Annals of Coloproctology

Volume 13(4); December 1997

Original Articles

Immunohistochemical Analysis of the EGFR and VEGF Expression in Human.: Lee, Sang Hyeong , Park, Seong Il , Lim, Hyun Muck , Park, Seong Jun; J Korean Soc Coloproctol. 1997;13(4):547-556.

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Abstract PDF: The EGFR has been proposed as a stimulator of cell growth in some neoplasms. The VEGF play an important role in angiogenesis of several tumors. This study aimed to determine the EGFR and VEGF expression in colorectal adenocarcinoma and to correlate the expression of these gene with variable prognostic factors. Significant relationship was observed between the EGFR and histopathologic differentiation or lymph node involvement. But EGFR had no relation to depth of invasiveness or serum CEA level. On the other hand, VEGF had only relation to histopathologic differentiation. VEGF had no relation to lymph node involvement, depth of tumor invasiveness or serum CEA level. We conclude that EGFR expression in human colorectal adenocarcinoma was significantly associated with prognosis. But VEGF expression was not associated with prognosis. More studies are needed to determine whether EGFR expression is a clinically valuable prognostic factor.

Clinical Significance of Palliative Resection in Advanced Colorectal Cancer.: Lee, Han Il , Yu, Chang Sik , Kim, Chang Nam , Kim, Jin Cheon; J Korean Soc Coloproctol. 1997;13(4):557-564.

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Abstract PDF: Palliative resection in colorectal cancer seems to be questioned due to high mortality and morbidity in spite of relief of cancer symptom and lengthening of survival time. We studied to identify benefits of palliative resection in advanced colorectal cancer. We retrospectively reviewed 96 patients who underwent palliative surgery during June 1989 to December 1995 at Asan Medical Center and evaluated quality of life(QOL), rates of morbidity and mortality, chemotherapy response rates, duration of symptom free and survival time. The overall rate of palliative surgery in total colorectal cancer patients was 9.1%(96/1055) and the most common location of primary tumor was rectum. The causes of palliative surgery were hepatic metastases(44), peritoneal disseminations(20), local invasions(17), combined causes(14) and lung metastases(one) in descending order. Postoperative complication was 13.3% (6/45) after resection surgery and 25.5%(13/51)after non-resection surgery. Mortality rates was 0 and 9.8 percent, respectively. Improvement of QOL was 75.6% and 72.5%, respectively. However, 30 cases(65.2%) showed still moderate or severe degree of poor QOL in non-resection group compared with 11.1% of resection group postoperatively. Response rates of postoperative adjuvant chemotherapy was higher(31.8% vs. 7.4%) and median relief of preoperative cancer symptom was longer(6.2 vs. 3.0 months) in resection group. One year survival rates were 42% in resection surgery and 16.7% in non-resection surgery Palliative resection can improve QOL, response rates of postoperative adjuvant chemotherapy, relief of preoperative cancer symptom and survival rates without increase of morbidity or mortality. So if feasible, palliative resection should be encouraged in selected patients.

Laparoscopic: Assisted Oncologic Right Hemicolectomy : Based on Vascular.: Choi, Gyu Seog , Jun, Soo Han; J Korean Soc Coloproctol. 1997;13(4):565-572.

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Abstract PDF: The aim of this study was to find out an effective method of laparoscopic oncologic right hemicolectomy based on vascular anatomy of the right colon and patterns of lymph node metastasis. From September 1994 to November 1997,20 hemodynamically stable patients received curative laparoscopic-assisted right hemicolectomy for adenocarcinoma by one surgeon. Simultaneously anatomic variations of right colonic vessels and patterns of lymph node metastasis were analyzed. All operations were performed by laparoscopic-assisted method that consisted of intracorporeal mobilization of the right colon followed by extracorporeal resection and anastomosis and lymph node dissection up to superior mesenteric vessels under direct vision through mini-incision just above the root of superior mesenteric vessels. Ileocolic (ICA) and mid colic artery (MCA) existed constantly (100%), right colic artery (RCA) existed only in 12 cases (60%). Mean distance from origin of MCA to ICA was 3.2cm. Mean number of lymph nodes harvested from SMA area was 2.9 per case. In 2 cases, they showed metastasis. Astler-Coilers stage Bl, B2, Cl, C2 were distributed in 6, 8, 1, 5 cases respectively. Mean number of lymph node dissected and length of resection margin was 29.3 and 8.7 cm. Operative time, time to oral intake, hospital stay was 187 minutes,2.6 days,7.2 days, respectively. Open conversion was needed in 1 case due to duodenal invasion. Mean 14 months follow-up showed 2 recurrences. One who have had duodenal wedge resection due to cancer invasion underwent reresection of duodenum because of duodenal recurrence 12 months after the first operation. The other suddenly died of myocardial infarction after operation for ovarian recurrence 8 months later to her right hemicolectomy. Right colonic vascular anatomy was so various but the area from MCA to ICA was constantly within 4 cm and, lymph nodes in that area must be cleared. Therefore, laparoscopic intracorporeal mobilization and extracorporeal resection of the right colon and lymph node dissection through small incision was effective, safe and one of the best method to get advantages of laparoscopic and open surgery simultaneously.

