Both THD and SH techniques are effective for the treatment of third-degree haemorrhoids in the medium term. THD has a better cost-effective ratio and lower (not significant) pain compared with SH. Postoperative pain and recurrence did not differ significantly between the two groups.

Aim This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome.Method Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni-and multivariate analyses of the potential predictive factors for failure were performed.Results The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 AE 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively.Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Dopplerguided dearterialization were associated with a better outcome.Conclusion THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.Keywords Haemorrhoids, haemorrhoidal disease, rectal bleeding, prolapse, transanal haemorrhoidal dearterialization, multivariateWhat does this paper add to the literature? To our knowledge this is the largest series ever published on the topic of Doppler-guided transanal haemorrhoidal dearterialization. This paper describes the changes in the technique that there have been over the years, and their impact on the results in short-and long-term follow-up. A detailed multivariate analysis of the potential predictive factors of failure is provided.

In our series up to 88% of the patients reported a good, or excellent one-year satisfaction score. Further comparative randomized studies with longer follow-up period are needed.

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