Background: Following injection sclerotherapy using ALTA (aluminum potassium sulfate and tannic acid) (ALTAS) and transanal rectocele repair (TAR), changes in anorectal physiology were analyzed to compare the significance of the two treatments. Methods: ALTAS was administered to 23 patients and 18 patients were treated using TAR. Efficacy measures included changes in defecography, anorectal manometry and constipation scoring system value. Results: This was a retrospective cohort analysis conducted on prospectively collected data. Comparing anorectal physiology pre- and post- ALTAS, a statistically significant difference in push was observed with pre-ALTAS treatment (pre-A) at 104.33 ± 4.91° compared with post-ALTAS treatment (post-A) at 113.95 ± 4.74° (p < 0.001). With a pre-A value of 1.55 ± 0.18 cm and a post-A value of 2.46 ± 0.34 cm, perineal descent also showed an increase as well (p <0.001). The rectocele size decreased post-A from a pre-A value of 7.74 ± 0.86 cm compared with a post-A value of 2.91 ± 0.52 cm (p < 0.001). The rectal sensation improved post-A compared with pre-A. Comparing anorectal physiology results of ALTAS and TAR treatments, no differences in defecography and rectal sensation were detected pre- and post- treatment. However, in terms of anorectal manometry, the mean resting pressure and maximal squeezing pressure showed statistical difference with two treatments. Conclusions: ALTAS treatment is a feasible option resulting in rapid and effortless long-term outcome, with low rates of complications. Therefore, this treatment may be an effective alternative for patients with symptomatic rectocele. Keywords: Rectocele, ALTA (aluminum potassium sulfate and tannic acid), Injection sclerotherapy, Transanal rectocele repair Background into vaginal canal due to defective or weak rectovaginal Several patients with chronic constipation require med- septum . Enlarged rectocele and functional disability ical treatment. However, patients with rectocele can eas- may result in retention of the feces in the rectum. In this ily be treated surgically [1, 2], suggesting that research case, insertion of finger into the vaginal wall may facili- investigations may yield a significant outcome. Rectocele tate the excretion of the feces by pushing them down is a disease, in which the anterior wall of the lower rec- the rectum in some patients. Rectocele was found in tum and posterior vaginal wall are curved and protrude 20–81% of normal female population [4–7], and 23–70% of patients with rectocele showed symptoms such as constipation, suggesting unclear relationship between * Correspondence: email@example.com Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, this anatomical disorder and symptoms of rectocele Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea [8, 9]. Current treatment methods for rectocele include Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kim et al. BMC Surgery (2018) 18:34 Page 2 of 8 transanal rectocele repair (TAR) [10–12], posterior col- impression, which was immediately adjacent to the porrharphy , transvaginal repair using Marlex mesh upper anal canal. Based on the perineal descent (resting , and laparoscopic transabdominal approach . value minus defecation value), movement across the However, physicians select the treatment method based anorectal junction during ‘squeeze’ and defecation were on their familiarity with specific procedures  in the calculated. The size of rectocele was calculated as the absence of robust evidence supporting individual treat- maximum depth of the bulge beyond the hypothesized ments or comparative analysis of different treatments. and conventional line of the anterior rectal wall . Recently, injection sclerotherapy using a combination of Patients were expected to fulfill at least two out of aluminum potassium sulfate and tannic acid (ALTA) has three conditions, which include constipation, for a diag- been reported as a possible treatment for rectocele be- nosis of rectocele indicated for surgery. The first condi- cause of its simplicity, low percentage of complications, tion was the size of rectocele greater than 3 cm. The and lack of