KSHARASUTRA APPLICATION IN PILONIDAL SINUS – A CASE STUDY

Pilonidal sinus is a common disease of the natal cleft in the sacrococcygeal region with weak hair accumulation occurring in the hair follicles, which can be chronic and undergo acute exacerbation. The patient presents with the complaints, which are characteristics of inflammation-a painful swelling, redness, local temperature raised or with a sinus discharge. Prolong sitting, presence of deepnatal cleft, obesity, repeated irritation due to hair, family historymay increase the risk of disease. In Ayurvedic science Pilonidal sinus is better correlated and treated as the Nadi vrana . Acharya Sushruta mentioned eight types of sinuses as nadivarna. Among these, pilonidal sinus canbe considered under shalyaj nadivrana (sinus due to foregion body) and He had explained Shastra Chikitsa with the intervention of kshar sutra as one of the treatment for Nadi vrana ( sinuses). A case of pilonidal sinus in 32y/m patient was thoroughly examined and treated with ksharsutra therapy. Tuft (bulk) of hairs were expled out during procedure. Ksharsutra is ideal procedure to be adopted for the management of sinus track for not only it destroys the fibrous wall of track but also helps in its curettage. In this study elicits a case report of a pilonidal sinus treated by the intervention of kshar sutra , which cured and No recurrence or No any complain were found in the patient during follow up.


INTRODUCTION
Pilonidal means nest of hair & is derived from the Latin words for hair (pilus) and nest (nidus). [1] The condition was first described by Herbert Mayo in 1833. [2] R.M. Hodges was the first to use the phrase Pilonidal cyst to describe the condition in 1880. [3] The incidence of Pilonidal sinus is approximately 26 / 100,000, [4] it is a benign disease that occurs in young adults in the age group of 15-30 years after puberty when sex hormones are known to affect pilosebaceous glands & change healthy body hair growth. [5] A Pilonidal sinus is a cyst or abscess near or on the natal cleft of the buttocks that often contains hair & skin debris. A Pilonidal sinus is usually painful but without draining, the patient might not feel pain. The etiology and pathogenesis of Pilonidal sinus are not clear although the disease is thought to be related to the accumulation of weak and lifeless hair in the intergluteal region. Over time, foreign body reaction occurs, causing abscess and sinus formation. Obesity, trauma, local irritation and a sedentary life style are usually associated with pilonidal sinus. However collection of the lifeless hair depends on the anatomy of the intergluteal area and accompanying risk factors can lead to inadequate surgery and subsequent recurrence. The management of Pilonidal sinus is variable, contentious and problematic. A principle of treatment requires eradication of the sinus tract, complete healing & prevention of reoccurrence. Several techniques such as cryosurgery, Z-plasty procedure, lancing under local anesthesia, vaccum assisted closure, excision with secondary healing, excision with primary closure, local flap surgery & Boscem procedure have been described by various authors. In Ayurveda texts, no direct reference to Pilonidal sinus as a disease entity is found. However, Acharya Sushruta had described that hair can be a root cause [6] for the formation of a sinus, and also mentioned various methods of management including agnikarma and kshar sutra. [7] Ayurvedic view about sinus and ksharasutra In Ayurvedicscience Acharya Sushruta described sinuses under the heading of nadivarna along with their symptoms and management. According to Sushruta the irresponsible person who mistakes a suppurated inflammation for an unripe one,ignore a suppurated one, or when patient allows a lot of pus to accumulate in an ulcer, then that pus having entered into his aforesaid tissues (i.e. skin, subcutaneous tissue, muscle), penetrates inside. [8] Beause of copious flow, it is known as "gait" (track) and as it flows like a drain, it is opened as "nadi" (sinus). That is caused by a combinedaction of the three dosas (vata, pitta, kapha) or due to each one of them separately and also due to two together only. The other are due to shalya (foreign bodies) such as hair, straw, wood pieces, stones, dust particles, bone pieces ets. [9] So thease are eight types of nadi (sinus) are told, among these pilonidal sinus can be considered to shalya nimitta nadi (foreign body sinus). According to Acharya Sushruta a surgeon should excise a sinus by means of a sutra (thread) impregnated with caustic (alkali) material (kshar-sutra) occurring in the emaciated,the weak and the timid and those (sinuses)which occur at the vulnerable areas. [10] Kshara is a caustic material obtained after processing from the ashes of various medicinal plants.The kshara are superior to sharp instruments and their subdtitutes because of their capability to perform excision, incision and scrapining,because of their c power to alleviate all the three dosas. [11] These caustic material are called kshara due to its capability of melting and destroying the lesion. [12] So kshara are not only cause the destruction (lysis) of unhealthy tissue but also help in their debridement. Hence this is an ideal procedure tobe adopted for the management of sinus track as it not only destroy the fibrous wall of track as it not only destroys the fibrous wall of track but help in its curettage. There is simultaneous cutting and healing of the tract and no pocket of pus is allowed to stay back. [13] Thus it provides an environment for healthy granulation tossue to develop providing an avenue for nadivrana(sinuses) to heal completely. Further application of ksharsutra was described by a probe. A ksharsutra was described by Sushruta as direction of the sinus should first be ascertained into the track and brought out from the other end with the help of probe.The two ends of the thread should be firmly tied together. Anather ksharsutra should adopt a similar procedure in case fistula-in-ano. [14] Properties of Kshara: [15] Rasa