Clinical Value of Pre- and Post-operative Serum Carcinoembryonic Antigen(CEA).: Yun, Young Wook , Yu, Hee Chul , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 1997;13(4):573-582.

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Abstract PDF: The clinical value of the pre-(165 pts) and post-operative(149 pts) serum levels of carcinoembryogenic antigen(CEA) in 190 patients(pts) with colorectal cancer was investigated, who had a curative surgery and an abnormally elevated levels of CEA (> or=5 ng/ml) at Department of General Surgery, Chonbuk National University Hospital during 1989 to 1996. The results are as follows: 1) The preoperative positive rates of CEA level were 49(29.7%) of 165 patients, so preoperative CEA level measurement was no usefulness for screening test of colorectal cancer. The incidence of preoperatively elevated CEA levels in Dukes stages A, B, C, and D were 0, 28.6, 32.8 and 42.9% respectively, There was significant association between increased proportion of patients with preopertive serum CEA(> OR = 5 ng/ml) and the progressive stages of colorectal cancers(P<0.05). 2) There was no significant association between the frequency of abnormal CEA level and histologic differentiation of tumor. 3) The recurrence rate was 16.4% and 30.6% in patients with preoperative CEA < 5 ng/ml and > OR =5 ng/ml, respectively(p<0.05). 4) In patients with recurrence, the lymph node positive group(70.6%) was larger than the negative(29.4%)(p<0.05), and preoperative positive rate of CEA value was 44%. 5) The recurrence rate in Dukes stages A, Bl, B2, Cl, C2, and D were 0, 8.7, 12.7, 16.7, 32.3, and 90.0% respectively(p<0.01). 6) There was no significant association between the frequency of abnormal CEA level and location of tumor. 7) The recurrence rate was 12.3% and 65.7% in patients with postoperative CEA < 5 ng/ml and > OR = 5 ng/ml, respectively(p<0.01). 8) In patients with metastasis, postoperative positive rate of CEA level was 63%(p< 0.01).

Can We Predict the Severity of Fecal Incontinence by Preoperative Physiologic.: Joo, Jae Sik , Son, Sang Ho , Han, Jung Ki , Son, Kyung Soo , Sung, Sang Young; J Korean Soc Coloproctol. 1997;13(4):583-590.

