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

2. 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

3. 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

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

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

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

9. Procedure of TST

10. Selection of the pile

12. Purse string suture

13. PPHplus(33mm)

14. Mucosal bridge & dog ear ends

15. specimen
PPH
TST

16. PPH
TST

18. Preop.
Postop.

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

21. 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 : cm above the apex of pile
stapled hemorrhoidopexy ?
stapled hemorrhoidectomy ?

22. 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

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

24. percentage of specimen with muscle

25. “…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”.

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

27. Surg Today. 2011

28. 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

29. 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,

30. 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

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

33. Thank you.