Annals of Coloproctology

Volume 15(4); October 1999

Original Articles

The Effects of Mutant p21 Protein on DNA & Protein Synthesis in the Cultured Colon Cancer Cell Lines.: Choi, Hoon , Chang, Suk Kyun; J Korean Soc Coloproctol. 1999;15(4):243-252.

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Abstract PDF: PURPOSE
The products of the ras oncogene are proteins of 188 or 189 amino acids and 21,000 molecular weights, termed simply p21 proteins. But the exact roles of c-ras proteins in cell proliferation and differentiation as well as in neoplastic transformation are little understood. The purpose of this study is to investigate the function of the p21 protein to the human colon cancer cell lines according to the exposure time and dosage of p21.
METHODS
The authors divided tumor cell lines into 3 groups as follows; group 1 (control, colon cancer cell lines without administration of p21 or polyclonal antibody), group 2 (administration of p21 with labelling of 3H-thymidine and leucine), group 3 (simultaneous administration of p21 protein and polyclonal antibody with labelling of 3H-thymidine and 3H-leucine). After deciding the most effective dose of p21 protein and culture time with target cells in preliminary studies, the morphologic changes of target cells with administration of p21 protein and the p21 expression and interaction with anti-p21 polyclonal antibody were examined by phase contrast microscopy each other.
RESULTS
The results were obtained as follows: 1. The most effective dose of the p21 with the colon cancer cell in increase uptake of 3H-thymidine and 3H-leucine were 50 ng but there were some differences in culture time of the 3H-leucine; 96 hours in SBA-1, 72 hours in HT-29 and 120 hours in SW-1116. 2. The increase uptakes of the 3H-thymidine by the different dosage of p21, 50 ng vs 200 ng were 131% (50 ng), 160% (200 ng) in SBA-1, 203% (50 ng), 123% (200 ng) in HT-29, and 127% (50 ng), 189% (200 ng) in SW-1116; and increase uptakes of 3H-leucine were 130% (50 ng), 159% (200 ng) in SBA-1, 113% (50 ng), 165% (200 ng), and 164% (50 ng), 169% (200 ng) in SW-1116. 3. There were some cellular proliferation and morphological changes of the colon cancer cells such as ruffling of the cell membrane, vesicle formation or rounding of the cell after administration of the mutant p21, but such changes were not observed after simultaneous administration of the mutant p21 and anti-p21 polyclonal antibody.
CONCLUSIONS
The role of p21 protein has not been to make manifest wholly. In our study, the p21 protein induce the cell proliferation and morphological changes.

Clinical Significance of Lymph Node Micrometastasis in Dukes' Stage A&B Colorectal Cancer: An Immunohistochemical Study.: Kim, Tae Soo , Hwang, Jae Kwan , Bae, Sun Young , Kim, Yang Hee , Hong, Kee Chun , Ahn, Seung Ik , Hur, Yoon Seok , Han, Hye Seung , Woo, Ze hong; J Korean Soc Coloproctol. 1999;15(4):253-261.

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Abstract PDF: PURPOSE
Lymph node metastasis is the most important prognostic factor in colorectal cancer. However, 20~30% of patients with lymph node negative colorectal cancer die of recurrent disease. We investigated whether the detection of micrometastasis is of any clinical significance in Dukes' stage A & B colorectal cancer.
METHODS
Ninety patients who underwent curative resection of colorectal cancer from Aug. of 1996 to Jan. of 1999 were entered the study. For examination, we used paraffin blocks of lymph nodes which were metastasis-free by conventional histopathology. After preparation of tissue blocks using the serial sectioning technique, the specimens were stained with immunohistochemical method using anticytokeratin antibody. And the hematoxylin-eosin staining was repeated.
RESULTS
We disclosed micrometastases in 15 of 90 cases, mostly located in subcapsular sinuses. And in 8 of 15 cases, we also found metastases in repeated H&E staining. There were no significant relationship between the detection of micrometastases and the depth of wall invasion, the histological grade and the status of lymphovascular invasion. With median follow-up of 15 months, we found no significant difference in recurrence between the micrometasis positive and negative groups.
CONCLUSIONS
The result showed that the micrometastasis of lymph node in colorectal caner might increase the risk for development of tumor recurrence. But because of small numbers of recurrent cases and relatively short follow-up period, there was no statistically significant relationship between micrometastasis negative and positive groups.