Prepration of Ksharastra
The Barbour"s surgical linen thread no.20 is tied on a hanger. Freshly collected latex of snuhi (Euphorbia nerifolia) is soaked in gauze piece and smeared over the thread. Once the thread is soaked with latex, the hanger is placed in a drying cabinet at a temperature of 40 0 C for a period of 6 hours. The process is repeatedly done for 11 times to achieve desire quantity of latex to adhere on the thread. The above thread is again smeared with latex and passed through fine power of anhydrous apamarga (Achyranthus aspara) kshar and placed in the cabinet. The process is repeated for 7 times. Similarly the above thread was smeared with fine powder of haridra (curcuma longa), the procedure is done foe 3times. Thus total number of coating is done for 21 times.

H/O PRESENT ILLNESS
Patient was apparently alright before 2 month.Then he had developes recurrent boil with intermittent discharge between the buttocks from last 1-2 months. He also complained of mild pain and itching over boil, and discomfort after prolonged sitting. Than above complaints occours suddenly. He had taken analgesics for it, but didn"t get relief. Therefore for further treatment he came in OPD of Shalyatanra, Sumitabhai Shah Ayurved Mahavidhalaya, Malwadi, Hadapser, Pune.

LOCAL EXAMINATION
In prone position of patient, the findings were:patient was hairy andhaving a small sinus opening near sacrococcygeal region with seropurulant-puss discharge through opening swelling (mild), tenderness ++, foul smell and hair projecting from the opening. At palpation a cord like indurated structure was felt at external opening to gluteal cleft. Probing was done from external opening to accessed branching and extention of track. About 4 cm tract was found during probing midglutial cleft. Secondary examination done in lithotomy position to acess any anal pathology or any anal connection. It is also important to perform a through anorectal examinationto evaluate for concomitant fistulous disease, crohn`s disease, or other anorectal pathology. [9] In that patient perianal skin was normal no dermatitis, no any external opening was present nearby anal verge, no sentenal tag, no prolapsed pile mass and no external pilewere found. At digital rectal examination no anyinduration, tendar point, pit, fissure bed, haemorrhoid mass or any pathology was found. By complet through examination the diagnosis was confirmed as pilonidal CHIKITSA: All routine investigation were ruled out, CBC, Hb, blood sugar, serum creatinine, CT,BT,ECG, were with in normal limit and HBsAG, HIV were non reactive to the patient. All situations about disease and its management were explained to the patient and finally it was planned for ksharsytra therapy under local anaesthesia as per day care procedure.

KSHARSUTRA APPLICATION Pre operative prepration
Local part preparation, 5gm Haritaki churna (Termanilia chebulata) with koshna jala were given to the patient at night before operation. Sope-water enema was given at early morning on day to be operated. After proper bowel clean up patient was taken to recovery room and injection T.T. 0.5ml IM was given and plane xylocaine 2% was given intradermal for sensitivity test.
Oprerative procedure Patient was taken in prone position on operation theatre table. After proper cleaning and drappinglocal anaesthesia with 2% xylocaine was infiltrate nearby opening and in gluteal cleft ( Figure 3). Reaccessmentof extention of tract was done by probining. There was a 1cm upword and 3cm downword track seen. Hairs and unhealthy granulation tissue was removed through the opening on skin (Figure 4). The opening of the skin was incisedto upword as the scoop can go inside and tract was cleaned withbetadine and normal saline. Probing done through opening and tract traced till its blind end and another opening was made over the skin up to the tip of the probe ( Figure 5). Probe removed through another opening after feeding of kshar sutra and kshar sutra ligated appropriately ( Figure 6). Heamostasis achived and tight bandegining was done. Broad spectrum antibiotics, analgesics, Ayurvedic drugs, Hot sitz bath given. Patient was discharged from hospital on next day after operation.

DISCUSSION
According to Ayurveda the action of kshar sutra is thought to be due to its healing and cleansing effect in the area where it is applied. The kshar sutra acted as good drainage for the wound. Kshar sutra have alkaline pH so it posses desloughing property. Collectively kshar sutra acts as simultaneous cutting and healing procedure. So the healing was good because no collection remain in the wound site. The pain after ligation of kshar sutra was bearable as the patient, who is working had not taken a break for this reason. So this is ambulatory method and patient need not take a leave for long period. No side effects or complications were noted during the study. After cut through of the tract, healing of the wound site is done properly & recurrence is not noted.

CONCLUSION
In ancient time Acharya Sushruta mention Kshar sutra therapy in Nadivrana chikitsa. In this case study Minimum tissue loss is seen in comparison to the other surgery. Minimal bleeding occurs & there is no need to put huge dressings.we also seen Kshar sutra is very efficient method for Pilonidal sinus. There was no post operative complication and there is no recurrence and any othercomplaints. The surgical treatment of Pilonidal sinus has many drawbacks including pain in sitting and recurrence but use of ksharasutra has good potential in the management of Pilonidal sinus. Ksharasutra helps in the debridement and lysis of tissues, and also exerts antibacterial and antifungal activities (it causes both cutting and healing actions). So we can conclude that in the management of Pilonidal sinus the use of ksharasutra minimizes the rate of complications and recurrence, and enables the patient to resume work and normal social activities very early.