Annals of Coloproctology

Volume 16(1); February 2000

Original Articles

Efficacy of Intra-Operative Lavage in One-stage Operation for Obstructive Left Colon Cancer.: Choi, Gyu Seog , Park, Jong Hoon , Jun, Soo Han; J Korean Soc Coloproctol. 2000;16(1):1-6.

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Abstract PDF: PURPOSE
Although staged operations have been thought a main treatment for obstructive left colon cancer, their disadvantages make one-stage operations popular. We tried to identify technical feasibility and oncologic safety of one-stage operation with intra-operative lavage (IOL) for the treatment of obstructive left colon and rectal cancer.
METHODS
From June 1996 to May 1999, of 456 colorectal cancer patients, 25 with obstructive left colon or rectal cancer underwent surgery. In 18 of those, we intended to do a one-stage operation with IOL. Male (n=14) were predominant to female (n=4). Mean age was 61.2 (29~78) years. Lesions were located on the sigmoid colon in 8, rectum in 4, descending in 3, and rectosigmoid junction in 3 cases. Operative technique: Lymphovascular division was initiated at the origin of IMA followed by mobilization of the left colon up to the splenic flexure and distal transverse colon. Thereafter antegrade irrigation of the proximal colon with warm normal saline was done by using a corrugated tube. Anastomoses were made by hand or stapler in end-to-end or side-to-end fashion.
RESULTS
Mean operative time was 221 (185~360) min. No significant post-operative complications occurred except for two wound infections and one pulmonary atelectasis. There was one unexpected conversion to Hartmann's procedure due to intra-operative fecal soilage during the lavage. Within 18 months follow-up period, 4 recurrences occurred with two of them expiring.
CONCLUSIONS
: One-stage operation for the treatment of obstructive left colon cancer with IOL could avoid colostomy or reoperation, and, was technically feasible, safe, and oncologically acceptable.

Comparative Review of Perianal Sinus & Fistula in Ano.: Kim, Jong Woo , Kwon, Sung Won , Son, Suk Woo , Ahn, Dae Ho , Lee, Kyung Po; J Korean Soc Coloproctol. 2000;16(1):7-11.

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Abstract PDF: PURPOSE
A fistula in ano is a granulating track between the anorectum and the perianal region or perineum. A typical fistula may consist of the track, the primary (internal) opening and secondary (external) opening. Its hallmark is frequent discharge through external opening. Sometimes this track become occluded and a sinus remains. Therefore abscence of an external opening should not be taken as evidence that there is no fistula, and then this study is aimed to make clear perianal sinus as another form of fistula in ano.
METHODS
This study is a clinical analysis of 17 patients with perianal sinus, who were treated at the Department of General Surgery of Pundang-CHA hospital from June, 1995 to December, 1998. As comparative group, 91 patients of typical fistula in ano were also taken in same period.
RESULTS
The ratio of male to female was 4.6:1 in sinus group, 4.1:1 in fistula group. The prevalent ages were in the third decade in both group. The main symptoms of sinus group were a palpable mass (94.1%), pain & discomfort (35.3%) but that of fistula group were purulent discharge (87.9%) and pain (28.6%). The most frequent duration of illness was 6 months~1 year (52.9%) in sinus group, within 6 months (40.7%) in fistula group. The distributions of sinus size were 7 cases (41.2%) in <1 cm, 8 cases (47.0%) in 1~2 cm and 2 cases (11.8%) in >2 cm. The most common type was intersphincteric in both group. The operative procedures included excision with fistulectomy in 4 cases (23.5%), lay open of sinus with fistulotomy in 11 cases (64.7%), seton procedure in 2 cases (11.8%). The mean hospital stay was 5.0 day in sinus group, 4.9 day in fistula group.
CONCLUSIONS
There was no distinct difference in the clinical features or characteristics between the both groups, therefore perianal sinuscould be taken as fistula in ano and treated similar procedures.

Investigation of Skip Lesion at the Appendiceal Orifice in Ulcerative Colitis.: Lim, Seok Won , Kim, Hyun Shig , Hwang, Do Yean , Kim, Khun Uk , Park, Weon Kap , Lee, Kwang Real , Yoo, Jung Jun , Lee, Jong Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2000;16(1):12-17.