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Abstract PDF: Many kinds of different treatment options for fecal incontinence such as biofeedback therapy, anterior or posterior sphincteroplasty, pelvic floor repair, gracilis or gluteus muscle transposition have been introduced. However, appropriate indications for these treatment options have not yet been delineated up to now. PURPOSE: The aim of this study was to access the preoperative severity of fecal incontinence by physiologic tests to give an idea that indications of appropriate selection criteria and parameters for assess the outcome could be simultaneously considered by preoperatively objective physiologic data. MATERIALS AND METHODS: From January 3, 1997 to, August 1, 1997 all patients with fecal incontinence who visited colorectal clinic in the Department of Surgery, Korea Veterans Hospital, were classified into two groups according to the severity of fecal incontinence (0~20): Group I (1~9), Group II (10~20) and compared them with the results of physiologic tests: anorectal manometry, endorectal ultrasound (ERU), cinedefecography, and pudendal nerve terminal motor latency (PNTML). Statistical analysis was performed by Student's-t test, and Chi-square test and p<0.05 was considered significant.
RESULTS
The number of GI was 25, and GII was 22. There were no differences between the two groups in terms of age (GI: 57.7+/-14.5, GII: 61.4+/-14.0years), gender (male: female, 19:6, 16:6), cause (neurogenic; 11/25 (GI),7/22(GII), postanal surgery; 6/25,6/22) obstetric trauma (2/25, 2/22), anal trauma (1/25, 1/22) diabetes melitus (1/25, 2/22), rectal prolapse (2/25, 1/22), and others (2/25, 3/22), duration of fecal incontinence (64.4+/-82.2, 48.7+/-65.3 months), high pressure zone (3.3+/-1.7, 3.5+/-1.4 cm), mean resting pressure (50.5+/-27.0, 51.9+/-18.7 cm H2O), maximal resting pressure (88.4+/-50.6, 89.4+/-41.8 cm), maximal squeezing pressure (150.6+/-71.0, 129.7+/-59.5 cm H2O), rectoanal inhibitatory reflex (13/21, 8/21 positive), sensitivity (37.5+/-15.2, 41.8+/-29.0 cc), compliance (19.0+/-14.5, 21.4+/-39.4 cc/cm H2O) in anorectal manometric findings, anal sphincter defect (13/21, 15/22 positive), size of defect (60+/-26.30degrees, 71 +/-30.8degrees/360degrees), thickness of the external anal sphincter (3.46+/-0.78, 3.84 +/-1.02 cm), thickness of internal anal sphincter (1.58+/-0.79, 1.74+/-0.81 cm) in ERU, anorectal angle in rest (85.2+/-28.0degrees, 97+/-22.9degrees), squeeze (72+/-27.1degrees, 82 +/-19.7degrees), push (100+/-43.9degrees, 117.9+/-34.5degrees), length of perineal descent in rest (3.7+/-1.2, 3.6+/-1.7 cm), squeeze (2.9+/-1.5, 2.7+/-1.5 cm), push (7.9+/-3.5, 6.6+/-2.6 cm) in cinedefecography. However, rectal capacity in manometry (212.5+/-99.9, 155+/-51.5 cc, p<0.05), right PNTML (1.73+/-0.39, 2.71+/-0.83 ms, p<0.001), and left PNTML (1.83+/-0.43, 2.94+/-0.80 ms, p<0.001) were significantly increased in GII compare to those of GI.
CONCLUSION
As the severity of fecal incontinence was increased, rectal capacity, right and, left PNTML were increased.

Defecographic Findings in Patients with Fecal Incontinence.: Park, Hyo Jin , Jung, Jun Keun , Shin, Jae Ho , Lee, Sang In , Park, In Suh; J Korean Soc Coloproctol. 1997;13(4):591-596.

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Abstract PDF: We performed this study to investigate defecographic findings in patients with fecal incontinence and to compare these findings with age-matched asymptomatic controls. Twenty patients with fecal incontinence and 20 asymptomatic subjects were included. Videodefecography and pelvic electrophysiologic test were performed. There were no significant differences on the presence of rectal wall changes such as rectocele, mucosal prolapse, or incomplete evacuation, but intussusception was more common in patients group. The anorectal angle were 112.8+/-16.2degrees, 93.0+/-15.0degrees, 118.8+/-16.3degrees at resting, squeezing, and straining, respectively in controls, whereas 121.5+/-20.8degrees, 110.8+/-22.2degrees, 132.0+/-21.1degrees, respectively in patients group. There were significant differences of anorectal angle at squeezing and straining in patients group compared with controls(p< 0.05). Perineal descent was significantly decreased at squeezing in patients group compared with controls(p<0.05). Anal canal width was signi(icantly widened in patients group compared with controls(p<0.05). There were no differences in various defecographic parameters depending on the presence of pudendal neuropathy. In conclusion, defecographic findings in fecal incontinence showed more obtuse anorectal angle, poorer perineal descent at squeezing, and widening of anal canal.

Treatment of Abnormal Rectal Sensation in Cerebrospinal Disease with.: Nah, Yong Ho; J Korean Soc Coloproctol. 1997;13(4):597-602.

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Abstract PDF: Cerebrospinal disease or injuries frequently result in defecatory difficulty. Management of these patients requires an understanding of the alterations in the mechanisms regulating colorectal function in the cerebrospinal disease. Rectal sensation is usually impaired in cerebrospinal disease and this is one of the pathogenic mechanisms of defecatory difficulty Aim : This study was carried out to evaluate a biofeedback treatment in the patients with impaired rectal sensation after cerebrospinal disease. Subjects : Thirteen patients (5F, 8M, mean age 36 years, range 14~56) with impaired rectal sensation and constipation over 6 months duration developed after brain or spine operation were studied. These included 7 traumatic head injury (5: temporoparietal epidural hematoma, 2: frontal lobe epidural hematoma) and 6 HNP (3: L4~5, 3: L5 ~S1) operation. METHODS: These patients were evaluated by questionnaire, office examination, colon transit studied, anorectal manometry including rectal sensation, balloon expulsion studies, and defecography. All patients underwent biofeedback treatment twice a week for 2 or 3 months.
Results
: Six brain hematoma and two HNP patients had impaired rectal sensation with anismus and the remaining 5 had only impaired rectal sensation. One brain hematoma (temporoparietal) had anosmia. All patients had normal anal basal pressure, squeeze pressure, rectal compliance, and intact rectoanal inhibitory reflex. Colonic transit time was delayed, but the delay was accounted for by prolonged rectal transit time. The mean volume at which anal relaxation first occurred were 12 ml (range 5~15 ml). The mean threshold volume at which these patients experienced rectal sensation were 90 ml (range 60~130 ml). Biofeedback conditioning in these 13 patients led to normal sensory threshold (mean 20m1, range 10~30 ml) in all patients. Biofeedback also provided spontaneous good passage of stool. Conclusion : Biofeedback treatment appears to be effective in impaired rectal sensation after cerebrospinal operation. Also central neural mechanism may be involved in the pathogenesis of anismus.

