Annals of Coloproctology

Reviews

The Roles of Anorectal Physiologic Tests and Treatment of Chronic Constipation.: Hwang, Yong Hee; J Korean Soc Coloproctol. 2008;24(2):148-159.; DOI: https://doi.org/10.3393/jksc.2008.24.2.148

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Abstract PDF: Patients with chronic constipation should be evaluated with physiological tests (defecography and cinedefecography, anal manometry, anal electromyography, and colon transit time) after structural disorders and extracolonic causes have been excluded. In the case of colonic inertia, at first, conservative treatment is necessary. If surgery is indicated, a subtotal colectomy with ileorectal anastomosis is the treatment of choice. Biofeedback is the best option for animus. For patients failing biofeedback, botulinum toxin injection of the puborectalis or sacral nerve stimulation may be indicated. Biofeedback treatment is also considered to be an option for moderate-degree rectoceles, rectal intussusception, and perineal descending syndrome. For the treatment of a severe rectocele, a surgical approach, including transrectal, transvaginal, and transperineal repair or stapled transanal rectal resection (STARR) should be considered. However, the long-term effects of a new technique including botulinum toxin injection, sacral nerve stimulation, and STARR remain to be established.

Diagnosis and Management of Fecal Incontinence.: Seong, Moo Kyung; J Korean Soc Coloproctol. 2007;23(5):386-394.; DOI: https://doi.org/10.3393/jksc.2007.23.5.386

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Fecal incontinence is a common problem that is underreported, underdiagnosed and poorly managed. It profoundly affects the quality of life and psychological function. It is widely known that the diversity of causes of fecal incontinence and different modes of action of various treatment modalities mandates a tailored approach in each case. Currently, several diagnostic tests are available that can provide useful insights regarding the pathophysiology of fecal incontinence, and also several advanced treatment modalities which make it possible to rehabilitate most of these patients become recently available. Strictly speaking, however, no specific test can tell the exact etiology of fecal incontinence and the modes of action in various treatment modalities are still not well-defined. In this sense, policy of approach to patients with fecal incontinence can rather be straightforward. Patients with endosonographically proven sphincteric defect should be treated with sphincteroplasty. But for patients without such defect, less invasive procedures among recently available modalities should be the first consideration and then more invasive ones next in case of failure.

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Evaluation of Anal Continence Function by Advanced Anal Manometric Parameters
Moo-Kyung Seong, Keun-Young Kim, Young-Bum Yoo
Journal of the Korean Society of Coloproctology.2009; 25(1): 20. CrossRef

Open Hemorrhoidectomy.: Kim, Do Sun; J Korean Soc Coloproctol. 2007;23(4):279-285.; DOI: https://doi.org/10.3393/jksc.2007.23.4.279

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The open hemorrhoidectomy has been recognized as the treatment of choice for symptomatic prolapsing hemorrhoids. Although the open hemorrhoidectomy is thought to be associated with more postoperative pain and delayed wound healing compared with other conventional procedures such as a closed hemorrhoidectomy, and a semi- closed or submucosal hemorrhoidectomy, it is still unclear which procedure is preferable in terms of postoperative pain, wound healing, hospital stay, and time off work. To address this issue, several studies have been performed. According to randomized controlled studies comparing an open hemorrhoidectomy to a closed hemorrhoidectomy, there are no significant differences in the severity of pain and the hospital stay between the two procedures; however, the healing time in the closed hemorrhoidectomy is faster and the operation time in the open hemorrhoidectomy is shorter. Since there are few randomized controlled studies comparing an open hemorrhoidectomy with a semi-closed hemorrhoidectomy or submucosal hemorrhoidectomy, it is difficult to conclude which procedure is superior to the others. Yet, there seems to be no significant difference between these procedures. In 1998, a novel procedure, a stapled hemorrhoidopexy, was introduced by Longo. Several randomized controlled studies comparing the open hemorrhoidectomy with the stapled hemorrhoidopexy showed that the latter was associated with less pain, shorter hospital stay, and earlier return to work. However, considering the lack of long- term data and the disastrous complications, such as retroperitoneal sepsis and rectal perforation, there is still controversy about its efficacy and safety as a definitive treatment of hemorrhoids. The open hemorrhoidectomy is time-tested and is comparable to other conventional techniques in terms of postoperative pain, hospital stay, and time off work. Further study should be performed to assess the long-term results of a stapled hemorrhoidopexy.