apparent signs of pain . Unfortunately, second condition was retention of barium contrast in studies investigating anal physiology are lacking. the anus even after more than three attempts of In this study, patients with rectocele were divided into defecation, post-defecography. The final condition was two groups: TAR and sclerotherapy using ALTA application of rectal pressure via insertion of finger in (ALTAS). Following these treatments, changes in anorec- the vagina to facilitate defecation [7, 18]. Postoperatively, tal function were analyzed using anorectal manometry 3 months after surgery, patients underwent defecography and defecography to obtain comparative results and de- and anorectal manometry similar to pre-surgical inter- termine the significance of ALTAS. vention. The anal functionality used in this study was based on methods used by Nguyen and Lubowski  Methods and Ger et al. . Patients TAR was performed as an operation for rectocele in a Between January 2010 and October 2013, patients from jack-knife position. Along the dentate line, a transverse Hanvit hospital coloproctology clinic who listed chronic incision was made. Via two vertical lacerations at either constipation as their chief complaint were reviewed to end, which extended for about 7 cm. Until the area determine the presence of rectocele based on anal ultra- above the weakness in the septum was converged, a sonography, anorectal manometry, and defecography. A muco-muscular flap was raised with a wider base. Start- total of 48 patients were subjected to ALTAS and 32 ing from the dentate line and developing adjacently, patients underwent TAR. Three months after these sur- three to four interrupted transverse sutures of 2–0 geries, patients were followed up with anorectal physio- Vicryl® (Ethicon, Norderstedt, Germany) were used to logical studies. Three years post-treatment, a total of 23 increase the lax rectovaginal septum without infiltrating patients who underwent ALTAS and 18 patients who the vaginal mucosa. Additional two to three vertical su- were treated with TAR consented to participate. This tures were used between the closest and farthest points, was a retrospective cohort analysis conducted on pro- increasing the rectovaginal septum to curtail the anterior spectively collected data. This study was approved by rectal wall. Lastly, the edge of the flap was stitched to the Institutional Review Board of Ajou University Hos- the dentate line with ongoing 4–0 Vicryl® (Ethicon, Nor- pital, Republic of Korea (No. AJIRB-MED-MDB-17-493). derstedt, Germany). The lateral lacerations were mea- The Institutional Review Board exempted the require- sured comparatively [10, 11, 21] (Fig. 1). ment for informed consent because we assessed on By taping the buttocks wide apart, the ALTAS was per- de-identified data retrospectively. formed under saddle-block anesthesia in the prone jack-knife position. A glycerin enema was used to empty Outcome measurements the rectum pre-operatively. In case of coexisting intus- A validated scoring system (constipation scoring system susception, a forceps was used to cascade the redundant [CSS]) was used to assess the severity of constipation rectum. Along the rectal submucosa, 1~ 2 mL of ALTA . The scoring system includes eight categories and the solution (Ziohn®, Yuhan Medica Corporation, Seoul, Re- scores ranged from 0 (normal) to 30 (severe constipa- public of Korea) was injected using a 5 mL syringe tion). All patients underwent complete proctological equipped with a 25-gauge injection needle and at 10 to 20 examination, followed by anal ultrasonography, anorec- different places at the edge of the rectocele (Fig. 2). tal manometry and defecography. During defecography, In terms of coexisting hemorrhoids, the physician used the anorectal angle, perineal descent, and size of recto- a Z-type proctoscope (Arakawa Seisakujo, Tokyo, Japan) cele during resting, squeezing, and push were reviewed. with a small opening. ALTA solution was administered Anorectal angle was defined as the angle between the based on a 4-step injection procedure [22, 23](Fig. 3). anal canal and the tangential line. The tangential line ex- After