Evaluation of Gastric Emptying in Patients with Chronic Slow Transit.: Moon, Yoon Jae , Park, Hyo Jin , Lee, Kwi Soon , Park, In Suh; J Korean Soc Coloproctol. 1997;13(4):603-610.

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Abstract PDF: OBJECTIVES
Slow transit type of chronic constipation can be divided into two types, colonic constipation, and generalized gastrointestinal dysmotility. However, it is debatable whether generalized GI dysmotility should be considered as upper gastrointestinal dysmotility secondary to colonic constipation or independent type of chronic constipation. In this study, we compared gastric emptying time(T1/2) of patients of chronic constipation with that of normal controls, and tried to find out any relationship between segmental colonic transit time and gastric emptying time.
METHODS
Twenty three patients with chronic slow transit constipation who either visited or admitted to Youngdong Severance Hospital between september 1995 to lune 1997, and 27 normal controls were recruited. Both the patients and normal controls were fed with radioopaque material and colonic transit time and gastric emptying time were measured.
RESULTS
1) Seventy four percent of patients with chronic slow transit constipation showed a delayed gastric emptying time. Patients group showed a significantly delayed gastric emptying time compared with that of normal controls(110.9+/-32.3 min vs. 72.1+/-11.4 min, p<0.05). Gastric emptying time in respect to gender showed significant differences in normal controls(M=65.5+/-9.6 min, F=78.7+/-10.4 min). However, no significant difference was found in patient group(M=97.8+/-11.8 min, F=114.5+/-35.4 min). 2) In chronic slow transit constipation, colonic transit time was 48.8+/-11.7 hr. Each segments of colon showed a different transit time: Right colon 19.3+/-7.3 hr, left colon 21.2+/-12.3 hr, and rectosigmoid 8.3+/-9.2 hr. All of which were significantly delayed, compared with those of normal controls. 3) In patients group, colonic transit time of the whole colon had no significant correlation with gastric emptying time. 4) Seventy five percent of patients with chronic slow transit constipation whose right colonic transit time was delayed showed a delayed gastric emptying time. On the other hands, 63% of patients with delayed left colonic transit time had a delayed gastic emptying time. Patients with delayed gastric emptying time and those with normal gastric emptying time had no significantly different colonic transit time(49.1+/-13.2 hr vs 48.0+/-6.5 hr).
CONCLUSIONS
Large number of patients with chronic slow transit constipation had a delayed gastric emptying time. When surgical treatment is considered in patients with chronic slow transit constipation, it seems to be beneficial to estimate such parameters as manometry or gastric emptying time in order to evaluate functional derangement of UGI tract. These parameters may provide a guideline in treatment of chronic idiopathic constipation.

Diagnostic Laparoscopy through a Right Lower Abdominal Incision in Suspected.: Suh, Hae Hyeon; J Korean Soc Coloproctol. 1997;13(4):611-618.

