Basic concept of TST (Tissue Selecting Technique) 2nd SERAF. Feb.25.2017 Basic concept of TST (Tissue Selecting Technique) HyeonKeun SHIN, M.D. Dept. of colorectal surgery Yang Hospital, Seoul

PPH procedure Good Bad 1. Less pain 2. Shorter operative time 3. Early recovery 1. Resection of unneceessary mucosa 2. Damage to normal anal physiologic function 3. Higher recurrence

Complications 1. Stricture : 1.6~22% 1) anastomotic dehescence 2) fibrosis d/t infection 3) low staple line 2. Passage disturbance 3. Fecal urgency → need to be improved

TST (tissue selective therapy) to inherit the merits of PPH to overcome the shortcomings of PPH  segmental stapled hemorrhoidopexy

Indication Indication : grade III – IV hemorrhoids 1) partial hemorrhoids 2) circular hemorrhoids

DAOTM unit Dilator Anoscope Obturator - exposes target tissue - clear visualization

Procedure of TST

Selection of the pile

Purse string suture

PPHplus(33mm)

Mucosal bridge & dog ear ends

specimen PPH TST

PPH TST

Preop. Postop.

What is different from PPH? 1. point of purse-string suture 2. depth of purse-string suture 3. mucosal bridges and dog-ear ends

1. Height of purse-string suture point of purse-string suture 1) PPH : 1 - 2cm above the apex of pile (3-4 cm above the dentate line, this can be changed according to the Pt. : 1st Korean consensus meeting) 2) TST : 0.5 - 1cm above the apex of pile stapled hemorrhoidopexy ? stapled hemorrhoidectomy ?

1. higher point of purse-string suture ( > 1cm above the apex of a pile)  stapled hemorrhoidopexy  recurrence 2. lower point of purse-string suture ( < 1cm above the apex of a pile)  stapled hemorrhoidectomy  bleeding, pain

2. dept of purse-string suture 1. only mucosa and submucosa 2. muscle involvement ? “PPH Procedure for Hemorrhoids is always a mucosectomy.”

percentage of specimen with muscle

“…the absence of muscle tissue in the resected specimen Colorectal Dis. 2012 “…the absence of muscle tissue in the resected specimen is an independent predictor of postoperative persistence of hemorrhoids prolapse”.

3. Mucosal bridge & dog ear Bleeding control with suture at each dog-ear ends

Surg Today. 2011

Tech Coloproctol. 2012 TST(n=34) PPH(n=38) p Op. time (min) 17 (8-25) 16 (8-25) Postop.pain (VAS) 2 4 During first defecation 0.001 Fecal urgency 4(11.8%) 13(34.2%) 12h 0.025 5(14.7%) 15(39.5%) Day 1 0.019 12(31.6%) Day 7 0.043 Gas incontinence 0 % 7.9% 0.242 Postop. Stenosis 2.6% 2 years 1.0 Recurrence rate 2.9% (1/34) 5.3% (2/38) 0.623

DCR. 2013 ABSTRACT: We describe a technique for the management of prolapsing hemorrhoids, with the aim to minimize the risk of anal stricture and rectovaginal fistula and to reduce the impact of the stapling technique on rectal compliance. This modified procedure was successfully applied in China, and preliminary data showed promising outcomes (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A117).

Summary PROS CONS No stricture Preserve normal mucosa No urgency No passage disturbance Easier procedure Shorter F/U period Less pain Address the target piles Circumferential piles  newer device Bleeding control (dog-ear ends) Manage ext. piles

Tailored operation Rubber band ligation ALTA Conventional hemorrhoidectomy : M-M submucosal hemorrhoidectomy PPH TST Laser hemorrhoidectomy …

Thank you.