Annals of Coloproctology

Volume 13(2); June 1997

Original Articles

Tumor Angiogenesis as a Prognostic Assay for Patients with Colorectal.: Hyun, Moon Soo , Choi, Hong Jo , Jung, Ghap Joong , Kim, Sang Soon; J Korean Soc Coloproctol. 1997;13(2):161-174.

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Abstract PDF: The growth and maintenance of solid tumors are dependent on new capillary ingrowth:a process called "angiogenesis." Thus, after a new tumor has attained a smallsize of a few millimeters in diameter(about 106 cells), further expansion of the tumor-cell population requires the induction of new capillary blood vessels. These new vessels also increase the opportunity for hematogenous or lymph node metastasis. Thus this study was designed to examine the microvessel count at the invasive margin in colorectal carcinoma to determine how angiogenesis correlates with clinicopathologic factors and prognosis. Paraffinembedded tissues from 127 patients with primary colorectal carcinomas that had been completely removed were retrieved and analyzed for angiogenesis. Vessels were immunostained with anti-factor VIII polyclonal antibody, and areas with the most discrete microvessels were counted in a 200 x field, which were defined as angiogenesis score(AS). The mean AS for anti-factor VIII antibody in this study was 55+/-08; therefore, cases were classified into two subgroups : AS high group(n=67), for which AS was greater than 55 and AS low group(n=60), for which AS was equal to 55 or less. There were no significant intergroup difference regarding sex ratio, histologic grade, depth of invasion, or lymphatic invasion. AS was, however, significantly related to tumor size, venous invasion, lymph node metastasis, and liver metastasis(P=0.000, P=0.001, P=0.021, and P=0.004, respectively). The incidence of high AS group in Antler-Coller D was significantly greater than that in Antler-Coller A and B, and Antler-Coller C(P<0.05, respectively). The recurrence rate in high AS group was 32.0%, which was, though statistically insignificant, higher than that in low AS group(17.2%). The 3 year survival rates of high AS group were significantly (P=0.004 both for overall cases and curatively-resected ones) worse than those of low AS group. This study suggests that the growth of colorectal carcinoma is dependent on ingrowth of new blood vessels, and that angiogenesis assessed by the microvessel count using immunohistochemical stains is an important predictor of tumor behavior and may identify patients at higher risk for recurrence and early death.

Pathologic Review of the Rectal Villous Adenoma.: Lim, Kyung Uk , Shin, Young Do , Lee, Seok Hwan , Kee, Kee Hyung; J Korean Soc Coloproctol. 1997;13(2):175-182.

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Abstract PDF: Neoplastic polyps of colon are one of the most risky factors for colorectal cancer. Particularly villous adenomas have more malignant potential than other neoplastic polyps. The preoperative detection of malignant change in villous adenoma is very important to determine treatment modality of patients. We conducted that total twenty-four cases of villous adenoma who were diagnosed and treated at our institution between January 1990 and December 1995 were reviewed retrospectively. The peak incidence of age was 7th decades. And male to female ratio was 2 : 1. Size of the adenoma ranged from 1.2 to 10.7 cm with a mean diameter of 3.9 cm. Five cases(20.8%) were between 1 and 2 cm, 10(41.7%) between 2 and 4 cm, and 9(31.5%) greater than or equal to 4 cm. Location of the adenoma were 10 cases(41.7%) in upper rectum, 8(33.3%) in rectosigmoid, and 6(25.0%) in lower rectum respectively. Pathologic examination of the resected specimen were diagnosed 9(37.5%) as benign villous adenomas, 10(41.7%) as in situ carcinoma, and 5(20.8%) as invasive carcinoma. The diagnostic accuracy to detect in situ carcinoma or invasive carcinoma was endoscopic examination in 66.7 percent and digital examination in 86.7 percent. The grade of in situ carcinoma had not significantly relationship with the size of the adenoma on our study. However, invasive carcinoma was significantly related to adenoma size(P<0.05) as following results zero percent between 1 and 2 cm, 20 percent between 2 and 4 cm, and 33.3 percent greater than or equal to 4 cm. In conclusion, the larger villous adenoma has higher malignant potential, especially greater than or equal to 4 cm in size. Added, the clinical impression of the malignancy on digital examination can be more accurate than preoperative endoscopic examination on our study.

Comparative Study of Sphincter Saving Resection and Abdominoperineal.: Yu, Chang Sik , Kim, Jin Cheon , chung, Hee Won , Lee, Han Il , Lee, Kang Hong; J Korean Soc Coloproctol. 1997;13(2):183-190.

