and complex

rotational flap. All these modalities have post-operative
Pilonidal sinus occurs in the natal cleft (cleavage between morbidities and recurrence hence need for finding an
buttocks) causing discomfort, embarrassment and alternative management modality. Kshar sutra
absentia from work in young hairy men. It is the chronic (Medicated Seton) was advocated by Sushruta for
Pilonidal disease which needs an eradicative surgery management of Pilonidal sinus in Sushrut Samhita (a
aimed at eliminating the disease process, which is treatise of Indian medicine).1
acceptable to patient with no complications, recurrence
and early resumption of normal work and social There are occasional case reports to indicate usefulness of
activities. The management option varies from phenol Kshar sutra mainly published in Ayurveda Journals. The

International Surgery Journal | February 2017 | Vol 4 | Issue 2 Page 834

 Akhtar M et al. Int Surg J. 2017 Feb;4(2):834-837

use of Seton therapy in Pilonidal sinus is not available in

allopathic literature. The study presents the results of a
small case series in a specifically selected group of
patients of Pilonidal sinus.

CASE REPORT

This is a case series from a tertiary care Allopathic

teaching hospital. The patient selection criteria was a
discharging sinus in and around natal cleft with only two
openings, one in the cleft or in the midline and other by
the side of the cleft, giving history of repeated infections
and clinically diagnosed as Pilonidal sinus and not treated
by any surgical modalities in the past. The exclusion Figure 3: Knotting of the thread.
criteria was the patient with multiple sinus, previously
treated, with co morbid conditions like DM,TB and
immune compromised patients. The study factor was
introduction of Kshar sutra under local anaesthesia after
thoroughly cleaning the tract with H2O2 and saline. By
using a malleable copper probe (Figure 1, 2) a Kshar
sutra was introduced, followed by ligation of suture
without tension (non- cutting seton) (Figure 3). The
outcome factors were duration of cutting open of tract
(Figure 4) and total duration of healing, number of times
Kshar sutra changed and post threading complications.

Figure 4: Post procedure image after 1 week.

Figure 1: Probing of the Pilonidal sinus tract.

Figure 5: Case no 4 before procedure.

Figure 2: Threading of the sinus tract. Figure 6: Case no 4 post procedure showing healed
tract.

International Surgery Journal | February 2017 | Vol 4 | Issue 2 Page 835

 Akhtar M et al. Int Surg J. 2017 Feb;4(2):834-837

Total of 5 cases fulfilling the inclusion criteria were was 23 days and total healing time was 29 days. The
recruited over 3 years’ time. All of them were males and number of times Kshar sutra was changed was 2-3 during
with median age of 21 years. The median duration of total duration of management. The recurrence rates were
presentation with the sinus was 8 months (range 1 to 27 nil after 19 months of median follow-up (Table 1).
months).The median duration of cutting open of the tract

Table 1: Demographic factors, clinical details and outcome factors.

Duration of No. Of times Days for cut

Age (years)/ Total healing Follow up
Patient presentation change of open of tract
gender (days) (months)
(months) thread (days)
Case 1 21/M 12 3 37 46 19
Case 2 32/M 8 2 23 29 21
Case 3 17/M 6 2 20 25 17
Case 4 21/M 1 2 18 23 9
Case 5 29/M 27 3 29 32 36
Median 24 8 2 23 29 20.4

