Annals of Coloproctology

Volume 16(2); April 2000

Original Articles

Expression of Glucose Transporter Gene in Colorectal Cancer.: Lee, Suk Hwan , Park, Jae Hoon , Kim, Yoon Wha , Oh, Soo Myung , Yoon, Choong , Joo, Hoong Zae , Lee, Kee Hyung; J Korean Soc Coloproctol. 2000;16(2):57-66.

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Abstract PDF: PURPOSE
The primary metabolic characteristic of malignant cells is an increased uptake of glucose and its anaerobic glycolysis. Recent studies have demonstrated that facilitative glucose transport across the plasma membrane is mediated by a family of proteins, i.e., glucose transporters. PURPOSE: In order to evaluate the clinicopathologic correlations of glucose transporter genes expressed in colorectal cancer, the author studied the expression of glucose transporter genes in human colorectal cancer and analyzed their expression in normal and malignant colorectal tissues.
METHODS
A reverse transcriptase-polymerase chain reaction (RT-PCR) was applied to quantitatively determine the levels of the glucose transporter genes, GLUT1 and GLUT3, from Crohnes diseases (N=2), adenomatous polyps (N=4), and colorectal cancers (N=40) and their normal counterparts.
RESULTS
The expresssion of the GLUT1 gene was detected in 50% of the inflammatory colonic mucosae and adenomatous polyp tissues, but the levels of expression were not significantly different from their normal counterparts. Among the 40 colorectal cancer patients, 23 patients (57.5%) showed GLUT1 gene expression and the levels of expression were increaed by 1.8 as compared to their normal counterparts (p<0.05). The expression of the GLUT3 gene was detected in almost all tissues examined, and the levels of expression were not significantly different from their normal counterparts. In colorectal cancers, there was correlation between GLUT1 expression, the extent of lymph node involvement and the stage of colorectal cancers (p<0.05). But, the correlation between the expressions of the GLUT3 gene and the clinicopathologic prognostic factors of colorectal cancers could not be determined because almost all tissues showed a GLUT3 gene expression.
CONCLUSIONS
In conclusion, the GLUT1 glucose transporter expression in colorectal cancer was associated with high possibilities of lymph node metastases and poorer prognosis, and the assessment of GLUT1 expression in colorectal cancer would be useful in identifying high risk patients.

Effect of Vaginal Delivery on Perineal Descent and Pudendal Nerve Terminal Motor Latency.: Hur, Min Hee , Choi, Yoon Mi , Woo, Sang Wook , Kim, Sei Joong , Hong, Kee Chun , Kim, Jong Hwa , Woo, Ze Hong; J Korean Soc Coloproctol. 2000;16(2):67-72.

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Abstract PDF: PURPOSE
Significant associations between perineal descent (PD) and pudendal nerve terminal motor latency (PNTML) have previously been described in patients with fecal incontinence. This had led to the hypothesis that pelvic floor muscle and nerve injury initiated by childbirth might progress and cause fecal incontinence. Purpose: This study was undertaken to evaluate the association between vaginal delivery and PD, PNTML. Also, we evaluated the correlation between PD and PNTML.
Methods
Sixty one women who visited the Dept. of Surgery from Aug. 1998 to May. 1999 were randomly selected. Women were excluded, who had chronic constipation,operation within 6 months before the investigation, anal trauma, diabetes mellitus, and neurologic disease. They had a mean year of 43 12.5 years (range: 23~70), a mean vaginal delivery 1.9 1.5 (range: 0~6). PD at rest and during push, and PNTML were measured.
Results
PD during push (p=0.006) and the change of PD between at rest and during push (p=0.003) were significantly increased with increasing number of vaginal deliveries. Rt PNTML (p=0.08) and Lt PNTML (p=0.03) were significantly increased with increasing number of vaginal deliveries. There was correlation between Lt PNTML and change of PD (r=0.59, p=0.0).
Conclusions
PD and Lt PNTML was increased with repeated vaginal deliveries. Our findings support the hypothesis that damage induced by vaginal delivery to pudendal nerve and pelvic floor will progress.

