Wound healing potential of Pañcavalkala formulations in a postfistulectomy wound.

Sushruta mentioned sixty measures for management of wounds. Panchavalkal is the combination of five herbs having properties like Shodhana (cleaning) and Ropana (healing) of wounds. Individual drugs and in combination have Kashaya rasa (astringent) dominant and useful in the management of Vrana (wounds) as well as Shotha (inflammations). A 35 years old male patient consulted in Shalya OPD with complaints like discharge per anum, induration and intermittent pain at perianal region since last five years. On inspection external opening was observed at anterior portion 1 O' clock position which was four centimeter away from anal verge. That case was diagnosed as Bhagandara (fistula-in-ano) and was treated with partial fistulectomy and application of Guggulu based Ksharasutra in the remaining tract. The big fistulectomy wound was treated with local application of Panchavalkal ointment daily and simultaneous change of Ksharasutra. The wound was assessed daily for pain, swelling, discharge, size, and shape. The wound healed completely within two and half month with normal scar having good tissue strength. This case demonstrated that post fistulectomy wound can be treated with Panchavalkal ointment.

INTRODUCTION

Suśruta has described bhagandara (fistula-in-ano) as one of the aṣṭamahagadas (eight major diseases) due to its recurrent nature.[1] It is clearly mentioned in Suśruta Saṃhitā that Bhagandara can be treated with chedana (i.e., fistulectomy: Excision of the fistulous tract) or kṣārasūtra in case of debilitated, weak, child or female patients.[2] Fistulectomy, fistulotomy, fistula plug and LIFT (Ligation of Inter-sphincteric Fistula Tract) techniques are the available options in modern surgery with their own limitations.[3] On other hand, surgery for fistula is associated with fear in the minds of patients because of recurrence and major complications such as faecal incontinence. Suśruta, the father of surgery, describes the application of kṣāra (alkaline ash) in nāḍivraṇa (sinus) and bhagandara (fistula-in-ano).[4] Later on, Cakrapāṇi and Bhāvamiśra detailed the preparation and application of kṣārasūtra in bhagandara (fistula-in-ano).[56]

In this case report, a patient suffering from fistula-in-ano at 1 O’ clock position, was treated with partial fistulectomy followed by kṣārasūtra applied in the remaining part of the tract. The wound formed after partial fistulectomy was treated with application of Pañcavalkala ointment which led to complete healing within two and half months.

Pañcavalkala ointment is a formulation made up of the bark of five trees viz. Vaṭa (Ficus bengalensis Linn), Udumbara (Ficus glomerata Roxb.), Aśvattha (Ficus religiosa Linn.), Pārīṣa/Pāriśa (Thespesia populenoides L.) and Plakṣa (Ficus lacor Buch-Ham.), having properties of śodhana (cleaning) and ropaṇa (healing) of wounds.[7] All five drugs have dominance of kaṣāya (astringent) rasa which is useful in management of śotha (inflammations) as well as vraṇa (wounds).

Pañcavalkala ointment was prepared under expert supervision. The ingredients of Pañcavalkala ointment are Pañcavalkala, siktha (Bee wax), tila tailam (Sesamum indicum oil).

Procedure

Pañcavalkala kvātha was prepared as per the general methodology of kvātha preparation.[8] Snehapāka (oil preparation) was made with Pañcavalkala kalka (paste), tila taila and Pañcavalkala kvātha (decoction) in the ratio of 1:4:16. After that, one fifth quantity siktha was added to the prepared oil and the ointment was prepared.[9] The ointment so prepared was packed in an airtight plastic container.

CASE REPORT

A 35 years old male patient of vātapittaja predominant prakṛti, suffering from bhagandara (Fistula-in ano), visited the outpatient clinic of Shalya Tantra, IPGT and RA Hospital, Jamnagar, Gujarat for treatment. He had the following characteristics: Thin build, dry skin, dry hair, unstable gait, and prominent vessel like characters which are indicative of vāta predominant prakṛti. Some pittaprakṛti dominant characters such as fair complexion, moles on skin, grey hair, reddish eyes and excess sweating were also observed. He had a non vegetarian and spicy diet and was working as a cook in a restaurant. The patient had complaints which included discharge per anum, indurations and intermittent pain at peri-anal region since the last 5 years. On inspection, an external opening was observed at 1 O’ clock in lithotomy position and 4 cm. away from the anal verge. The patient was admitted in Shalya male ward for kṣārasūtra treatment. The laboratory investigation for blood, urine, and stool were conducted and found within normal limits. Chest X-ray and USG of whole abdomen were done and no abnormal signs were detected.