the operation, patients were administered with tended from the posterior rectal wall right below the prophylactic oral antibiotics (cefaclor, 750 mg/day) and Kim et al. BMC Surgery (2018) 18:34 Page 3 of 8 Fig. 1 Transanal approach of rectocele repair (TAR). This approach aimed to reduce anterior rectal capacity by placating the full thickness of the anterior rectal wall up to 5–7 cm into the rectum oral analgesia (Etodolac, 600 mg/day) for 3 days without verified through one-way ANOVA. Statistical signifi- any dietary restrictions. Patients were monitored on an cance was considered when P value was less than 0.05. outpatient basis using anorectal physiology study and CSS as the primary efficacy measures. Patients were Results evaluated by the physicians before and 3 months after Age, operative duration, total injection dose of ALTA the treatment. CSS were evaluated 3 years after the The average age of patients who underwent ALTAS was treatment by contacting the patients to determine any 53.70 ± 7.17 years, and that of patients who were treated changes in their symptoms. with TAR was 51.89 ± 8.37 years (P =0.461). The operative duration for ALTAS was 7.74 ± 2.85 min, and that of TAR Statistical analyses was 49.17 ± 11.79 min. The mean total injection dose of All statistical analyses were performed using IBM® Statis- ALTA was 27.39 ± 7.62 mL (range,18–45 mL). No postop- tics SPSS® for Windows 23.0 (SPSS Inc., Chicago, IL, erative complications were found in any patients. USA). Variables such as scale value of anorectal physi- ology tests and CSS of ALTAS and TAR were analyzed CSS comparison of pre-treatment, 3 months and 3 years by paired-samples t-test. Age and comparative treatment post-treatment method were analyzed by independent-samples t-test. The baseline value in patients who underwent ALTAS was CSS of baseline, after 3 months, after 3 years were 11.61 ± 2.84, 3 months post-treatment was 4.78 ± 1.09, Fig. 2 Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy. The rectum was prolapsed to its maximum extent using forceps. Along the rectal submucosa, 1~ 2 mL of ALTA solution was circumferentially injected using a 5 mL syringe equipped with a 25-gauge injection needle and at 10 to 20 different places at the edge of the rectocele to the dentate line Kim et al. BMC Surgery (2018) 18:34 Page 4 of 8 post-A of 2.46 ± 0.34 cm, perineal descent also showed an increase (p < 0.001). The rectocele size decreased post-A from a pre-A of 7.74 ± 0.86 cm to a post-A value of 2.91 ± 0.52 cm (P < 0.001). In anorectal manometry, both mean resting pressure (MRP) and maximal squeeze pressure (MSP) were not dif- ferent pre-A and post-A. In rectal sensation, sensory threshold (ST) showed a pre-A value of 85.53 ± 11.30 mL and a post-A value of 78.48 ± 11.91 mL (P =0.002). The earliest defecation urge (EDU) was recorded at a pre-A level of 158.71 ± 23.70 mL, and a post-A level of 116.97 ± 25.07 mL (p < 0.001). Finally, the maximal tolerable volume (MTV) decreased significantly from a pre-A level of 207.64 ± 34.12 mL to a post-A level of 148.48 ± 22.38 mL (P < 0.001) as shown in Table 2. Comparing anorectal physiology pre-TAR treatment (pre-T) Fig. 3 Four-step injection of aluminum potassium sulfate and tannic acid. ① Submucosa at the superior pole of hemorrhoids ② Submucosa and post-TAR treatment (post-T) in the central part of hemorrhoids ③ Mucous lamina propria in the Similar to ALTAS, defecography showed no difference in central part of hemorrhoids ④ Submucosa at the inferior pole resting and squeezing phases of anorectal angle pre-T and of hemorrhoids post-T. However, with pre-T at 106.10 ± 5.94°, post-T 112.21 ± 4.92°, the push phase showed statistically signifi- and 3 years post-treatment was 5.61 ± 0.94. Comparative cant difference (P < 0.001). Perineal descent of 1.58 ± analysis of these results showed that the treatment had a 0.23 cm occurred with pre-T compared with 2.43 ± 0.38 cm statistical significance (P < 0.001). The baseline value post-T, suggesting a significant increase post-T (P <0.001). for patients who underwent TAR was 10.83 ± 2.55, In anorectal manometry, MRP of 20.18 ± 2.90 mmHg oc- 3 months