DISCUSSION could be introduced in patient with multiple ramifications

in future studies.
Chronic pilonidal disease presents with pain and
discharge around the natal cleft with single or multiple In present study only 5 cases which fulfilled the selection
openings associated with hairs or debris which is criteria were included. The mean cutting open and final
commonly addressed as Pilonidal sinus even if it has 2 or healing time was between 3 to 6 weeks respectively
more opening. Use of Kshar sutra (Medicated Seton) is suggesting slow cutting and gradual healing by fibrosis.
well documented in fistula in ano but its use in Pilonidal The change of Seton gave adequate opportunity to
sinus is predominantly followed in Ayurveda and irrigate the tract and remove residual debris and hairs
available literature is sparse.1-4 The Sushrut Samhita which was done 2 to 3 times depending upon the length
describes a condition called as ‘Shalayaj Nadi Varan” of tract based on clinical judgment.
which is similar to Pilonidal sinus and advocated the use
of Kshar sutra for its management. Kshar sutra is a No complication like severe pain in post-operative phase
medicated seton coated with herbal alkaline drugs like and no recurrence with follow-up of more than 2 years.
Apamarga ( Kshar) ( ash of achyranthus ascera), snuhi As the Seton was not tightly ligated in our patient’s post-
(euphorbia neurofolia) Latex and Haridra ( curcuma operative pain due to cutting effect was not observed.
longa). This medicated seton helps in debridement and Only drawback of present study is study design, which
lysis of tissues with antibacterial, anti-fungal and anti- was observational case series and its sample size is small
inflammatory action. There is lack of any quality due to stringent inclusion criteria, so also the references
evidence in literature due to rarity of condition and lack from the literature are few for comparing the results.
of publications of research work by Ayurveda surgeons. Hence there is a need for more studies with large sample
size.
The surgical principle of this Kshar sutra in Pilonidal
sinus is similar to Seton used in fistula in ano but its only CONCLUSION
requirement is the presence of single tract, at least with
two openings to allow threading of Kshar sutra which Kshar sutra as a modality could be a minimal invasive
works by cutting the tract by chemical cauterization and procedure done under local anaesthesia as outpatient or
mechanical strangulation along with through drainage of day care procedure without any side effects and
the tract.3 This process is slow and lasts for weeks and complications with good healing potential in selected
simultaneously producing fibrosis of the cut sides of the group of patients. Kshar sutra being laced with antibiotics
tract finally cutting through and laying open the tract and anti-inflammatory properties also minimizes the uses
similar to lancing which gradually granulates and heal. of antibiotics and analgesics.
The study selected single tract patients that are why the
validity of study is limited and it is a drawback of the ACKNOWLEDGEMENTS
study. Use of MRI or soft tissue sonography after
injection of H2O2 might helpful in identification of tract Authors would like to thanks Dr. Kajal Mitra, Dean
for confirmation of single tract. Multiple Kshar sutras NKPSIMS and VSPMAHE for their kind permission to
publish this research.

International Surgery Journal | February 2017 | Vol 4 | Issue 2 Page 836

 Akhtar M et al. Int Surg J. 2017 Feb;4(2):834-837

Funding: No funding sources 3. Ho KS, Tsang C, Seon-Choen F, Ho YH, Tang CL.

Conflict of interest: None declared Prospective randomised trial comparing Ayurvedic
Ethical approval: The study was approved by the cutting seton and fistulotomy for low fistula in ano.
institutional ethics committee Tech Coloproctol. 2001;5:137-41.
4. Upadhya S, Shankar S, Shailaja SV. Kshara Sutra
REFERENCES therapy a boon for pilonidal sinus: a case study.
Inter J Ayurved Med IAMJ. 2015;3(7);(ISSN 2320
1. Trikumji VJ. Editor Sushrut Samhita of Sushrut 5091).
with the Nibandh sangraha commentary of Shree
Dalhanacharya. Varanasi: Publisher Chaukhambha
Surbharti Prakashan; Nidan Sthan, Chapter; Cite this article as: Akhtar M, Gupta H, Mishra S,
2003:307-8. Rangwala M, Kad A. Kshar sutra in Pilonidal sinus: a
2. Krishna G, Kumar PH. Effect of Madhu Kshara minimal invasive modality of management. Int Surg J
Sutra in the management of Bhagandara (Fistula-in- 2017;4:834-7.
ano). Inter J Ayurved Med. 2013;4(3):237-41.

International Surgery Journal | February 2017 | Vol 4 | Issue 2 Page 837