THD® Doppler: indications
Clinical evidence and comprehensive scientific literature reviews state THD® Doppler Procedure is indicated for the surgical treatment of all degrees of haemorrhoids.1,2,3
The technique has proven to be effective and safe for all degrees of haemorrhoids, including grades that do not respond to conservative and outpatient treatments. Depending on the symptoms and disease grade, the surgeon can decide whether to perform haemorrhoidal artery ligation only or dearterialization with mucopexy to repair prolapse.
- Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: a single-center study on 1000 consecutive cases and a review of the literature, Ratto C. et al, Tech Coloproct. (2017) 21: 953-962
- Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes, Trenti L., Biondo S. et al, Tech Coloproctol. 2017 May;
- Hemorrhoidal dearterialization with mucopexy versus hemorrhoidectomy: 3-year follow-up assessment of a randomized controlled trial, Denoya P. et al, Tech Coloproct (2014) 18: 1081-1085
THD® Doppler: surgical procedure
THD® Doppler Method is the result of a significant input from colorectal surgeons, cutting-edge technological advances, and constant medical research. THD® Doppler manages both causes and symptoms of haemorrhoidal disease.
THD® Doppler is a two-step procedure that handles both blood overflow and haemorrhoidal prolapse. Haemorrhoidal disease is associated with haemorrhoid hypertension (vascular component) and connective tissue degeneration (mechanical component). Both the vascular and the mechanical components are connected with haemorrhoidal symptoms like bleeding, pain, and prolapse.
The THD technique is acting on the pathophysiology of the disease and correcting its main consequences. This is why the THD® Doppler Method includes both haemorrhoidal dearterialization and mucopexy.
Dearterialization reduces arterial hyperflow to haemorrhoids through the ligation of terminal branches of the rectal artery under the guide of a Doppler ultrasonography. While the aim of mucopexy is to reposition prolapsed tissue into its anatomical position, as well as to provide support for degenerated tissue.
During the procedure, the surgeon fully inserts the anoscope by gently dilating the anus.
Then the surgeon moves the anoscope distally to identify the maximum doppler signal, just above the anorectal junction.
The signal is usually greatest close to the internal haemorrhoidal plexus: within this area, there is a point where the signal is stronger, due to the fact that the artery is more superficial in the tissue and so the blood flow is more conspicuous. This point is therefore the best target for effectively reducing the hyperemia by dearterialization through ligation.
The surgeon then places a fixation stitch as an anchoring point (Figure 8 knot).
The dearterialization procedure is performed in an area without nerve endings, thus considerably reducing pain, one of the main complications associated with traditional haemorrhoidectomy.
The surgeon then removes the anoscope and re-inserts at the next position on the ‘clock face’ to begin the locating of the next artery. The surgeon will usually find a maximum of 6 arteries for ligation.
The second stage of the procedure involves the repair of prolapse. This is done by ‘eye balling/visualizing’ the area of prolapse. The anoscope is then re-inserted and the surgeon pulls back the sliding part of the anoscope to perform a running stitch starting as proximal as possible and finishing above the dentate line.
Upon closing the knot, the prolapsed tissue is lifted inside restoring the anatomical condition. The scarring process induced by mucopexy helps to stabilize and affix the tissues to the underlying rectal muscle.
The surgeon gently extracts the Doppler protecting the mucopexy and repeats the procedure on the next site of prolapse.
THD® Revolution Doppler generator with built-in LED light source and the dedicated anoscope THD® Slide are specifically designed to perform the procedure.
The procedure is normally performed in a day surgery setting and the patient is normally discharged 8 hours after surgery.