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Long-term follow-up of Starion™ versus Harmonic Scalpel™ hemorrhoidectomy for grade III and IV hemorrhoids
Joo Hyung Kim, Dae Hyun Kim, Yong Pyo Lee, Kwang Wook Suh
Asian Journal of Surgery.2019; 42(1): 367. CrossRef
Have Any Changes in Pain Been Noted After a Hemorrhoidectomy Since the Establishment of the Milligan-Morgan Hemorrhoidectomy?
Do Sun Kim
Annals of Coloproctology.2016; 32(3): 90. CrossRef
Randomized Trial Comparing a Starion™ and a Harmonic Scalpel™ Hemorrhoidectomy
Joo Hyung Kim, Yong Pyo Lee
Journal of the Korean Society of Coloproctology.2009; 25(1): 8. CrossRef

Evaluation and Treatment of Pelvic Floor Disorders.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2007;23(3):206-220.; DOI: https://doi.org/10.3393/jksc.2007.23.3.206

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Abstract PDF: Pelvic floor disorders are of interest to many surgeons who specialize in organ systems within this region. Colorectal surgeons are especially interested in disorders of the posterior compartment, which may broadly be divided into defecation disorders and fecal incontinence. These disorders distress patients socially and psychologically and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, are often incompletely understood, and cannot always be determined. However, over the past decades, advances in the understanding of these disorders, together with rational methods of evaluation in anorectal physiology laboratories, radiology studies, and new surgical techniques, have led to promising results. This review summarizes the evaluation and treatment strategies, as well as the recent updates on the clinical and the therapeutic aspects of pelvic floor disorders.

Present and Future in the Treatment of Fecal Incontinence.: Park, Duk Hoon; J Korean Soc Coloproctol. 2007;23(2):136-143.; DOI: https://doi.org/10.3393/jksc.2007.23.2.136

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Abstract PDF: Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem. The diversity of causes of fecal incontinence and different modes of action of the various treatment modalities mandate a tailored, individualized approach in each case. Surgery is the last treatment modality for patients suffering from severe fecal incontinence. Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are reported by acceptable success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental untill enough high- evidence data are gathered for their objective evaluation.

Artificial Bowel Sphincter for Fecal Incontinence.: Lee, Kil Yeon; J Korean Soc Coloproctol. 2006;22(5):350-355.

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Abstract PDF: Fecal incontinence is a common disorder, affecting all ages and both sexes. It is a devastating condition and has a major impact on quality of life. The level of treatment must be appropriate for the severity of symptoms. Nonsurgical techniques are appropriate for patients with minor degrees of incontinence. Patients with sphincter disruption or rectal prolapse can benefit from the appropriate surgical therapy. Patients with intractable, clinically significant fecal incontinence, caused by trauma or the failure of surgical therapy, need salvage options. In the past if a patient was not amenable to a tissue repair or failed a tissue repair, a colostomy was his or her only surgical option. However, new innovations can give patients more options to regain continence. The artificial bowel sphincter (ABS) is one of those newer options. It is an implantable device used to treat the patients with severe fecal incontinence, who have failed, or are not candidates for less invasive forms of restorative therapy. It is intended to mimic the natural process of bowel control. This device is reserved for patients with severe fecal incontinence that is not amenable to lesser forms of therapy. Because it is an artificial device, ABS is unfortunately associated with high morbidity and low success rate. With experience, however, the infection rate has declined due to new standardized prophylactic antibiotics regimen. Therefore, the ABS has become a good option for patients with severe fecal incontinence. The results are quite impressive with a significant number of patients obtaining complete continence. This review presents the technique of ABS implantation and the current status of ABS.

Treatment of Peritoneal Carcinomatosis from Colorectal Cancer.: Kim, Hyung Jin , Oh, Seong Taek; J Korean Soc Coloproctol. 2006;22(4):285-290.