Comparative Analysis of Clinicopathologic Features and Tumor Suppressor Genes Expression According to Growth Patterns in Colorectal Carcinomas.: Kwak, Gwan Soo , Paeng, Sung Suk , Chang, Hee Jin , Park, Sei Hyuk , Choi, Kyong Woo; J Korean Soc Coloproctol. 1999;15(4):263-271.

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Abstract PDF: PURPOSE
Growth patterns of colorectal carcinomas can be divided into polypoid growth (PG) and nonpolypoid growth (NPG). This study was intended to find characteristic clinicopathologic features and the expression status of p53, p21, and p16 with relation to growth patterns in colorectal carcinomas.
METHODS
Sixty-one surgically resected colorectal carcinomas including 43 PG and 18 NPG carcinomas were reviewed in this study. Immunohistochemical stains for p53, p21, and p16 were done, and the results were analyzed with respect to growth patterns, and other prognosic parameters.
RESULTS
PG carcinomas were significantly correlated with adenoma (p=0.0001), and with favorable histology group (p=0.04). On the contrary, NPG carcinomas were significantly correlated with unfavorable histology group (p=0.04). In NPG carcinomas, the frequency of positive expression of p53 was higher and the expression of p16 was lower than that of PG carcinomas. But there was no statistical significance (p=0.150, 0.210 respectively). The expression of p21 has no difference between NPG and PG carcinomas (p=0.953).
CONCLUSIONS
As a result, it can be thought that the tendency of higher expression of p53 and lower expression of p16 in NPG carcinomas than in PG carcinomas may suggest more aggressive biologic behavior of NPG carcinomas.

Lymph Node Metastases and Tumor Deposits in the Mesorectum Distal to Rectal Cancer: A Need of Total Mesorectal Excision.: Joh, Nam Sun , Kim, Nam Kyu , Yun, Seong Hyeon , Kim, Ho Geun , Min, Jin Sik; J Korean Soc Coloproctol. 1999;15(4):273-279.

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Abstract PDF: PURPOSE
Total mesorectal excision has been advocated as the effective operation for patients with rectal cancer to reduce the local recurrence rate after curative resection. Its rationale is to remove possible tumor foci at the mesorectum distal to the level of the rectal cancer. This study was undertaken to clarify the rationale for total mesorectal excision.
METHODS
Total mesorectal excision was performed in 72 patients with rectal cancer who admitted in Severance Hospital between December, 1996 and December, 1997. The obtained mesorectums were classified to M0 (from the proximal margin to the distal margin of the tumor), M1 (from the distal margin to 2 cm below the distal margin), M2 (from 2 cm to 5 cm below the distal margin), and microscopic examination was done.
RESULTS
The nodal metastases were detected in 7 cases and tumor deposits in 4 cases. Especially in M2 with Dukes' C2, the rate of nodal metastases was 3.6 percent and the rate of tumor deposits was 7.1 percent. The nodal metastases and tumor deposits in the distal mesorectum have no correlation with gross finding, size, location and differentiation of the tumor.
CONCLUSIONS
En bloc excision of all mesorectal tissue down to at least 5 cm below the lower margin of the tumor is required for patients with advanced rectal cancer to remove possible metastatic lymph nodes and tumor deposits in the distal mesorectum.

Development of Second Stage Software in the Anal Sphincter Control System Based on the Anal Electromyography, and Investigation of Therapeutic Outcome of the Patients withChronic.: Park, Ing Chae , Seong, Moo Kyung , Chung, Soon Sup , Kim, Jong Jun , Park, Seung Hun; J Korean Soc Coloproctol. 1999;15(4):281-290.