Culture-Sensitivity Test and Infectious Complication in Perforated Appendicitis.: Yun, Seok Joo , Koh, Young Taeg , Sim, Myung Seok , Suh, Dong Youb , Park, Dong Sun; J Korean Soc Coloproctol. 2000;16(2):73-77.

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Abstract PDF: PURPOSE
The purpose of this study was aimed to disclose main affected organisms in patients with perforated appendicitis and to analyze correlations between culture-sensitivity test and infectious complication.
METHODS
In 26 of 421 patients who had undergone appendectomy due to acute appendicitis from April 1996 to March 1999, we performed culture-sensitivity test. The clinical records of these patients were collected and reviewed about clinicopathological features and results of culture-sensitivity test, retrospectively. Culture material was collected in BBL transport media with cotton swab and cultured by MacConkey agar plate. The method of MIC by VITEK was used for sensitivity test.
RESULTS
Cultured organisms were E. coli (18 cases), Pseudomonas (4), Enterobacter (2), Enterococcus (1), and Proteus (1). In sensitivity test, sensitive antibiotics against all cultured organism were amikacin, ceftriaxone, imipenem and cefotetan. But ampicillin, sulfametoxazole/trimethoprim and piperacillin were mostly resistant. Infectious complications occurred in 11 of 26 patients (42.3%) and consisted of 9 wound infection and 2 intraabdominal abscess. Especially, 13 of 18 cases in which E. coli were isolated, were resistant to ampicillin. And they had infectious complications statistically more than those who were not resistant to ampicillin (p=0.036).
CONCLUSIONS
E. coli was a main organism in perforated appendicitis. In case of ampicillin-resistant E. coli, the patients were susceptible to infectious complication such as wound infection and intraabdominal abscess.

Clinical Significance of Occult Micrometastases in Colorectal Cancer.: Lee, Suk Hwan , Kim, Tae Young , Kim, Yoon Wha , Koh, Suck Hwan , Yoon, Choong , Oh, Soo Myung , Lee, Kee Hyung; J Korean Soc Coloproctol. 2000;16(2):78-86.

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Abstract PDF: BACKGROUND
One of the most important prognostic factors in colorectal cancer is lymph node metastasis, which predicts a reduced survival time. Although lymph node metastases were not detected by a conventional hematoxylin-eosin stain technique, 20 to 30 percent of patients fail long-term survival on account of a local or systemic recurrence. Recurrent disease in these patients is believed to develop from occult tumor in lymph nodes. PURPOSE: The authors have conducted an immunohistochemical study with two different antibodies against cytokeratin to identify occult micrometastases in lymph nodes which were diagnosed as tumor negative by conventional histopathology.
METHODS
Paraffin blocks of sixty-five patients with colorectal cancer (T2/3, N0, M0) after a curative resection between January 1991 and December 1993 at Kyung-Hee University Hospital were stained with avidin-biotin-peroxidase complex technique using two monoclonal antibodies (anti-cytokeratin AE1/AE3 and anti-cytokeratin No. 20, DAKO, Hamburg, Germany). To assess the clinical correlation between micrometastasis in lymph node and patients survial, 5-year disease-free survival rates were calculated by Kaplan-Meier method and the significance of the differences was estimated by the log-rank test. P values <0.05 were taken to be significant.
RESULTS
Of the sixty-five patients with 1133 lymph nodes, tumor cells detected by anti-cytokeratin AE1/AE3 and anti-cytokeratin No. 20, were 2.4 percent (27/1133) and 3.4 percent (38/1133), respectively. Micrometastases were detected in twenty-six patients (40.0 percent). The histologic stage of four cytokeratin positive cases was upstaged from T2, N0, M0 to T2, N1/2, M0, and twenty-two of T3, N0, M0 to T3, N1/2, M0. Cytokeratin-positive cases showed statistically significant recurrence rate (42.3 percent) compared to that of cytokeratin -negative cases (17.9 percent)(x2 test, p=0.032). With the median follow-up of 62 months, 5-year disease-free survival rates of the micrometastses negative and positive cases were 81.7 percent and 61.3 percent, respectively (p=0.0438).
CONCLUSIONS
In conclusion, immunohistochemical technique to identify the occult micrometastases in lymph nodes overlooked in conventional histopathology is a useful staging method to anticipate a recurrence and a prognosis more precisely.