The mean operative time is approximately 30 minutes1 and the patient can typically return to normal activities in 2-3 days on an average.2
- Evaluation of Transanal Hemorroidal Dearterialization as a Minimally Invasive Therapeutic Approach to Hemorroids, C. Ratto et al., Dis Colon Rectum 2010; 53 (5): 803-811
- Dearterializzazione emorroidaria transanale doppler guidata, C. Tagariello et al., Casa di Cura M. F. Toniolo, Villa Erbosa, Bologna, Chirurgia Italiana 2004; Vol. 56 (5): 693-697
Outcomes and Benefits
The THD® Doppler Procedure has changed the surgical approach to haemorrhoids treatment by maximizing the effectiveness of results while reducing discomfort, invasiveness and pain for the patient.
THD® Doppler method offers durable results in grade II, III and IV haemorrhoids with advantages and benefits for both the clinician and the patient:
- minimally invasive procedure: non-excisional, preserves the anorectal physiology and the vital function of haemorrhoids. Furthermore, it is performed in area free from nerve endings. All these aspects result in shorter recovery times, quick return to normal activities, minor post-operative pain and minor post-operative bleeding
- wide indications: the procedure is indicated for all haemorrhoid grades and has proven to be effective on prolapse and thrombosed haemorrhoids.
- low recurrence rate: unlike most outpatient procedures, it has a low recurrence rate.
- repeatable: unlike excisional haemorrhoid surgery, it can be performed multiple times, as needed
- no major complications.1,2
Quick return to normal activities, mild post-operative pain, low recurrence rate, preservation of anorectal physiology and high rate of resolution or improvement of symptoms are the main reasons of high patient satisfaction3,4.
- Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial Available for Open Online Access. Ratto C., Parello A., Veronese E., Cudazzo E., D’Agostino E., Pagano C., Cavazzoni E., Brugnano L. & Litta F. Colorectal Disease 2015 Jan;17(1):O10-9.
- Transanal haemorrhoidal dearterialization (THD) for haemorrhoidal disease: a single center study on 1000 consecutive cases and a review of the literature. Ratto C., Campenni P., Papeo F. et al. Tech Coloproctol. (2017) 21:953-962.
- Evaluation of Transanal Hemorroidal Dearterialization as a Minimally Invasive Therapeutic Approach to Hemorroids, C. Ratto et al., Dis Colon Rectum 2010; 53 (5): 803-811.
- Evaluation of the effectiveness and patients’ contentment with transanal haemorrhoidal artery dearterialisation and mucopexy (THD) for treatment of haemorrhoidal disease: a 6-year study, Qurat Ul Ain et al, Irish Journal of Medical Science, Published online 6° December 2017.
Recognition and Endorsements
THD® Doppler Procedure positive outcomes are supported by scientific literature, independent associations and institutes and long-term clinical evidence.
NICE Interventional procedure Guidance
In 2010, the National Institute for Health and Clinical Excellence (NICE) acknowledged doppler-guided haemorrhoidal artery ligation as an efficacious alternative to haemorrhoidectomy or stapled haemorrhoidopexy. NICE is an independent British institute that issues influential guidelines in the healthcare sector, but is also accredited by the international scientific community.
In May 2010, NICE issued an interventional procedure guidance for haemorrhoidal artery ligated dedicated to THD® Doppler Procedure: “Treating Haemorrhoids by tying off their blood supply” (IPG342).
ASCRS Clinical Practice Guidelines
Recently, the American Society of Colon and Rectal Surgeons (ASCRS) issued new clinical practice guidelines for the management of haemorrhoids. ASCRS is committed to defining high quality patient care for colorectal disorders, based on the best available clinical evidence.
In 2018 ASCRS guidelines listed Doppler-guided haemorrhoidal artery ligation with mucopexy among surgical treatments for haemorrhoids, based on the review of 28 prospective studies for a total of 2904 patients with grade I to IV haemorrhoids.
Clinical Evidence and Scientific literature
Today THD® Doppler procedure efficacy is proven by long-term clinical evidence and authoritative scientific studies, being recognized as an effective and safe surgical method by healthcare professionals worldwide.
More information on THD scientific literature is available on Clinical Studies.