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Abstract PDF: BACKGROUND
Generally ulcerative colitis has a character that has a continuous pathological lesion from the rectum toward the cecum. Ulcerative appendicitis with a skipped appendiceal orifice lesion, which is unusual in ulcerative colitis, has been infrequently reported, and its clinical characteristics have not been identified. PURPOSE: This study was carried out to evaluate the incidence rate and the clinical characteristics of ulcerative appendicitis.
METHODS
One hundred consecutive patients with ulcerative colitis who had been treated from Jan. 1997 to Aug. 1998 at Song-Do Colorectal Hospital were used for the study. Data evaluated included age, sex, involved site, clinical type, clinical severity of the disease, and endoscopic severity of the disease.
RESULTS
Nineteen (19%) of the 100 patients had skipped lesions around the appendiceal orifice; the other 81 did not. There were no significant differences between these two groups with respect to the age and the sex distributions, the involved site, the clinical type, and the clinical severity. There was a correlation between the endoscopic grades, based on the Riley classification, of the lesions at the rectum and at the appendiceal orifice. Seven patients (36.8%) of the 19 patients with appendiceal orifice lesions showed an extended lesion from the appendiceal orifice to the cecum.
CONCLUSIONS
We suggest that appendiceal lesions in ulcerative colitis are not infrequent. Even though no significant differences in the clinical characteristics of ulcerative colitis with ulcerative appendicitis, compared with those of ulcerative colitis without ulcerative appendicitis, were found, we suggest that more profound study of ulcerative appendicitis probably contribute to understand the pathophysiology of ulcerative colitis.

Clinical Analysis of Right Colonic Diverticulitis That was Operated under the Impression of Acute Appendicitis.: Cho, Hyeoun Jun , Cho, Seung Yeon , Oh, Jae Hwan; J Korean Soc Coloproctol. 2000;16(1):18-24.

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Abstract PDF: PURPOSE
Because there are no significant differences of the clinical findings between the appendicitis and cecal diverticulitis, it is very difficult to make a correct diagnosis preoperatively and to choose a appropriate management intraoperatively. The purpose of this study is to investigate the clinical charateristics of right diveticulitis and to evaluate the appropriateness of surgical management.
METHODS
We reviewed 45 cases of right colonic diverticulitis which underwent emergency operation under the impression of acute appendicitis during 10 years from January 1988 to December 1997.
RESULTS
Of them, 38 cases were treated by diverticulectomy with appendectomy (Group I), and 7 cases were treated by resection (ileocecal resection or right hemicolectomy) (Group II). The male to female ratio was 4:1, and the mean age was 38.2 years. In Group I, all cases had a solitary inflamed cecal diverticulum. In group II, two cases had a solitary cecal diverticulitis, whereas five cases had multiple ones. Postoperative complications were found in 14 cases, but all of them were not significant. Postoperative Barium enema was performed in 22 cases of Group I, in two cases of Group II. In Group I, 8 cases had a residual diverticulum at postoperative Barium enema. In Group II, no residual diverticulum was shown. Follow-up study by Telephone was done at 16 cases, there were no symptomatic recurrences.
CONCLUSIONS
In conclusion, when right colonic diverticulitis is found at the time of operation, surgical management is a safe treatment with low morbidity and low recurrence rate. Diverticulectomy with appendectomy is a safe surgical procedure for the uncomplicated diverticulitis. If diverticulitis is complicating, multiple or undistinguishable with malignancy, resection (ileocecal resection, right hemicolectomy) should be considered as a primary surgical treatment. Postoperative colon study is helpful, due to high incidence of residual diverticulum.

Treatment of Fistula in ano by Kshara Sutra.: Choi, Kyung Dal; J Korean Soc Coloproctol. 2000;16(1):25-28.

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Abstract PDF: PURPOSE
Sushrutra (BC 5th century) advocated a conservative management by applying Kshara Sutra (phyto-chemically processed thread) for the treatment of anal fistulas in India. In 1965, this technique was introduced by Deshpande and 40 cases were treated on an "outpatient" ambulatory basis. The purpose of this study is to determine the result of Kshara Sutra (KS) in treatment of fistula in ano.
METHODS
One hundred and five patients with anal fistula were treated with KS. Excision of the primary lesion and fistula tract was done externally and KS was passed around the tract. Tissue gripped within the thread was the anoderm, mucosa, and sphincter. Finally, the thread encircled the part of the anal wall that needed excision and an additional clamp for loose tying.
RESULTS
The range of age was from 21 to 59 years while the sex ratio was 6.5:1 (M:F). In 94 patients, the average cutting time was about two weeks, and the other were three to four weeks. KS thread was applied only once for primary operation in 98 cases, and a successive change was required in 7 cases. The mean hospital stay after operation was 4.2 days. In 76 cases, the mean period of follow up was 23 (range 7~32) months. There were no recurrences, but there were 4 mild deformities of the anus, 2 mild soilings, 1 delayed cutting, and 5 delayed healings.
CONCLUSIONS
Kshara Sutra is a technically easy, safe, and simple method and does not require a long hospitalization.