Prognostic Factors after Hepatic Resection for Metastatic Colorectal Cancer.: Kim, Hee Cheol , Kim, Chang Nam , Hong, Hyoun Kee , Lee, Dong Hee , Yu, Chang Sik , Lee, Je Hwan , Kim, Tae Won , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(2):87-92.

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Abstract PDF: Metastases to the liver from carcinoma of the colon and rectum occur as many as 80% of cases. As resection of metastases is proven to enhance survival and to reduce hepatic recurrence, the criteria for selection of patients and surgery type appear to be indispensable. Purpose: The aim of this study was to assess the prognostic factors after hepatic resection for metastatic colorectal cancer and propose the optimal surgical principles for resection of metastatic colorectal cancer. Methods: Sixty-three patients who underwent initial hepatic resection for liver metastases from colorectal cancer between 1989 and 1998 were analyzed regarding clinical and pathologic parameters. Results: Overall 5-year survival rate was 32%. Preoperative serum CEA level and resection margin of metastatic tumors were found to be significant predictors for poor long-term outcome. Resection margin of greater than 5 mm was closely associated with better survival. In multivariate analysis, resection margin alone was an independent prognostic factor.
Conclusions
Preoperative serum CEA level and surgical resection margin may affect the outcome for the patients who underwent hepatic resection for metastatic colorectal cancer. Surgical resection margin must be kept enough to avoid re-recurrence or metastasis during hepatic resection for metastatic colorectal cancer.

Preoperative Concurrent Chemoradiotherapy in Locally Advanced Rectal Cancer.: Kim, Nam Kyu , Sohn, Seung Kok , Min, Jin Sik , Sung, Jin Sil , Noh, Jae Kyung; J Korean Soc Coloproctol. 2000;16(2):93-98.

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Abstract PDF: PURPOSE
Preoperative concurrent chemoradiation for locally advanced rectal cancer can reduce tumor volume and can eliminate viable tumor cells at surgical margin (lateral or posterior margin). It also achieve a rate of high resectability, and negative margin and also have been known to be a safe treatment modality even though its fatal complication was reported as 4%. The aim of this study is to analyze its efficacy and complications after concurrent chemoradiation treatment for advanced rectal cancer.
METHODS
We recruited a total thirty three patients with locally advanced rectal cancer, which were staged preoperatively as T3 or T4 and multiple enlarged lymph nodes by Transrectal Ultrasonography or pelvic Magnetic Resonance Image between march 1996 and June, 1998. 5 Fluorouracil 450 mg/m2 and leucovorin 30 mg infused intravenously during the first and fifth weeks of radiation therapy (4500~5040 cGy). Surgical resection was performed after four or six weeks after completing radiation therapy. To follow up tumor response, digital rectal examination and transrectal ultrasonography were done every two weeks.
RESULTS
Tumor level was distal (N=16, 48.4%), middle (N=9, 27.2%) and upper (N=8, 24.4%). mean age was fifty two years old. Overall resectability was 91%. Types of operations were abdominoperineal resection (N=10, 30.3%), Low anterior resection (N=8, 24.2), Hartmann (N=8, 24.2%), Posterior exenteration (N=2. 6.1%), Total pelvic exenteration (N=2, 6.1%), colostomy only (N=3, 9.1%). Tumor response was Complete remission (N=3,10%), Partial response (N=17, 57%), Non-response (N=10, 33%), progressive disease (N=3). Pathological status was No residual tumor (N=3, 10%), T2N1 (N=5, 16.6%), T3N0 (N=6, 20%), T4N0 (N=4, 13.3%), T2N1 (N=1, 3.3%), T3N1 (N=11, 36.6%). Downstaging status was as follows: from T3 to T0 (N=2), to T2 (N=3) and From T4 to T0 (N=1), to T2 (N=3), to T3 (N=3). Postoperative morbidity was noted in 2 patients (1 case of anastomotic leakage, 1 case of wound infection).
CONCLUSIONS
Preoperative concurrent chemoradiation therapy for locally advanced rectal cancer can be performed safely and show high tumor response and resectability.