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Abstract PDF: To eliminate the inconvenient shortcomings of our formerly designed system for the biofeedback treatment, the development of second stage software was indispensable. PURPOSE: The aims of current study were to supplement the prototype software, and to improve the application software for the database management system. Moreover, we assessed the practical value and outcome of biofeedback therapy for the patients with functional evacuation disorders by using the upgraded system.
METHODS
A new system was worked out a design to be composed of Windows based GUI (graphical user interface), DB (database) management software, and networking system. Main software performs a signal processing and a protocol making mode to train pelvic sphincter. DB program administers patient profiles and the recorded signal data. Networking system was designed to execute RS-232C serial communication of signal data with use of fast ethernet LAN networking. To affirm the reproducibility of signal display for the clinical practice, system was applied to 5 healthy volunteers. To evaluate the practical appraisal, system was applied to 27 patients with functional evacuation disorders who were undertaken anorectal physiologic tests. Patient groups were categorized as nonrelaxing puborectalis group (group I, n=17), incontinencegroup (group II, n=10). Overall patients were underwent a mean 3.7 (range, 2~10) sessions of biofeedback treatment, and the outcome was analysed in the period of 5.8 (range, 3~12) months follow-up.
RESULTS
Signal data not having drift or noise were adequately processed and displayed in a real time. Specifically, data upload with use of multi-processing overay display function was appropriately embodied. Overall data and profiles of patients groups were safely saved, sorted, and reproduced by using the upgrading database management software. Regarding to the therapeutic outcomes, 63 percent of 27 overall patients (12 of 17 patients in group I, 5 of 10 patients in group II) were improved. The subjective symptoms of 2 patients in group I were recurred in a period of 3 months follow-up.
CONCLUSIONS
Hardware and software functions of upgraded system were applicable to the Windows environment of personal computer. A developed system with second stage software made it possible to perform biofeedback treatment. Specifically, current results could be useful for the improvement of the motivation and patient's willingness in the self-learning process of biofeedback treatment.

Availability of Flexible Sigmoidoscopy for Outpatients, Inpatients,and Mass Screening at a Proctologic Clinic.: Yoo, Jung Joon , Kim, Hyun Shig , Park, Weon Kap , Hwang, Do Yean , Kim, Kuhn Uk , Lee, Kwang Real , Lim, Seok Won , Lee, Jong Kyun; J Korean Soc Coloproctol. 1999;15(4):291-300.

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Abstract PDF: PURPOSE
The clinical guidelines and rationale published by the American Gastroenterological Association in 1997 recommended that it is not necessary to screen patients in the average risk group who are below the age of 50. The purpose of this study was to evaluate both the effectiveness of flexible sigmoidoscopy (FS) as a diagnostic and screening tool and the utility of screening at an age earlier than 50 years.
METHODS
From Jan. to Dec. 1997, FS was used in 8964 cases. These cases were divided into three groups: Group A, 1336 outpatients; Group B, 5308 cases involving a hemorrhoidal operation; and Group C, 2320 cases of mass screening.
RESULTS
The mean age was lower in Group B (42.4 11.5) than in Group A (47.0 14.5) and Group C (46.1 10.7). The incidences of cancer, inflammatory bowel disease (IBD), and nonspecific proctocolitis in Group A were significantly higher than they were in Groups B and C, and the FS findings in Groups B and C were similiar. The locations of the polyps, cancer, IBD, and nonspecific proctocolitis were below the left colon in 91.9% cases involving an abnormal finding. Also, the locations of polyps and IBD determined by using FS and by using colonoscopy (CS) were not very different. About two-thirds of the carcinomas found by using FS in all three groups were located in the upper rectum and the sigmoid. In Group B, the FS findings did not depend on whether or not an enema had been administered. Also, the total incidence of cancer in patients less than forty years of age was nearly the same as the incidence of cancer in Group B and the incidence of cancer in Group C.
CONCLUSIONS
The risk of cancer for patients in the average risk group who are under 50 years of age should not be underestimated. FS is effective not only for the diagnosis of colorectal disease but also as an initial screening technique for patients below forty years of age.

Surgical Review of the Rectal Villous Adenoma.: Lee, Jong Ho , Kim, Hung Dai , Son, Byung Ho , Yoo, Chang Hak , Park, Yong Lai , Shin, Jun ho , Kim, Yong Shin , Han, Won Kon , Pae, Won Gil; J Korean Soc Coloproctol. 1999;15(4):301-306.