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Abstract PDF: We compared the recurrence rate, survival and functional results of 159 low rectal cancer patients retrospectively, who had been performed 75 sphincter saving resections (SSR) and 84 abdomino-perineal resections(APR) during July 1989 to December 1994. The local recurrence rate was 9.3% in SSR and 8.3% in APR group, while systemic recurrence rate was 20.5% and 16.7%, respectively(p>0.05). Three year survival rate was 70% in SSR and 85% in APR group. Comparing with Dukes'stage, it was 69%, 89% in Dukes'B and 63%, 84% in Dukes'c stage, respectively(p>0.05). In respect to the number of metastatic lymph node,3 year survival rate was 80%,95% in Nl group(< OR =3 metastatic lymph nodes) and 61%,72% in N2 group(> OR =4 metastatic lymph nodes), respectively(p>0.05). According to the distal resection margin(DRM), it was 100% in group 1(1 cm< OR =DRM<2 cm), 63% in group 2(2 cm< OR =DRM < 3 cm) and 72% in group 3(DRM> OR = 3 cm), respectively(p>0.05). Voiding dysfunction was developed 36.0% of SSR and 28.6% of APR postoperatively. Erectile and ejaculatory dysfunction rate was 33.3%, 66.7% of SSR and 58.8%, 88.3% APR group respectively, There were no significant differences in recurrence rate, survival rate and functional results Between SSR and APR group. Conclusively, sphincter saving resection in low rectal cancer surgery did not seem to affect survival or recurrence. A good functional outcome in the SSR suggests it to be a procedure of choice, if possible.

A Clinical Study of Colorectal Cancer in Patients More Than 65 Years Old.: Park, Byeong Seon , Baek, Moo Jun , Lee, Moon Soo , Song, Ok Pyung; J Korean Soc Coloproctol. 1997;13(2):191-202.

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Abstract PDF: This report is a retrospective clinical analysis fo 84 cases more than 65 years of colorectal carcinoma treated surgically by the Department of General Surgery, College of Medicine, Soon Chun Hyang University from January 1991 to December 1995. The average age was 71.3 years; 49 patients were male and 35 were female. Tumor location was as follows; rectum 39(46.4%), sigmoid 22(26.2), ascending colon 12(14.3%), descending colon 8(9.5%), transverse colon 3(3.6%). The most frequent symptom in colorectal cancer was abdominal pain. The patients whose clinical symptom had been for less than 1 month before the hospitalization was about 31.0%. The rate of curative resection was 88.1%, Emergency operation was performed about 19.0%(16 cases). By Astler Coller classification, there were stage A 2 cases(2.5%), Bl 13 cases(16.5%), B2 28 cases(35.4%), Cl 2 cases(2.5%), C2 24 cases(30.4%), D 10 cases(12.7%). The average size of mass was 4.41 on. The most common pathologic type was moderately differentiated adenocarcinoma. Postoperative mortality rate was 4.7%(4 cases). The 5 year cumulative survival rate was 42.9%. In conclusion, the postoperative mortality and survival rates obtained in this study encourage us not to consider age as a limiting factor for curative surgical treatment. Early detection of colorectal cancer, adequate management of preoperative underlying disease and aggresive curative resection are improving outcome in the surgery of old aged patients with colorectal cancer.

Results of Surgical Treatment of Crohn`s Disease.: Lee, Wang Jun , Park, Kyu Joo , Park, Jae Gahb , Lee, Kuhn Uk , Choe, Kuk Jin; J Korean Soc Coloproctol. 1997;13(2):203-214.

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Abstract PDF: We have performed a retrospective analysis of 42 patients with Crohn's disease operated at the Department of Surgery, Seoul National University College of Medicine between 1978 and 1997. The most frequently involved site was ileocecum(40.5%) and small bowel(40.5%), whereas the large bowel and anorectum occupied only 2.4% and 7.1% rutspectively. In 39 patients with bowel involvement, 35 patients(90%) required resection as primary surgical operations(small bowel 18, right colon 11, ileocecum 6). The remaining 7 patients underwent intaabdominal abscess drainage(2), perianal abscess drainage(2), appendectomy(1), and exploration only(1). Two cases of small bowel resection were combined with multiple stricturoplasties. After mean follow-up period of 46 months(range 1~180, median 22 months) after primary operation, the cumulative reoperative recurrence rate was 25% at 3 years,47% at 5 years, and 79% at 10 years, respectively. The ileocecal type had higher cumulative reoperative recurrence rate than small bowel type(50% compared to 34% at 5 years). The age at symptom onset, age at time of first operation, duration between symptom onset and operation, and the indication for operation had no effect on reoperative recurrence rate. Despite short follow-up period and limited number of patients, our results confirmed that Crohn's disease is associated with high rate of recurrence requiring re-operations.