Clinical Analysis of Colorectal Cancer in the Elderly.: Yoo, Kwang Real , Jeong, Yeon Jun , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 2000;16(2):99-108.

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Abstract PDF: PURPOSE
Elderly patients of colorectal cancer compose a steadily expanding portion of the population in Korea. The decision whether or not to operate on elderly patients who have carcinoma of colon and rectum is often unduly complicated. The aim of this study is to evaluate the results of the operations for colorectal cancers in the elderly.
METHODS
This report is a retrospective clinical analysis for 365 cases of colorectal cancer who were treated surgically at the Department of surgery, Chonbuk National University Medical School from January 1994 to December 1998. To evaluate the age factor in colorectal cancer, the patients were divided into two groups: The elderly group included 79 patients who were aged > or =70 years on first presentation; The control group comprised 286 patients aged <70.
RESULTS
There is no significant difference between the two group with regard to the mode of presentation, gender, location of tumor, clinical symptom and sign, duration of symptom, coexistent disease, operation method, tumor size, histopathologic findings, the Astler-Coller classification, lymphatic and distant metastasis, perioperative complication and 5-year survival. The emergency operation is significantly higher incidence in the elderly group.
CONCLUSIONS
It is concluded that surgical resection of colorectal cancer in elderly is standard method and should not be restricted on the basis of age alone.

Rectal Carcinoid: Effectiveness of Endoscopic Resection.: Park, Weon Kap , Kim, Hyun Shig , Cho, Kyung A , Hwang, Do Yeon , Kim, Kuhn Uk , Kang, Yong Won , Yoon, Seo Gue , Lee, Kwang Real , Lee, Jong Kyun , Lee, Jung Dal , Kim, Kwang Yun; J Korean Soc Coloproctol. 2000;16(2):109-114.

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Abstract PDF: PURPOSE
Small-sized carcinoids, less than 1 cm, are easily detected using flexible sigmoidoscopy or total colonoscopy and can be treated by local excision. Recently, there has been many advances in the technique of endoscopic resection. The aim of this study was to determine the endoscopic findings of a rectal carcinoid and to evaluate the effectiveness of endoscopic resection.
METHODS
We experienced 22 rectal carcinoids in 21 patients who were treated by endoscopic resection from June 1996 to February 1999. Nineteen cases were followed for an average of 21 months. Follow-up studies consisted of chest P-A, hepatic ultrasonography, and total colonoscopy.
RESULTS
The male-to-female ratio was 1.6 to 1. The most common age group was the 4th decade. The tumor was located at the lower rectum in 10 patients, at the upper rectum in 10 patients, and at the rectosigmoid junction in 2 patients. The tumor sizes ranged from 3 to 12 mm in diameter and were smaller than 10 mm in 20 cases (90.1%). Endoscopic finding revealed that the tumors were covered by a normally appearing mucosa in 12 cases, were yellow-discolored polyps in 17 cases, and were sessile-type tumors in 19 cases. The method of treatment was an endoscopic mucosal resection (EMR, 14 cases) or a snare polypectomy (8 cases). Microscopically positive margins were noticed in four cases, two cases of EMR (2/14, 14%) and two cases of snare polypectomy (2/8, 25%). All the patients were alive and clinically free of disease; however, the duration of the follow-up is short.
CONCLUSIONS
Endoscopic resection for rectal carcinoid tumors smaller than 1 cm in diameter is a safe, functional, time-saving, and effective treatment. If the tumor suggests a carcinoid, EMR is advised rather than a polypectomy even though the tumor is small. Microscopically positive margins are not absolute indications for further surgery in the treatment of carcinoids smaller than 1 cm in diameter. It is much more important for an endoscopist to be confident that the endoscopic resection is done completely. It is necessary to identify the factors influencing the malignancy potential and to have a longer follow-up.