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Abstract PDF: PURPOSE
This study was undertaken to evaluate retrospectively the clinical results of surgery for the rectal villous adenoma.
METHODS
The study took place from the period of Mar. of 1988 to Feb. 1998 at the Dept. of Surgery, Sungkyunkwan Univ., Medical college. The study consisted of : Among the 97 cases diagnosed with colon & rectal villous adenoma, and 59 were rectal villous adenoma, and 42 cases underwent resection. We focused on these 42 cases, especially on the position of tumor, its size, surgical technique, histologic results & keeping close follow up post-surgically.
RESULTS
The sex ratio was 2:1 with male predominence, 18 cases were in their fifties with the average age of 55. In 30 cases, the lesion was situated within the 8 cm of anal verge. The average size of tumor was 3.64 cm. The applied methods were; rectotomy 19 cases, anterior resection 13 cases (including low anterior resection), endoscopic excision and transanal excision were 7 cases, and 2 cases, respectively. And in one case where the tumor size was 14.5 cm and which was situated within 3 cm of anal verge, Miles' operation was conducted. Death due to post-operative complication was not observed. 2 cases of wound infection in postoperation, one case of transient urinary incontinence & hematoma were found. And in the case of explo-laparotomy, anastomosis site leakage, in one case, anastomosis site stricture in 2 cases were noted. malignant cells were observed in total of 73.8%, among these, 80% were from villous adenoma, 70% from tubullovillous adenoma. In the case of tumor size less 1 cm, and tumor size greater than 1 cm, the probability of finding malignant lesion were 33.3% and 76.9%, respectively.
CONCLUSIONS
We suggest that wideexcision through York-Mason approach is a safe and effective technique for huge villous adenomas of the rectum.

Colon Perforation.: Choi, Kwang Ho , Hong, Yun Sik , Suh, Sung Ock , Moon, Hong Young; J Korean Soc Coloproctol. 1999;15(4):307-314.

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Abstract PDF: PURPOSE
To evaluate factors that predict prognosis of colon perforation, we review the hospital records of 37 patients who underwent emergency operation for colon perforation.
METHODS
Information of clinical findings, Acute Physiology and Chronic Health Evaluation (APACHE II score), perforation sites and causes, operation methods, and postoperative complications were obtained.
RESULTS
The causes of perforation were traumatic 11 (29.7%), iatrogenic 10 (27.0%), diverticular 6 (16.2%), cancerous process 6 (16.2%), strangulated hernia 2 (5.4%), ischemic colitis 1 (2.7%) and stercoral 1 (2.7%). The longer duration from colon perforation to operation, the more severe intra-abdominal fecal contamination was seen. The complication rate was increased as the intra-abdominal fecal contamination increased or APACHE II score increased (p<0.05). But there were no correlation between the complication rate and perforation sites and causes. In according to operative managements, one-stage operation (simple closure or resection with anastomosis) group had more lower complication rate than two-stage operation (formation of colostomy) group, unexpectedly (31.3% vs. 52.4%, p>0.05). Also former group had lower complication rate compared to latter group in left colon (40% vs 50%).
CONCLUSIONS
The factors that predict of mortality and morbidity are not perforation site, causes, and operation method, but preoperative physiologic status (APACHE II score) and intra-abdominal fecal contamination. So preoperative proper and vigorous treatment for improvement of physiologic status and shortening of interval to operation are important for better results. And primary closure and resection with anastomosis is useful for colon perforation in selected circumstance regardless of its site and cause.

Appendiceal Mucocele.: Choi, Young cheol , Jeong, Keuk Won , Lee, Seok , choi, Hyun cheol; J Korean Soc Coloproctol. 1999;15(4):315-320.