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Abstract PDF: Intraperitoneal carcinomatosis accounts for 25~35% of recurrences of colorectal cancer, and peritoneal carcinomatosis from colorectal cancer has been regarded as a lethal condition. However, a combination of aggressive cytoreductive surgery and intraperitoneal chemotherapy has been tried and appears to be beneficial in selected patients. The primary goal of cytoreductive surgery is to remove all visible tumor within the peritoneal cavity. The goal of intraperitoneal chemotherapy is to eradicate the microscopic residual tumor and to prevent its recurrence. There are various ways to perform intraperitoneal chemotherapy. One is postoperative intraperitoneal chemotherapy, and another is intraoperative hyperthermic chemotherapy during surgery. Hyperthermia increases the penetration of chemotherapy into tissues and the level of chemotherapy cytotoxicity. The timing of surgery in cases of intraperitoneal chemotherapy and the optimal dosage of drugs must be evaluated in further studies. In colorectal cancer, the peritoneum should be regarded as an intra-abdominal organ, like the liver. Therefore, intraperitoneal carcinomatosis must be treated by using a combination of aggressive surgical treatment and intraperitoneal chemotherapy. Eventually, the long-term overall survival will be increased.

Surgical Treatment of Anal Fistula.: Lee, Jong Kyun; J Korean Soc Coloproctol. 2006;22(3):214-220.

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Abstract PDF: Various methods of surgical treatments were introduced for the treatment of anal fistulas. A surgeon has to select carefully the method most ideal to each type of anal fistulas. The fistulotomy is an ideal technique for the treatment of intersphincteric or transsphincteric fistulas because less serious problems of incontinence and/or recurrence follow after it. For the treatment of suprasphincteric and extrasphincteric fistulas, fistulotomy is of no use because of high incidence of incontinence. In such cases, most surgeons like to use the seton technique, muscle filling method, muscle closure method, advancement flap, re-route procedure, or fibrin glue injection in order to decrease the incidence of incontinence. The techniques and indications of each surgical procedure are reviewed in detail.

Imrpoving Outcomes with Chemotherapy in Colorectal Cancer: Current Options, Current Evidence.: Kim, Ik Yong; J Korean Soc Coloproctol. 2006;22(2):137-149.

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Abstract PDF: The last several years have major advances in chemotherapy treatment for adjuvant and metastatic colorectal cancer. We've come from an overall survival of 6 months in patients treated with best supportive care in the mid 1980s and even in the early 1990s. The use of 5-FU/leucovorin alone generates an overall survival of about 6 months. The addition of irinotecan/oxaliplatin allows patients to live a median of about 15 to 17 months. If we make use of all 3 active drugs, FOLFOX and FOLFIRI in a sequential manner, we'll be able to generate an overall survival of about 20 months. Recently, the addition of molecular therapy, in particular bevacizumab and cetuximab to these cytotoxic drugs has allowed us to break the brick wall that was placed at about 2 years median overall survival in large phase 3 trials in patients with metastatic colorectal cancer. The recent presentations provided further evidence that the standard of care in the treatment of advanced CRC consists of a combination of highly active cytotoxic chemotherapy plus the addition of a biologic agents, For clinical research, investigation of the best therapy for CRC has clearly shifted away from investigating conventional chemotherapy toward the question of how to make best use of all available active agents, particularly the novel biologics. Randomized trials have also shown that preoperative chemoradiation yields higher rates of pathologic complete response and local control, compared with radiotherapy alone. In this article, I review recent trials on preoperative and adjuvant therapy of localized rectal cancer. The roles of newer agents, such as capecitabine, oxaliplatin, and bevacizumab, are also discussed, and other key issues in the treatment of localized rectal cancer are reviewed. The planned phase 3 first-line trial will continue to elucidate the role of the currently available biologics in the treatment of CRC. In this article, the important advances in optimal chemotherapy of colorectal cancer will be summarized and approaches to multidisciplinary treatment decision-making in both adjuvant and metastatic settings will be reviewd.

Signal Transduction Pathways in Colorectal Cancer Carcinogenesis and Metastasis.: Baek, Moo Jun; J Korean Soc Coloproctol. 2005;21(6):433-444.

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Abstract PDF: Cell proliferation and differentiation are regulated by a number of hormones, growth factors. These molecules interact with cellular receptors and communicate with the nucleus of the cell through a network of intracellular signal transduction pathways. A great deal of recent work has defined signal transduction pathways that distinguish malignant from normal cells, and hence identified potential targets for cancer therapy. In colorectal cancer cells, key components of these pathways may be altered by oncogenes through overexpression or mutation, leading to dysregulated cell signaling, inhibition of apoptosis, metastasis, and cell proliferation. The molecular mechanisms and signaling pathways that regulate cell proliferation and survival are receiving considerable attention as potential targets for anticancer strategies. This article was reviewed the role of signal transduction in colorectal cancer, introduce promising molecular targets, and outline therapeutic approaches under development.