A Study of Gender Difference in Colorectal Cancer.: Kim, Hyeong Rok , Choi, Il , Kim, Young Jin; J Korean Soc Coloproctol. 2000;16(1):29-33.

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Case Reports

Hormonal Treatment of Intestinal Cavernous Hemangioma Report of 2 cases.: Ahn, Byeong Yul , Lee, Dong Hee , Kim, Hee Cheol , Kang, Gyeong Hoon , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(1):34-36.

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Abstract PDF: Cavernous hemangioma in the gastrointestinal tract is a rare benign vascular lesion, which can produce massive or persistent blood loss. Herein, we present two cases of gastrointestinal hemangiomas that could not be resected completely and were treated with estrogen because of multiple involvement of the gastrointestinal tract and viscera, including the anal canal. A 49-year-old male presented with unknown chronic melena and anemia. Preoperative work-up could not reveal the definite cause of bleeding. During exploration, hemangioma scattered in whole small bowel was identified and feeding vessel ligation was performed. Postoperative recurrent bleedings were controlled by additional estrogen therapy. A 25-year-old young woman had suffered from painless anal bleeding with subsequent anemia since her youth. She had diffuse carvernous hemangioma in the large intestine involving the anal canal and uterus. Total proctocolectomy and ileal-pouch anal anastomosis was performed, however the uterine hemangioma was left intact because the patient wanted to be pregnant. She was also treated with estrogen, postoperatively. It is suggested that estrogen may be a good alternative treatment modality for gastrointestinal hemangioma that can not be removed completely.

Primary Melanoma of the Anorectum Report of Three Cases.: Park, Jng Hyun , Lee, Sang Kuon , Oh, Sung Taek , Kim, Se Kyung , Kim, In Chul; J Korean Soc Coloproctol. 2000;16(1):37-40.

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Abstract PDF: Primary melanoma of anorectum is a very rare, aggressive tumor with a reported 5-year survival rate of 6%. Over 90% of all anorectal melanomas arise at the dentate line, but primary lesions well above this line in the rectum or rectosigmoid have been reported. Surgical treatments of this virulent tumor have ranged from conservative approach, such as wide local excision to abdominoperineal resection (APR) with or without bilateral inguinal lymphadenectomy. When wide local excision was compared to APR in terms of survival, no significant difference was noted. However, five-year survivors had 2 mm thin lesion, and underwent radical surgery. We have experienced three cases of primary anorectal melanoma, two of which underwent radical surgery and survived 20 months and 6 months respectively. One patient had wide local excision, and survived 5 months. One of the three patient had von Recklinghausen disease with caf -au-lait spots and primary melanoma, which is probably one of the first reported case in the literature.

The Conservative Treatment of Rectal Perforation after Insertion of A Stent and Chemo-Radiotherephy in the Patient with Obstructive Rectal Cancer.: Jung, Jai Hun , Kim, Seog Mo , Kim, Cheong Yong , Ko, Kang Seog; J Korean Soc Coloproctol. 2000;16(1):41-46.

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Abstract PDF: The use of self-expanding metal stent has been widely reported that its utility can make a palliative decompression treatment and one stage operation without doing colostomy in the patient with unresectable and resectable obstructive colorectal cancer, respectively. It, however, can sometimes cause complications such as intestinal perforation. We report that the conservative treantment could be possible without removing stent or performing laparotomy in case of intestinal perforation during chemoradiotheraphy after insert of stent for relieving colonic obstruction in the 53 years old female patient with stage IV rectal cancer.

Original Article

Management of Colorectal Cancer Liver Metastasis.: Hwang, Dae Yong; J Korean Soc Coloproctol. 2000;16(1):47-56.

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Abstract PDF: The liver is the predominant metastatic site of colorectal cancer. When the patients general condition, the absence of extrahepatic metastases, number and locations of hepatic lesions permit, hepatic resection may be curative and should be considered standard therapy. Regional approaches, such as cryotherapy, alcohol injection, radiation therapy, interstitial laser therapy, and chemoembolization even that may bring about effective palliation suggest experimental approaches to the treatment of hepatic metastases. Regional infusion of chemotherapeutic agent via hepatic artery has shown a great tumor response, but further studies are needed for evaluation of precise benefit of this approach. Manipulation of the gene level was recently possible and addressed for the treatment of unresectable hepatic metastases, but still many problems to overcome are remained for the effective delivery and selective expression of the therapeutic gene or gene product to the target cells. Thus, new approaches to the colorectal cancer liver metastases are clearly warranted.

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