post-treatment was 4.39 ± 0.61, and 3 years curred at pre-T: compared with 21.93 ± 3.54 mmHg post-T post-treatment was 5.44 ± 1.04, suggesting that TAR (p = 0.049), while MSP was 87.87 ± 11.45 mmHg pre-T: also had a statistical significance (P < 0.001), and there compared with 94.23 ± 11.31 mmHg post-T (P < 0.001). was no sign of relapse. These results showed that, unlike ALTAS treatment, there Therewas no differenceinCSS between thetwo treat- Table 2 Comparison of defecographic and anal manometric ments in terms of pre-treatment, 3 months post-treatment, findings between pre- and post-treatment of ALTAS in rectocele and 3 years post-treatment outcomes (Table 1). ALTAS Pre-treatment Post-treatment P value Defecography, mean (SD) Comparing anorectal physiology pre-ALTAS treatment (pre-A) and post-ALTAS treatment (post-A) Anorectal angle (°) Defecography results showed that the resting and Resting 98.86 (5.03) 98.05 (4.24) 0.153 squeezing performance from the anorectal angle showed Squeezing 91.30 (0.60) 90.84 (2.50) 0.400 no difference between pre-A and post-A. However, there Push 104.33 (4.91) 113.95 (4.74) < 0.001 was a statistically significant difference in push with a Perineal descent (cm) 1.55 (0.18) 2.46 (0.34) < 0.001 pre-A) at 104.33 ± 4.91° compared with post-A at 113.95 Rectocele size (cm) 7.74 (0.86) 2.91 (0.52) < 0.001 ± 4.74° (P < 0.001). With a pre-A of 1.55 ± 0.18 cm and Anorectal manometry, mean (SD) Table 1 Comparison of constipation scoring system between MRP (mmHg) 19.12 (1.98) 19.66 (2.55) 0.394 ALTAS and TAR in rectocele MSP (mmHg) 86.17 (9.40) 85.57 (9.28) 0.791 a,b a b a,b Treatment Baseline value After 3 months After 3 years P value Rectal sensation (mL) ALTAS 11.61 (2.84) 4.78 (1.09) 5.61 (0.94) < 0.001 ST 85.53 (11.30) 78.48 (11.91) 0.002 TAR 10.83 (2.55) 4.39 (0.61) 5.44 (1.04) < 0.001 EDU 158.71 (23.70) 116.97 (25.07) < 0.001 P-value 0.368 0.176 0.600 MTV 207.64 (34.12) 148.48 (22.38) < 0.001 Data are expressed as absolute mean (standard deviation) Minimum Score, 0; Maximum Score, 30 Data are expressed as absolute mean (standard deviation) ALTAS sclerotherapy using aluminum potassium sulfate and tannic acid, TAR ALTAS sclerotherapy using aluminum potassium sulfate and tannic acid, SD transanal rectocele repair standard deviation, MRP mean resting pressure, MSP maximal squeezing significant data between baseline value and after 3 months pressure, ST sensory threshold, EDU earliest defecation urge, MTV maximal significant data between baseline value and after 3 years tolerable volume Kim et al. BMC Surgery (2018) 18:34 Page 5 of 8 was a significant increase post-T. In rectal sensation, similar The rectocele can be examined by physical examination to ALTAS, ST showed a pre-T value of 85.67 ± 11.25 mL digitally using anal finger. However, the significance of and a post-T value of 78.06 ± 12.02 mL (P = 0.001), while rectoceles that are larger than 2 cm is disputed [7, 24], EDU showed a pre-T value of 157.86 ± 22.54 mL compared with a few experts suggesting that the size is not corre- with post-T level of 109.19 ± 22.20 mL (P < 0.001). The lated with the symptoms [25–27]. These disagreements MTV value pre-T was 197.52 ± 31.35 mL compared with a highlight several controversies floating around regarding post-T value of 142.22 ± 23.83 mL (P < 0.001), which were the relevance of rectocele size and symptoms. Therefore, significant statistically (Table 3). several clinicians are uncertain regarding the appropriate timing for surgery and the specific surgical intervention Comparing anorectal physiology results of ALTAS and that is most appropriate. TAR treatments Anatomical and physiologic studies of rectocele are es- No differences in defecography and anorectal manometry sential to address this challenge. As the CSS level de- index are found pre-treatment. No differences in defeco- creased pre-A, post-A and pre-T, post-T, the rectocele graphy and rectal sensation were detected post-treatment. size was significantly reduced in defecography. The However, in terms of anorectal manometry, the MRP and treatment effect was sustained without any significant MSP showed statistical difference with two