Motility Disorders of the Colon.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2005;21(5):337-353.

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Abstract PDF: Human colonic motor activity is quite a complex issue and is a relatively difficult topic to investigate, still only partly understood and investigated, due to anatomic and physiological difficulties. Colonic motility measurement are hampered by the relative inaccessibility of the colon, especially in the unprepared state. Major motor events are infrequent, necessitating long observation periods. Moreover, correlating intraluminal pressure changes with stool transport is difficult. Disturbances of normal colonic motor activity may interfere with healthy colonic physiologic function. The pathophysiological mechanisms responsible for colonic motility disorders are still less understood. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, although only in part, some pathophysiological mechanisms of colonic motility disorders. In this review article, after a brief of relevant normal aspects of colorectal motility in man, we limit our discussion to more common motility disorders involving the colon and rectum. In particular, what is known or hypothesized regarding the underlying pathophysiology of slow-transit constipation, diverticular diseases, irritable bowel syndrome, and intestinal pseudo-obstruction is reviewed.

Sharp Pelvic Dissection for Abdominoperineal Resection for Distal Rectal Cancer Based on Anatomical and MRI Knowledge.: Kim, Nam Kyu; J Korean Soc Coloproctol. 2005;21(4):258-267.

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Abstract PDF: Even though sphincter saving surgery such as coloanal anastomosis or intersphincteric resection have been popular in era of Total Mesorectal Excision (TME) in distal rectal cancer, unreasonable sphincter saving surgery might cause a couple of troublesome complications in terms of oncologic or functional outcomes. Since preoperative staging work up recently have been developed with MRI or MDCT, it is important to assess whether rectal cancer invaded into surrounding sphincter or levator ani muscle based on MRI or MDCT coronal image study. If tumor is located at a very close distance or has invaded the adjacent sphincter muscle, the need of abdominoperineal resection is definite without any hesitation for curative resection. But, the actual number of cases of APR have been decreased in favor of sphincter preserving surgery even APR remains an important therapeutic option in the surgical treatment of low rectal cancer. Indication case for APR have become a intersphincteric resection or ultralow anterior resection and coloanal anastomosis Even patients who showed invasion of sphincter underwent sphincter saving surgery, lately proven safe in terms of recurrence and defecation functions. On practical view points on operative techniques, abdominal phase are same as TME techniques. Sharp pelvic dissection must be carried out along the visceral fascia enveloping the mesorectum to the levator ani muscle with preservation of pelvic autonomic nerve. Perineal phase dissection is a key process in APR. During perineal dissection, inadequate resection margin and blunt tissue dissection along the nonanatomical plane encourage implantation of a malignant cell and local recurrence. Moreever, it could lead to serious complications such as prostatic urethral injury, vaginal wall perforation, perineal sinus and fistula. Massive bleeding from pelvic side wall major vessels injury. Especially in males with very narrow pelvis, pelvic dissection is very difficult due to deep narrow and blunt sacral curvature of the pelvis. It is nearly impossible to reach the levator ani muscle and result in perineal dissections performed on excessively high levels. For colorectal surgeons with insufficient experience, it is difficult to dissect the rectum from the perineum upto the seminal vesicle level. In the classic pattern, anterior and lateral dissection from the prostate or vagina after the completion of posterior dissection. The dissected proximal colon was delivered outward through the perineal wound and with traction of the delivered portion of the colon, anterior dissection was performed. However, in patients with narrow pelvis, such delivery of the proximal colon through perineal wound can result in fractured tumor and local recurrence due to limited operation field. Therefore, it is mandatory that specimen must be delivered in situ after posterior, anterior and lateral dissection. During posterior dissection, gluteus muscle must be observed and removal of the ischiorectal fat tissue should be accomplished. In lateral dissection, levator ani muscle must be divided near the bony insertion. Finally, during anterior dissection, seminal vesicle and prostate gland must be exposed and neurovascular bundle observed at the 10 and 2 o'clock direction. In addition to TME on abdominal phase, Sharp Anatomical Perineal Dissection (SAPD) empowered by 3D concept based on MRI is a key process for prevention of local recurrence in APR.