After administration of spinal anesthesia (sadal block) painting and draping of peri-anal region was done in lithotomy position. After that, four-finger anal dilatation was performed by Lord's procedure. A big cavity was detected in posterior region of left side after insertion of diluted methylene blue dye in the external opening of fistulous tract. This cavity was laid open and partial fistulectomy was performed. Guggulu (Commiphoramukul) based kṣārasūtra was applied in the remaining part of the fistulous tract at 1 O’ clock position. A T-bandage was applied after packing the big wound with betadine soaked gauze pieces. Appropriate antibiotics and analgesics were given for the initial 3 days. Later on, adjuvant therapy was given as mentioned below till complete healing of the wound.

Avagāhasvedana (Hot sitz bath) of water mixed with Pañcavalkala kvātha twice a day throughout the treatment

Cleaning of wound with freshly prepared Pañcavalkala kvātha and dressing with Pañcavalkala ointment was done daily

Harītakī (Terminalia chebula) powder, 5 g, at bed time was prescribed in case of constipation

During the treatment, patient was advised a diet which included green vegetables, fruits, rice, roti (bread) and plenty of water. Patient was instructed not to consume non-vegetarian, spicy food, oily food, junk foods and alcohol. He was also advised to avoid long sitting and riding/travelling during the course of treatment.

RESULTS AND DISCUSSION

The wound size after partial fistulectomy was 10 × 4 × 3 cm. was full of slough and fibrosed tissue [Figure 1]. The initial length of applied kṣārasūtra in the remaining part of fistulous tract was 8 cm. The wound was cleaned with freshly prepared Pañcavalkala kvātha and dressing was done with Pañcavalkala ointment daily [Figure 2]. The kṣārasūtra was changed after every seven days till the cut through of tract with complete healing was achieved. The wound was observed for its size, slough, discharge, edges and margins. The wound was observed and assessed daily for healthy granulation tissue as well as wound healing promoted from base within 15 days [Figure 3]. The wound size was observed to be reduced with contracted margin and healthy granulation tissue [Figure 4]. The healing process continued with contraction of margins without any complications with simultaneous reduction of the kṣārasūtra length Figure 5. The wound healed completely with normal scar after two and a half month period [Figure 6].

Figure 1

Fistula-in-ano treated with partial fistulectomy and kṣārasūtra application

Figure 2

Pañcavalkala ointment applied

Figure 3

kṣārasūtra in situ and fistulotomy wound after 15 days

Figure 4

Wound status postoperative 1 month

Figure 5

Wound status after one and half months

Figure 6

Complete wound healing with normal scar after two and half months

In this study, Pañcavalkala kvātha was used for sitz bath and played important role in maintaining local hygiene, śodhana (cleaning) as well as ropaṇa (healing) of the fistulous wound.[1011] The wound was repeatedly cleaned with freshly prepared Pañcavalkala kvātha and Pañcavalkala ointment was applied daily. The Pañcavalkala ointment has soothing and antimicrobial activities. A previous study in wound healing with Pañcavalkala cream also showed encouraging results.[12] Hence, this ointment potentiates the healing process by preventing infection at the wound site. Though the peri-anal area is more prone to get infected by local sweating, hair follicle infection and feces, but in this case wound was healed without any complications due to the Pañcavalkala used in different forms such as sitz bath (with diluted Pañcavalkala decoction), cleaning (using concentrated Pañcavalkala decoction) and dressing (Pañcavalkala ointment).

CONCLUSION

This single case study demonstrates that bhagandara (fistula-in-ano) is healed after partial fistulectomy followed by kṣārasūtra application and by application of certain adjuvant therapies with Pañcavalkala ointment for śodhana as well as ropaṇa of the wound. This approach needs further investigation on a greater number of patients.

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Conflicts of interest

There are no conflicts of interest.