To evaluate the efficacy of Gomutra Ghan Sutra in the management of Bhagandara ( fistula-in-ano ) .

From the onset of civilization, the human being suffered from various diseases and among the many an uncomfortable condition, Bhagandara was the one of the most important one. Acharya Sushruta, paid great attention towards Bhagandara. Sushruta while dealing the management of the disease employed surgical, parasurgical measures. In this study, inspite of Standard Ksharsutra i.e. Apamarga Ksharsutra, Arka kshar is replaced by Gomutra ghan. Where, Gomutra Ghan acts as bio-enhancer, antifungal, anti-microbial, anti-bacterial.


AYURVEDIC REVIEW
The Bhagandara considered being one of the 'Ashtoumahagad' (maharog) by the acharyas of Ayurveda. So, they give much importance to its etio-pathogensis and management. It is commonly associated with symptoms like Bhagandarpidikotpatti (Boils at perianal region), Puyastrava (Pus discharge), Gudakandu (Itching at anal region), Gudavedana (Pain at anal region), etc.

AYURVEDIC REVIEW OF BHAGANDARA -Defination -
The daran of Bhaga, Guda and basti (tear in the area of pelvis, rectum and urinary bladder) with surrounding skin surface called Bhagandara. Further he has described that a deep rooted apakva pidika within two angula circumference of Guda Pradesh associated with pain and fever is called Bhagandara pidika. When it suppurates and burst open, is called Bhagandara.
The word 'Daran' means splitting, tearing, rending or making openings in the perianal skin. Hence, in the cases of Bhagandara there are symptoms like irritation, uneasiness and having discharging opening. Nidan / Aetiology -Nidan i.e. causes of bhagandara is mainly described by Acharya Vaghbhata as follows -Traveling on elephant, horses etc. sitting on hard seats and improper sitting posture, indulging factors causing arsha, apathya ahara-vihara, ill deeds of previous life and outranging of sages. Acharya Sushruta has considered separately the aetiology of bhagandara to each type in relation to the classification of the disease. Samprapti / Pathogenesis -No dosha singularly is able to produce the disease. The three doshas take part in development of Bhagandara. Rakta (blood) does not take part as a dosha in the formation of bhagandara. Acharya Vaghbhata has clearly told that bhaganadara is located about one to two fingers away from the anal margin within the rakta and mamsa dhatu.  Acharya Sushruta state that mamsa and shonita as the dushya for shatoponaka bhagandara and repeats the 'purvavadaawasthitaha' for the pathogenesis of other variety of bhagandara. (su. Ni. 4/6) Where, enumerating the inflammatory diseases, Acharya Sushruta has included vidradhi, pidaka, gudapaka and arsha in the category of which owe their origin to rakta. (Ref su. Su. 24/11). In the sharirsthana he also state that the site of bhagandara is mamsadhara kala. According to this data we can say that the vitiated Rakta and Mamsa dhatu produces Bhagandara. The vitiated Rakta burns the Mamsa dhatu and formed the abscess and further discharge also. In this whole procedure pakvawastha of Mamsa its daran occurs and hence abscess followed by nadivrana called bhagandara is produced.

Classification of Bhagandara -
From the text of the different samhitas it is clear that Acharya Sushruta has mentioned that there are five types of Bhagandara according to vata, pitta, kapha, sannipataj and agantuj. 1 Acharya Vaghbhata considered the Dwidoshaj types and mentioned the total eight types of the Bhagandara.
Three types are from the vatadi dosha, three from the dwandaj dosha and one from the agantuj.

SADHYASADHYATA -Opinion of Acharya Sushruta -
All the types of bhagandara are difficult to treat. The bhagandara which produce by combination of all doshas like shambukavarta and kshataja (unmargi) bhagandara are in curable.

BHAGANDARA CHIKITSA
According different acharyas from the ancient Ayurvedic classics the treatment of bhagandara mentioned on the basis of stage of the disease (i.e. Pakwa and Apakwa) and according to the type of bhagandara.

CURATIVE MEASURE
If apakwa pidaka is not treated in the earlier stage it gets suppurated and turns into Bhagandara. Then the curative treatment should be done. There is various types of the curative treatment is described various acharyas for same. These are described under four headings as follows -

D) PARA SURGICAL TREATMENT Acharya Chakradatta mentions Kshar karma (chemical cauterization)
It is associated with the surgical intervention and is used to achieve haemostasis and in whom the surgery is contraindicated like weak, timid and emaciated.

APPLICATION OF KSHARASUTRA IN BHAGANDARA MATERIALS AND METHODS
Ksharsutra therapy has been found very effective in the management of fistula-in-ano has been reported by a team of surgeon at the BHU headed by Dr. P.J.Deshpande. They standardized it in the present form.
Though ksharsutra treatment has been found very effective in the management of fistula-in-ano, but major problem involved in ksharsutra treatment is, its prolonged duration of wound healing associated with itching, pain and excess amount of purulent discharge.
The preparation of Apamarga kshar for standard Apamarga ksharsutra preparation is time consuming method and not so easily available as compare to availability and preparation of Gomutra Ghan powder. CRITERIA FOR SELECTION -INCLUSION CRITERIA -1) Patients between the age group of 20 yrs. to 60 yrs. were selected Irrespective of sex, religion.
2) Diagnosed cases of low-level fistula-in-ano were selected. 3

PLAN OF STUDY -NO. OF PATIENT SELECTED FOR STUDY
To conduct these study 60 patients of fistula-in-ano were selected from OPD and IPD of our Ayurved college hospital randomly.

GROUPS OF PATIENT
Selected patients were divided into 2 groups. 30 patients were in each group. GROUP -A -Treated by Gomutra Ghan sutra GROUP -B -Treated by Standard Apamarga Ksharsutra.
The threads were changed at weekly interval. And orally Triphala Guggulu 500 mg tablet twice a day. The duration of treatment along with oral medication i.e. Triphala Guggulu was till the track completely cut through and heals for both groups with anupana luke warm water. Maximum duration for each case was 12 weeks.
The detailed information of patients like history, Investigation and progress was noted in a standard proforma prepared in the department. The threading was done in operation theater as well as in OPD by standard technique under Local or General anaesthesia.

PREPARATION
OF GOMUTRA GHANSUTRA

KSHARSUTRA -
The Ksharsutra treatment and technique is derived from ancient Ayurvedic literature and then it was modified on the basis of a number of experiments and trials. Chakrapanidatta is the authorative commentator of ksharsutra prepared by smearing the Snuhikshira and Haridra powder repeatedly on a thread.

PREPARATION
The initial track length as well as the length of Ksharsutra at each successive changed was measured and recorded. The gradually shortening of the thread after each successive changed corresponds to cut the tissue, which provided an idea of the progress of a particular case.
U.C.T. = U.C.T. indicates the average time in days taken to cut through 1 cm of fistulous track. Unit of unit cutting time is days per cm. Here the cutting time not only indicates the cutting rate of the track but also it covers healing status.

OBSERVATIONS: UNIT REDUCTION IN PAIN (GRADES/WEEK) Group -A
Group -B Sr. No.

Grade Weeks Grades per week
Sr.

STATISTICAL ANALYSIS
The observations with respect to objective and subjective symptoms were recorded before treatment and after the complete cut throughout the fistulous track. For comparative study of subjective and objective parameters of these 2 groups un-paired 't' test is applied. For pain, itching, Discharge and Local tenderness 4 -Grades scale is used. According to severity of symptoms the score 30 is given to most severe, 20 for moderate, 10 for mild and 0 for absence of symptoms. Note -For large sample, 't' distribution tends to normal distribution. 1. Pain -