treatments differences between the two groups in CSS testing, sug- (MRP: P =0.022, MSP: P =0.010) (Table 4). gesting that ALTAS is an effective intervention for the management of rectocele. Additionally, in defecography, Discussion a significant increase was observed in anorectal angle Rectocele has always been considered as a gynecologic under exertion. Another significant increase occurred in problem. It was not until 1968 when Sullivan et al.  perineal descent after surgery compared with introduced TAR that rectocele was considered as an- pre-surgical level. Van Laahoven et al.  interpreted other type of chronic constipation amenable to anorectal that the size of rectocele shifted the vector force of surgery. Recent advances in anorectal physiology eluci- defecation in a physiological direction post-operation. In dated the factors underlying the increased size of recto- anorectal manometry, which is used to determine the cele and the inability of the rectocele to promote physiological changes, the MRP indicating the function- defecation in the direction of the anal canal during ality of internal sphincter muscle, and MSP indicating defecation. Instead, defecation is diverted towards the the function of the external sphincter muscle, were sig- weakened rectovaginal septum and additional push is nificantly lowered postoperatively. This result was attrib- needed for excretion, which enlarges the rectocele . uted to damage of anal muscles due to anal retractor, which is used during TAR. In addition to the effect of anatomical correction, surgery also improved the rectal Table 3 Comparison of defecographic and anal manometric sensation in both ALTAS and TAR, which significantly findings between pre- and post-treatment of TAR in rectocele lowered the ST, EDU, MTV, and rectal sensation TAR Pre-treatment Post-treatment P value post-surgery. Defecography, mean (SD) Currently, treatments such as TAR [10–12], posterior Anorectal angle (°) colporrpaphy , transperineal repair, which uses Resting 97.67 (3.78) 99.22 (5.06) 0.229 Marlex mesh , and laparoscopic transabdominal ap- proach , stapled transanal rectal resection (STARR) Squeezing 91.79 (3.65) 91.76 (3.84) 0.979  are used to treat rectocele. TAR, which is an opera- Push 106.10 (5.94) 112.21 (4.92) < 0.001 tive method used by many coloproctologists, has been Perineal descent (cm) 1.58 (0.23) 2.43 (0.38) < 0.001 used to treat anal diseases such as hemorrhoids, mucosal Rectocele size (cm) 7.78 (1.00) 2.67 (0.69) < 0.001 prolapse, and complete rectal prolapse, simultaneously Anorectal manometry, mean (SD) . However, the disadvantages of TAR related to its MRP (mmHg) 20.18 (2.90) 21.93 (3.54) 0.049 inability to treat vaginal disease in addition to increasing the risk of complication associated with vaginal tightness MSP (mmHg) 87.87 (11.45) 94.23 (11.31) < 0.001 . Posterior colporrhaphy, used by several gynecolo- Rectal sensation (mL) gists can be used to treat urological or gynecological dis- ST 85.67 (11.25) 78.06 (12.02) 0.001 ease at the same time. However, it cannot be used to EDU 157.86 (22.54) 109.19 (24.20) < 0.001 treat anal disease, and is associated with extreme post- MTV 197.52 (31.35) 142.22 (23.83) < 0.001 operative pain and complications of vaginal strictures Data are expressed as absolute mean (standard deviation) . Transperineal repair, which uses Marlex mesh, is a TAR transanal rectocele repair, SD standard deviation, MRP mean resting new treatment modality that has a theoretical advantage pressure, MSP maximal squeezing pressure, ST sensory threshold, EDU earliest defecation urge, MTV maximal tolerable volume of recovery of anatomical function by attaching the Kim et al. BMC Surgery (2018) 18:34 Page 6 of 8 Table 4 Comparison of anorectal physiology between ALTAS and TAR in rectocele Anorectal physiologic Pre-treatment Post-treatment study ALTAS TAR P value ALTAS TAR P value Defecography, mean Anorectal angle (°) Resting 98.86 97.67 0.411 98.05 99.22 0.426 Squeezing 91.30 91.79 0.664 90.84 91.77 0.358 Push 104.33 106.10 0.303 113.95 112.21 0.261 Perineal descent (cm) 1.55 1.58 0.642 2.46 2.43 0.808 Rectocele size (cm) 7.74 7.78 0.895 2.91 2.67 0.196 