A Clinical Study of Periappendiceal Abscess.: Kim, Dong Hoan , Chung, Woo Shik , Ryu, Seong Ryul , Chang, Tae Soo; J Korean Soc Coloproctol. 1997;13(2):215-222.

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Abstract PDF: This is a clinical analysis and review of one-hundred ninety-four patients with periappendiceal abscesses who were treated at the Departmeat of Surgery, Masan Samsung Hospital over a ten year period from January 1985 to December 1994. The following results were obtained. The incidence of periappendiceal abscesses was 7.24% of the total cases of appendicitis operated on during the same period, and most of the patients(43.8%) were over fifty years old. The male to female ratio was 1:1.02. 41.2% of the patients had operations within four days after their symptoms occurred. On admission, the most common physical finding was tenderness on the right lower quadrant of the abdomen (92.9%) and leukocytosis(> OR = 10,000/mm3) was noted on CBC in 82% of the patients. Abdominal sonograms revealed periappendiceal abscesses in 88% of the patients, 83% were revealed with barium enema and 88% with abdominal CT scan. Many patients(75.5%) visited the local clinic and were treated under the diagnosis of gastritis or enteritis instead of appendicitis. One-hundred eighty-three patients(94.3%) had appendectomies with drainages(94.3%), two patients had drainages of abscesses without appendectomy, six patients had ileocecal resections and three patients had right hemicolectomies. Microbiologically, E. coli was the most frequently cultured species(63%) from abscess, and Klebsiella, Enterococcus and Proteus were isolated in some cases. Postoperative complication occurred in seventy-five patients(38.6%) and the most frequent complication was wound infection(28.8%). There was no mortality and the mean hospital stay was fifteen days.

Randomized Controlled Trial

A Comparison of Oral Sodium Phosphate and Polyethylene Glycol Solution for.: Cho, Hang Jun , Kang, Yoon Sik , Kim, Tae Soo , Jung, Seung Yong , Kim, Do Sun; J Korean Soc Coloproctol. 1997;13(2):223-228.

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Abstract PDF: BACKGROUND
Polyethylene glycol(PEG) has been the most widely used colonic lavage solution. But large volume and salty taste of PEG solution is a problem which can lead to the noncompliance and the poor bowel cleansing. Recent reports have suggested that sodium phosphate solution of much smaller volume is more effective in colon cleansing ability and more easier to complete. Therefore, this study was designed to compare two solutions for colonoscopy and to determine the differences in either patient compliance or cleansing ability.
METHOD
Eighty-two patients were randomized to take either oral sodium phosphate solution or 2 liter of PEG solution. Patient's discomfort and tolerance during ingestion was asessed by questionnaire and one colonoscopist who did not know the type of solution, assessed colonic preparation status.
RESULTS
Among 25 patients experiencing two separate colonoscopies with PEG solution and sodium phosphate solution respectively, 19(76%) patients preferred sodium phosphate solution. Sodium phosphate solution was found to be easier to take. Sodium phosphate caused thirst more frequently(p=0.013) than PEG solution. Particulate stool and water retention status were similar in two groups. Gas bubble formation that disturbs luminal observation was more frequently found in sodium phosphate preparation group(P=0.00). Sodium phosphate was more effective in right colon cleansing ability than PEG preparation(P=0.04). The Colonoscopist assessed sodium phosphate as "good" in 47.2% vs 58.6% after PEG preparation as a whole, but there was no statistical difference. CONSLUSION: Sodium Phosphate solution is better tolerated and more easier to take than PEG solution. Gas bubble formation is a correctable problem, but right colonic cleansing effect is not. Our results showed that sodium phosphate is likely to be more effective in colonic cleansing effect comparing to polyethylene glycol solution.

Original Articles

New Technique for Treatment of Hemorrhoids by Using Bipolar.: Yoo, Jung Joon , Lee, Chul Ho , Lee, Kwang Real , Park, Se Young , Lim, Seok Won; J Korean Soc Coloproctol. 1997;13(2):229-238.