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Abstract PDF: Recently, diagnostic laparoscopy has proved useful in reproductive women and patients with suspicious appendicitis. Diagnostic laparoscopy is usually performed through an incision just above or below the umbilicus. But the periumbilical incision of laparoscopy sometimes causes unnecessary skin incision when converted to open conventional appendicectomy and incisional hernia through the periumbilical port site. To prevent these disadvantages I have performed diagnostic laparoscopy through a right lower abdominal incision in suspected appendicitis. A transverse skin incision of 1.5~2.0 cm in length is made in the right lower abdomen. Using the open method, a cannula is inserted into the peritoneal cavity. After establishing the pneumoperitoneum, the whole peritoneal cavity can be carefully observed by tilting the operation table. According to the laparoscopic findings, appendicectomy and/or other operations may be performed with the laparoscopic or conventional method. I have used this technique in 39 patients (17 men and 22 women; age range 6 to 69 years). Pathologic findings of removed appendices were 2 normal; 17 catarrhal; 13 suppurative; and 7 gangrenous. The appendix was not visualized in 4 patients; but, were diagnosed to be appendicitis according to the findings of neighboring structures. There was a false negative which was a focal appendicitis accompanied with salphingitis. But there was no false positive. Associated diseases were gall stone (3 cases), uterine myoma (2 cases), an inguinal hernia, an intestinal adhesion, an ulcerative colitis, and a Crohn's disease. In conclusion, this technique can be an alternative route when the periumbilical route is difficult to approach due to previous incisional scars. Compared to periumbilical laparoscopy: (1) it is technically easier because it is familiar to the general surgeon; (2) it is more effective for esthetic purposes because it does not leave an unnecessary skin incision; and (3) it can prevent incisional hemia.

Effective Control of Presacral Hemorrhage by Transfixing Suture.: Kim, Jin Cheon; J Korean Soc Coloproctol. 1997;13(4):619-622.

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Abstract PDF: A wide transfixing suture including sacrum successfully controlled severe presacral hemorrhage during rectal resection. The basic principle of this technique lies in safe tamponade of injured fragile vessels attached to sacral periosteu. This technique can be equipped as one of the efficient armamentarium competing lethal presacral hemorrhage during pelvic surgery.

Carcinoma in an Ileal Pouch after Proctocolectomy, with Ileal Pouch-Anal.: Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 1997;13(4):623-628.

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Abstract PDF: Familial adenomatous polyposis(FAP) has a significant risk of developing colorectal cancer. As a consequence, their surgical treatment is currently widely performed by restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA). Frequently, the potential for recurrence in FAP patients after above operation was overlooked. In fact, several reports were presented for warning of recurred cancer in ileal pouch. We report a case of a patient who developed adenocarcinoma in an ileal pouch after restorative proctocolectomy for familial adenomatous polyposis with a review of literature.

Case Reports

A Case Report of Recurred Rectal Leiomyosarcoma in the Abdominal Wall.: Cho, Yong Geun , Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 1997;13(4):629-636.

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Abstract PDF: Leiomyosarcoma is the most commonly nonepithelial gastrointestinal malignancy. It may arise from the smooth muscle of the muscularis propria, muscularis mucosa, or blood vessels. This malignant tumor is most common seen in the fifth and sixth decades, although it may occur in infants and children. Leiomyosarcoma of the large intestine are unusual neoplasms, comprising less than 0.1% of all malignancies of the colon and rectum. Leiomyosarcomas in gastrointestinal tract are mostly found 61% in the stomach, 24% in the small bowel, 7% in the rectum, and only 3% in the colon. The survival rates and therapeutic approaches to gastrointestinal leiomyosarcoma vary widely. We experienced a case of recurred rectal leiomyosarcoma in the abdominal wall and report with review of literatures.

A Case of Chronic Idiopathic Pseudo-Obstruction Caused by a Degenerative.: Kim, Jin Ah , Kim, Je Hyung , Hwang, Ho Geun , Ahn, Sun Ho; J Korean Soc Coloproctol. 1997;13(4):637-642.

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Abstract PDF: Intestinal pseudo-obstruction is characterized by symptoms and signs of mechanical bowel obstruction in the abscence of an occluding lesion of the intestinal lumen. The chronic forms of intestinal pseudo-obstruction are separated into primary and secondary in according to the underlying disorders. primary or chronic idiopathic intestinal pseudo-obstruction(CIIP) is not associated with systemic illness and a progressive nature with relapses and remissions. Since Dyer described the rare histologic subtype of idiopathic pseudo-obstruction, the primary abnormality is in the myenteric plexus of the bowel at first in 1969, only few cases are reported. We report a case of CIIP caused by degeneration of myenteric plexus of the colon and he was successfully treated with surgical management.

Fournier's Gangrene: A report of one case.: Kim, Kyoung Hwan , Yoon, Yoe Dae; J Korean Soc Coloproctol. 1997;13(4):643-647.

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Abstract PDF: Fournier's gangrene is a rare infection with high mortality rate. it consists of a mixed bacterial infectin of the skin, subcutaneous tissues and superficial fascia of the perinium and genitalia. Old patients especially with diabetes mellitus, alcoholism and maligancy are more affected. This disease requires prompt treatment: early diagnosis, broad spectrum antibiotic therapy, nutritional support and immediate extensive surgial debridement are necessary We report one case of Fournier's gangrene associated with diabetes mellitus.

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