Two Cases of Stercoral Perforation of Colon.: Jeong, Keuk Won , Chung, Woo Shik , Chang, Tae Soo; J Korean Soc Coloproctol. 2000;16(2):115-118.

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Abstract PDF: While colon perforation as a complication of diseases such as carcinoma, colitis, diverticular disease, or abdominal trauma is not uncommon, spontaneous perforation of the colon is rare. Although spontaneous perforation is classified as either stercoral or idiopathic on the basis of its etiological background, the pathological mechanisms of the lesions have yet to be determined in detail. Stercoral perforation is a very rare cause of acute abdomen, with fewer than 70 cases documented in the literature; and idiopathic perforation is also infrequently reported. Both disease entities have often been grouped together as idiopathic or spontaneous perforation, resulting in confusion. We report herein two cases of stercoral perforation of the sigmoid colon. The clinical features, diagnosis, and treatment of the disease are reviewed. Surgeons should be aware of the possibility of this fatal disease, despite its rare incidence. Furthermore, it is important to recognize the condition at an early stage of the disease because it has significantly high mortality if surgery is delayed.

Case Reports

2 Cases of Metachronous Triple Primary Cancers.: Kang, Jae Hee , Lee, Kee Hyung , Lee, Sang Mok , Ko, Young Kwan , Hong, Sung Hwa , Yoon, Choong; J Korean Soc Coloproctol. 2000;16(2):119-124.

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Abstract PDF: Multiple primary cancer for the colon and rectum was reported in numorous literature. Therefore, complete preoperative evaluation of patients presenting with colorectal cancer seems to be essential. In addition, it is fundamental that patients who have been treated for colorectal cancer require careful follow up evaluation. When symptoms and signs of tumor develop in a patient who has been treated for an initial colorectal cancer, the possibility of a localized and curable second, third primary cancer should be considered and evaluated. We report 2 cases of metchronous triple primary cancer with a review of literature.

A Case of Secondary Amyloid Colitis in Rheumatoid Arthritis.: Cho, Jae Wan , Chae, Hiun Suk , Im, Kuk Hee , Kim, Tae Ho , Lee, Gang Mun , Kim, Sung Soo , Lee, Chang Don , Choi, Gyu Yong , Chung, In Sik , Sun, Hee Sick , Maeng, Yi So , An, Chang Hyuk; J Korean Soc Coloproctol. 2000;16(2):125-130.

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Abstract: Amyloidosis is known as a disease caused by the deposition of a insoluble and fibrous amyloid protein in the extracellular space of various organs and tissue. Intestinal amyloid deposition may develop motility disturbance, malabsorption, bleeding and perforation. A 70-year old woman with lower abdominal pain, watery diarrhea was admitted and had the past history of diabetes mellitus, hypertension for 8 years and rheumatoid arthritis for 10 year. On colonoscopic examination for evaluation of diarrhea, multiple edematous and shallow ulcers was found from distal sigmoid to terminal ileum. A green colored positive birifringent stained amorphous material was found in polarizing microscopy of colon biopsy specimen stained with Congo-red on microscopic examination,. We report a case of amyloidosis causing colon ulcers confirmed by colonoscopic biopsy with review literature.

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