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Abstract PDF: Hemorrhoids are the most common problem in anorectal disease, presenting bleeding and prolapse. The definitive treatmant for severe hemorrhoids is surgery, but for milder cases, it is difficult to recommend a hemonhoidectomy. Some patients, especially relatively young and active males, don't want to be admitted, and they ask for ambulatory surgery. For that reason, we have developed a modified bipolar probe which can be simply and conveniently applied and which produces as good a result as that produced by a radical hemouhoidectomy. We restrospectively analyzed the cases of 341 patients who had received a BHC(bipolar homo-coagulation) between July 1994 and December 1995 and who had been followed up for at least six months. The results are as follows: 1) 309 cases(90.6%) were Grade II, and 32 cases(9.4%) were Grade III hemorrhoids. The chief complaint was bleeding in 179 cases(52.5%) and prolapse in 148 cases(43.4%). 2) Evaluation of the BHC procedure was based on patient satisfaction. About threefourths of the patients were very satisfied, and 59 patients(17.3%) were somewhat satisfied. Grade III patients were relatively more satisfied than others, regardless of the number of piles managed by BHC, and patients whose symptom was bleeding were significantly more satisfied, in general, than those with prolapse. Only 26 patients(7.6%) were dissatisfied. 3) No postoperative discomfort was observed in 153 cases(44.9%). However, post-operalive pain and bleeding were present in 92 and 50 cases, respectively. 4) Complications were observed in a total of 26 cases(7.6%). Skin tags were the most frequently observed complication(13 cases), followed by secondary bleeding which was managed by sutures(6 cases). 5) Three patients experienced recurrent hemorrhoids. Two were treated by using a radical hemorrhoidectomy, and one by using a second BHC. Based on these five results, we consider BHC to be a very useful technique for treating Grade II and early Grade III hemorrhoids by outpatient surgery and to be a time-saving procedure for treating accessory piles after main pile extirpation. Furthermore, early detection of hemorrhoids along with their early management by BHC will reduce the need for more radical surgery at some later time.

A Clinical Study on Sliding Skin Graft for the Treatment of Anal Stenosis.: Huh, Moo Ryang; J Korean Soc Coloproctol. 1997;13(2):239-246.

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Abstract PDF: Twenty five patients with moderate to severe anal stenosis were treated with sliding skin graft during the period of time from April 1987 to March 1996. And a follow-up study was carried out on 18 cases among them. The original causes of the anal stenosis were previous necrotherapy in 14, hemouhoidectomy in 3, and cryotherapy in one. Postoperatively, partial disruption of the suture line developed in 2 cases and perianal fistula in one. Long term clinical results were good in 12 cases, fair in 4, and poor in 2. As a result, sliding skin graft is thought to be a simple and effective method for the treatment of moderate to severe anal stenosis.

Proper Selection of Antibiotic According to the Bacterial Culture of Anorectal.: Kang, Hae Sung , Shim, Kang Sup , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 1997;13(2):247-254.

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Abstract PDF: The aim of this study was to determine the guideline of usage of antibiotics for anonectal suppurative disease. This study was conducted in consecutive 96 patients, who were taken surgical treatments for the anorectal abscess at the department of general surgery of Ewha Womans University Hospital, from January 1990 to December 1994. All subjects were classified in terms of age, gender, duration, history, associated disease, classification, location, and isolation of organism. The incidence of the anorectal abscess was highest in the 3rd and 4th decade of age and male in terms of gender. 80.3% of all patients were admitted within 10 days after onset. The most common past history of anorectal disease was the anorectal abscess(15 cases, 15.6%) and the associated systemic disease was tuberculosis(9 cases, 9.4%). The main type of anoreclal abscess was the perianal abscess(87.5%) and the most frequent location was posterior area(39.6%). In the pus culture and isolation test, 90.6% of all patients had colony formation and the most frequently cultured organism was E.coli(55 cases,57.3%), followed by Klebsiella species(15 cases,15.6%) and anaerobic Bacteroid species(14 cases,14.6%). In antibiotic sensitivity test, the 3rd generation of aminoglycoside was sensitive in 89 cases and resistant in 3 cases, and the 3rd generation of cephalosporin was sensitive in 87 cases and resistant in 5 cases. These results suggest that the 3rd generation of aminoglycoside or the 3rd generation of cephalosporin could be selected to treat the anorectal suppurative disease.

Clinical Study of External Thrombotic Hemorrhoids-A study of the changes in.: Lim, Seok Won , Park, Weon Gap , Lee, Chul Ho , Lee, Kwang Real , Yoo, Jung Jun; J Korean Soc Coloproctol. 1997;13(2):255-262.