Epigenetic Alterations and Loss of Imprinting in Colorectal Cancer.: Kim, Jong Woo; J Korean Soc Coloproctol. 2005;21(3):181-190.

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Abstract PDF: Two forms of genomic instability have been described in colorectal cancer: chromosomal (CIN) and microsatellite instability (MIN). Colorectal cancer has been considered to progress through one of these two major pathways. However, recently a CpG island methylator pathway (CIMP) has been established among sporadic MIN cancers. Aberrant methylation of a promoter CpG island is associated with inactivation of tumor suppressor genes and is one of the epigenetic alterations identified to be involved in tumorigenesis. Now, several types of epigenetic alterations appear to play roles complementary to genetic mutations in colorectal carcinogenesis and seem to contribute to the progression of cancer. Epigenetic alterations also increase the probability that genetic changes will lead to cancer initiation. So far, major epigenetic alterations have been categorized into four groups of dysregulations: 1) hypomethylation with oncogene activation and chromosomal instability, 2) hypermethylation with tumor suppressor gene silencing, 3) chromatin modifications, and 4) loss of imprinting (LOI). Especially, LOI is a common epigenetic variant and should have a field effect on the colon, making it more vulnerable to genetic insults. Genomic imprinting is parental-origin-specific allele silencing, a form of gene silencing that is epigenetic in origin and does not involving alterations in the DNA sequence but does involve methylation and other modifications that are heritable during cell division. LOI is the loss of parental-origin-specific marks, leading either to aberrant activation of a normally silent allele of a growth promoter gene or to silencing of the growth inhibitor allele. Most of the attention has been focused on LOI of the IGF2 (insulin-like growth factor II) gene in a Wilms' tumor and colorectal cancer. LOI of IGF2 involves abnormal activation of a normally silent maternally inherited allele and has been associated with personal and family history of colorectal cancer, supporting a role for LOI in carcinogenesis. LOI may be a valuable predictive marker of an individual's risk for colorectal cancer. Now, epigenetics and imprinting are emerging areas in the study of human-cancer genetics.

Current Status of Laparoscopic Colectomy for Colon Cancer.: Lee, Woo Yong; J Korean Soc Coloproctol. 2005;21(2):112-119.

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Abstract PDF: Although laparoscopic colon resection is a widely accepted treatment for benign colon disease, many questions have been raised about its value in management of colorectal cancer. The short-term benefits of this operation, such as decreased incidence of pulmonary complications, faster return of the bowel function, decreased narcotic requirements, shortened hospital stay, and faster recovery time, are now well established. However, there are many controversies for this method as a treatment of cancer. The main issues are adequacy of oncologic resection, recurrence rates and patterns, and long-term survival. Considering the results so far reported, laparoscopic colectomy seems to be feasible and safe. Modest benefits in the quality of life are observed. Same oncologic resection can be performed laparoscopically with no adverse influence on the recurrence rate. At least, equivalent survival is obtained by laparoscopic colectomy. Even the early results of laparoscopic colectomy for cancer are encouraging, the fate of this procedure rests with the long term analysis of number of trials currently underway.

Current Status of Stoma Researches in Korea.: Lee, Suk Hwan , Park, Eung Bum; J Korean Soc Coloproctol. 2005;21(1):57-63.

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Abstract PDF: Stoma operations are one of the most frequently performed operation by the colorectal surgeons. And the consequences of the stoma operation of the patients are well known. However, most colorectal surgeons who performed stoma operation were not aware of the problems that are part of the rehabilitation of the ostomates. In order to elucidate the current status of the stoma studies in Korea, literature reviews were performed by using the Korean medical literature database. Most of the Korean literatures written by the colorectal surgeons are related with the postoperative complications of stoma surgeries. Very few papers are concerned with rehabilitation issues including postoperative adaptation of ostomates, quality of life, and stoma nursing care. Recently, more and more papers concerning the stoma rehabilitation issues were published and the interests in the patient's adjustment to a change in body function are growing. Stoma rehabilitation program should be the part of the nations' welfare program which would be successful with the active participation of the colorectal surgeons, enterostomal therapists and ostomates. We, colorectal surgeons, and the Korean Society of Coloproctology should do the major role in stoma-related researches and cooperate with the enterostomal therapists and ostomates organizations in order to establish and develop the stoma rehabilitation program in Korea.

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