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Background
Complex fistula-in-ano is a challenging anorectal condition characterized by multiple tracts, high
fistulas, recurrent disease, and proximity to sphincter muscles. Conventional surgical approaches
risk sphincter damage, incontinence, and recurrence. Kshara Sutra Therapy (KST), an
Ayurvedic minimally invasive technique using medicated setons, has been recognized for decades
as an effective option for fistula management.
Objective
To review the evidence base for Kshara Sutra therapy in complex fistula-in-ano, discuss technical
innovations, and contextualize its mechanism and outcomes within both Ayurvedic and modern
surgical frameworks.
Methods
A narrative review was conducted using databases including PubMed, Google Scholar,
DHARA, AYUSH Research Portal, and key surgical journals. Traditional Ayurvedic texts
(Sushruta Samhita, Ashtanga Hridaya) and recent clinical trials, case series, and systematic
reviews were analyzed.
Results
Kshara Sutra therapy demonstrates high healing and low recurrence rates in complex fistulae
when compared to conventional fistulotomy/fistulectomy, particularly in high anal fistulas and
recurrent cases. Innovations such as modified setons (Guggulu/Triphala coated), preoperative
imaging guidance, and improved postoperative care have enhanced outcomes. Mechanistic
evidence suggests gradual chemical cauterization, fibrosis, and drainage as critical components
of healing.
Conclusion
Kshara Sutra therapy is a viable, sphincter-preserving approach for complex fistula-in-ano with
robust clinical evidence. Integrative surgical practice incorporating Kshara Sutra may reduce
morbidity and recurrence. Future directions include standardization and multicenter RCTs.

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