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Abstract PDF: An external thrombotic hemorrhoid is a very painful disease with a high incidence rate. The chief complaints encountered by the surgeon are protrusion and pain. However, because the spontaneous healing rate is very high, there is no consensus on whether conservative management or surgery is a more effective treatment policy. In an attempt to resolve this problem, we performed a clinical analysis of fifty patients with external thrombotic hemorrhoids who were treated by conservative management at Song-Do Colorectal Hospital from October 1996 to December 1996. We recorded the time required for the protrusion and the pain to disappear and performed manometry to check the sphincter pressure and tissue pathology to determine the pathogenesis of the external thrombotic hemorrhoid. The results are as follows: 1) Based on pathology, the cause of the external thrombotic hemorrhoids was venous thrombosis due to venous stasis, not a hematoma due to venous rupture. 2) Manometry showed that the resting sphincter pressure and the squeezing sphincter pressure for the patients with external thrombotic hemorrhoids was higher than those of the control group, which was the reason for the venous stasis. In conclusion, because an external thrombotic hemorrhoid is just a thrombosis due to venous stasis, the thrombosis can be improved by using methods such as a warm sitz bath and analgesics to decrease the sphincter pressure. Hence, conservative management should be the preferred treatment in almost all cases.

Case Reports

Three Cases of Familial Adenomatous Polyposis.: Kim, Jin Ah , Seo, Geom Seog , You, Keyoung Hoon , Hwang, Ho Geun; J Korean Soc Coloproctol. 1997;13(2):263-272.

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Abstract PDF: Familial polyposis is a rare genetic disorder which the large intestine is diffusely carpeted by numerous adenomatous polyps. According to the recent studies, familial polyposis is a disease which produces polypoid lesions not only in the large intestine but also in the stomach, duodenum, ileum and jejunum. The natural course of extracolonic lesions is variable, but the colonic polyps are associated with high incidence of cancer. The risk of malignant change is virtually 100% if untreated. Thus when adenomatosis is noted, familial members at risk for familial adenomatous polyposis must be screened and prophylactic surgery performed to prevent inevitable colon cancer. Controversy exists about the most appropriate prophylactic treatment. Because of many disadvantages of ileostomy, total colectomy with ileorectal anastomosis (ileoproctostomy) or total colectomy with rectal mucosa stripping and ileoanal anastomosis has become a more preferred approach. After ileorectal anastomosis, polyps in the retained rectum must be removed by endoscopic polypectomy and rigorously followed by sigmoidoscopy every few months for prevention of polyp reccurence or malignant transformation. We experienced three cases of familial adenomatous polyposis and 2 of them were treated successfully by preoperative colonoscopic polypectomy, total colectomy and ileoproctostomy.

A Case of Omental Actinomycosis.: Lee, Do Sang , Song, Moo Hyung , Kim, Wook , Park, Il Young , Im, Keun Woo; J Korean Soc Coloproctol. 1997;13(2):273-278.

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Abstract PDF: Actinomycosis is relatively rare infection which is produced by an anaerobic organism, actinomycetes, normally residing in the mouth, bowel and female genital tract. This disease is characterized by chronic inflammatory induration with abscess and multiple sinus formation. In most cases, the onset of this is preceded by an inflammatory or traumatic history on abdomen but diagnosis can't be made until operation. Recently this disease is treated with antimicrobial therapy and wide surgical excision. We experienced a case of omental actinomycosis and report it with brief review of literatures.

Original Articles

A Case Report of Papillary Serous Peritoneal Carcinoma Arising from the Rectum.: Lee, Sang Jeon , Sung, Ro Hyun; J Korean Soc Coloproctol. 1997;13(2):279-284.

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Abstract PDF: Papillary serous peritoneal carcinoma(PSPC) is a rare malignancy that arises in the peritoneum and histologically resembles papillary serous carcinoma of the ovary. If peritoneal carcinomatosis occurs in the absence of an obvious primary tumor site and is associated with a papillary serous pathology, we may be dealing with the distinct entity of PSPC of extraovarian origin. Radiological findings suggesting the diagnosis are diffuse microcalcifications in the peritoneum, which occur in relation to psammoma bodies. The Ca-125 is most often abnormal and, not uncommonly, markedly elevated. The diagnosis requires that the surgeon identify grossly normal ovaries or minimal surface involvement. If PSPC is confirmed, a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and aggressive debulking surgery should be carried out, followed by cisplatin-based chemotherapy. We report a case of PSPC arising from the rectum in a 41 year-old woman.

Concurrence of Colon Cancer and Dermatomyositis.: Lee, Kyeong Geun , Park, Young Seok , Jun, Kyu Young; J Korean Soc Coloproctol. 1997;13(2):285-290.

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Abstract PDF: Dermatomyositis is a severe, idiopathic systemic disorder with predominant involvement of skin and skeletal muscle. The association of adult dermatomyositis and malignancy in particular has generated much attention. The reported prevalence of cancers in this disease varies from 6.7% to 52.2%. We experienced a concurrent case of transverse colon cancer and dermatomyositis on 67 year old female patient and report with review of literatures.

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