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Abstract PDF: PURPOSE
Mucocele of the appendix is merely a descriptive term for abnormal mucus accumulation causing distension of the appendiceal lumen, irrespective of the underlying cause. If untreated, one type of mucocele may rupture producing a potentially fatal entity known as pseudomyxoma peritonei. The purpose of this study is to clarify the clinical pictures of appendiceal mucocele and to provide a guide for treatment.
METHODS
To search the clinical characteristics of appendiceal mucocele, we retrospectively investigated 16 cases of appendiceal mucocele treated from January 1983 to December 1998 at the Department of Surgery, Masan Samsung Hospital.
RESULTS
There were 3 males and 13 females aged 44 to 83 years (mean 59.3 years). The peak incidence was in the 6th decade (6 cases, 37.5%). The most common symptom was right lower quadrant pain, and right lower quadrant tenderness was the most common physical finding. Histopathologic diagnoses were mucosal hyperplasia in 12 cases and mucinous cystadenoma in four. Simple appendectomy was performed in 8 patients with uncomplicated mucosal hyperplasia. Right hemicolectomy was performed in 3 patients with mucinous cystadenoma. Ileocecal resection was performed in one patient with mucosal hyperplasia and in another patient with mucinous cystadenoma. Appendectomy and oophorectomy was performed in 2 patients with mucosal hyperplasia and coexisting ovarian cyst, and appendectomy and fistulectomy, in one patient with mucosal hyperplasia and coexisting appendiceocutaneous fistula. Postoperative complications such as intestinal obstruction and wound infection occurred in 4 cases (25%). There was no postoperative mortality. Thirteen patients remain free of disease after surgical intervention, and one patient died 6 year later of peritoneal seeding caused by advanced gastric cancer.
CONCLUSIONS
Simple appendectomy is a reasonable choice for uncomplicated, unruptured mucoceles; however, a right hemicolectomy or ileocecal resection may be indicated if the mucocele is adherent to, or shows signs of invasion to cecum or ileum. At operation, a careful search should be made for 'coexisting' tumors of the ovary and gastrointestinal tract.

A Retrospective Analysis and Clinical Review of Fistula-in-Ano.: Lee, Yong Jik , Lee, Mi Ok , Kim, Sung Su , Lee, Young Taek , Park, Yong Ki , Choi, Chang Rock; J Korean Soc Coloproctol. 1999;15(4):321-330.

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Abstract PDF: PURPOSE
The results for treatment of fistula-in-ano have much improved, along with the development of anatomical knowledge, classification, and operative techniques, during last several decades. The authors retrospectively reviewed the results for treatment of fistula-in-ano, especially complex fistulas, during the last 11 years.
METHODS
A retrospective study of fistula-in-ano was performed for 229 patients who had been operated on in St. Benedict Hospital between January 1988 and December 1998. Complex fistulas (IIH, III & IV) were analyzed separately.
RESULTS
The most common type was IILs (92 cases, 40.2%), and the most common horseshoe type was IIIBc (5 cases, 2.2%). The average hospital stay was 11.5 days for all fistula-in-ano types, but 15.1 days for complex fistulas. Non-specific inflammation (209 cases, 91.3%) was the most common pathologic finding. Various operative procedures were used : fistulotomy (80 cases, 34.9%), fistulectomy (74 cases, 32.3%), coring out fistulectomy (63 cases, 27.5%), seton technique (11 cases, 4.8%), and muscle-filling technique (1 case, 0.4%). There was no difference in the recurrence rate among the operative types. Various procedures were tried for complex fistulas, but the sphincter-preserving fistulectomy by Takano seemed to have a low recurrence rate and a short postoperative course. However, because of the small number of cases, this difference in recurrence rate and postoperative course was not statistically significant. The overall postoperative complication rate was 7%: anal infection (4 cases, 1.7%), anal bleeding (3 cases, 1.3%), and urinary retention (2 cases, 0.9%).
CONCLUSIONS
The operations for most of the fistulae, IH, IL & IIL, were simple and uneventful. However, the operations for complex fistulae were complicated and more skill was required. We have thought Takano's operation to be a good curative procedure with less postoperative deformity and shortened postoperative course. However this research couldn't prove that with statistical significance, probably because of the insufficient number of patients. If further cases are collected and continuous follow-up is done, then a better result can be expected.

Pedigree of the Specific Family of the FAP in Specific District of Korea and Psychologic Distress.: Hur, Suk Joo , Lee, Seok Hwan , Park, Ho Chul , Oh, Soo Myung , Yoon, Shoong , Lee, Kee Hyung; J Korean Soc Coloproctol. 1999;15(4):331-338.