Anorectal manometry, mean MRP (mmHg) 19.12 20.18 0.172 19.66 21.93 0.022 MSP (mmHg) 86.17 87.87 0.605 85.57 94.23 0.010 Rectal sensation (mL) ST 85.53 85.67 0.967 78.48 78.06 0.911 EDU 158.71 157.86 0.907 116.97 109.19 0.323 MTV 207.64 197.52 0.335 148.48 142.22 0.397 Data are expressed as absolute mean ALTAS sclerotherapy using aluminum potassium sulfate and tannic acid, TAR transanal rectocele repair, MRP mean resting pressure, MSP maximal squeezing pressure, ST sensory threshold, EDU earliest defecation urge, MTV maximal tolerable volume prostatic patch to the anatomically defective area. How- of complications. Another advantage of ALTAS is that it ever, this treatment leads to fibrotic tissue formation and does not need suturing or excision, unlike transanal pro- associated pain as well as perineal pain and dysuria . cedures. The treatment is not associated with the risk of Other disadvantages include prolonged scar healing, in- anastomotic dehiscence or bleeding, and can be per- creased discharge, and continuous administration of an- formed rapidly under local anesthesia, without any post- tibiotics . Laparoscopic transabdominal approach is operative complications such as rectovaginal fistula or indicated for cases of relapse or when rectal intussuscep- infection and alleviates postoperative pain. ALTAS can tion accompanies rectal prolapse. However, it is a larger be used to treat hemorrhoids, rectal intussusception, procedure compared with other surgeries . and mucosal prolapse, which are concomitant anorectal Longo came up with STARR for patients diagnosed diseases, simultaneously. ALTAS, using the Z-type with obstructed defecation through rectocele and intus- proctoscope, provides effective access to high rectoceles susception. While STARR was very effective in improv- as well . ing the rectal symptoms related to rectocele and Complex internal muscle control such as nerve plex- intussusception, it was associated with complications uses, muscle, colon and pelvic floor activity and various . The postoperative bleeding rate ranged from 3.3 to chemical and hormones play an important role in nor- 26.6%, and fecal urgency rate ranged from 1.1 to 34%, mal defecation . Therefore, psychologic factors, while incontinence to flatus rate ranged from 6 to 26.7%. long-term idiopathic constipation, and hormonal disor- The recurrence rate was less than 40% [31, 32]. ders can have a huge impact on defecation impairment Injection sclerotherapy is indicated for hemorrhoids . Rectocele, which is one of the main causes of and rectal prolapsed. It is minimally invasive and eco- defecation disability, is an anatomical abnormality sug- nomical, but seldom used to treat rectocele . ALTA gesting that surgery that reduces the size of the rectocele treatment interrupts the blood flow to the hemorrhoids effectively improves the symptoms. However, even resulting in sporadic hemostatic effect and contraction though the size of the rectocele is reduced after the sur- of hemorrhoids. Eventually, sterile inflammation induces gery, it does not completely disappear, which suggests persistent fibrosis. Further, attachment and fixation of that the relationship between postoperative anatomical submucosal layer and mucosa to the muscular layer is correction and symptom improvement is still unclear promoted. Finally, bleeding of hemorrhoids is stopped . Our study has shown that both treatments signifi- and the prolapse is resolved . cantly improved the rectal sensitivity, consistent with Abe et al.  reported injection sclerotherapy as a Van Laarhoven et al. ’s findings suggesting that the treatment that is easy, rapid, and shows fair mid-term significantly reduced size of rectocele post-treatment al- results. More importantly, it is associated with a low rate ters the vector force in the normal, physiological Kim et al. BMC Surgery (2018) 18:34 Page 7 of 8 direction. However, the concept of physiological changes Received: 15 March 2018 Accepted: 22 May 2018 in improving rectal sensation along with the underlying mechanism needs to be explored further. References 1. 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Published: May 31, 2018