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Abstract PDF: Familial Adenomatous Polyposis (FAP) is a rare and autosomal dominantly inherited disorder characterized by the development of hundreds to thousands of colorectal polyps. Korean Polyposis Registry was established in July, 1990 for early detection and management of the FAP patient. Recently, we have experienced in our institution a case of the FAP family kindred living in Jeju Island of Korea. Their relatives have been managed for the past 20 years and are listed in the Korean polyposis registry. Pathologic diagnosis of our proband was stage III (T3N1M0) rectal cancer with thousands of colonic polyps. Intrafamilial strife and psychologic distress was significant due to the late detection and progression to rectal cancer. Therefore, we reviewed our case of the FAP family with literature regarding the psychologic distress and the role of the regional registry.

A Combined Treatment of Tamoxifen, Goserelin, and Sulindac in 2 Cases of Recurrent Desmoid Tumor in the Abdomen.: Kim, Hee Cheol , Suh, Byung Sun , Lee, Dong Hee , Ahn, Byung Yool , Chung, Choon Sik , Kang, Gyeong hoon , Ha, Hyun Kwon , Kim, Jin Cheon; J Korean Soc Coloproctol. 1999;15(4):339-343.

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Abstract PDF: Desmoid tumor is a subtype of fibromatosis arising from deep fascial or soft tissue structure. It is characterized by locally aggressive behavior with a tendency to local recurrence, but is generally accepted the lack of ability for distant metastasis. Although excision is the best initial therapy, surgery is not always amenable in cases of lesions lying in difficult anatomical area. Two female patients with recurrent desmoid tumor in abdomen and pelvis after excision were treated with tamoxifen, goserelin, and sulindac. This therapy led to a progressive decrease of tumor size within 13 months in one patient. However, in the other patient, this combined therapy failed to reduce the size of the tumor. Despite the success of combined therapy with hormone and nonsteroidal anti-inflammatory drug is anecdotal, this treatment may improve the survival and reduce the recurrence in certain sub-group of desmoid tumor.

A Parastomal Hernia Causing Small Bowel Obstruction.: Lee, Seung Hoon , Jeon, Hae Myung , Kim, Jeong Soo , Kim, Kee Hwan , Oh, Seong Taek , Chae, Hun Suk; J Korean Soc Coloproctol. 1999;15(4):345-349.

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Abstract PDF: A parastomal hernia is an incisional hernia in relation to an intestinal stoma on the abdominal wall and a common complication after stoma formation. Most parastomal hernias are relatively asymptomatic, but sometimes, a loop of bowel may become trapped in the sac, resulting in obstruction or strangulation. We reported a case with a para-colostomy hernia causing small bowel obstruction in a 45-years-old female who had had a transverse loop colostomy for severe rectovaginal fistula 2 years before due to recurrent cervix cancer. The patient required resection of gangrenous portions of small bowel and large bowel. A review of the preventative information of parastomal hernia and management is discussed. A parastomal hernia shonld be considered as a cause of small bowel obstruction in anyone who has a stoma. Early detection and repair of the strangulated hernia are recommended.

Case Report

A Case of Synchronous Triple Primary Adenocarcinomas Occurring at the Duodenum, Right Colon and Sigmoid Colon.: Kim, Young Wan , Kim, Nam Kyu , Lee, Jae Kil , Kim, Won ho , Kim, Ju Hang , Min, Jin Sik; J Korean Soc Coloproctol. 1999;15(4):351-356.

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Abstract PDF: It is rare to find three separate primary cancers in one individual. But, multiple primary cancers have been increasing because of improved methods of diagnosis and treatment and greater longevity of the population. We experienced a 52-year old male patient with synchronous triple primary adenocarcinomas occurring at the duodenum, right colon and sigmoid colon, who complained of abdominal pain and hematochezia for 2 months. The patient underwent pancreaticoduodenectomy, right hemicolectomy, and anterior resection, and was recovered uneventfully. After surgery, postoperative adjuvant chemotherapy (5-FU and Leucovorin) is currently being administered.

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