Annals of Coloproctology

Volume 16(3); June 2000

Original Articles

Expression of Survivin in Human Colorectal Cancer Tissues.: Lee, Ryung Ah , Kim, Kwang Ho , Shim, Kang Sup; J Korean Soc Coloproctol. 2000;16(3):131-138.

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Abstract PDF: Survivin, the recently discovered apoptosis inhibitor of inhibitor of apoptosis (IAP) family is located in chromosome 17q25. It is found only in fetal tissue and transformed tissue but is never found in normal adult tissue. Several authors reported survivin expression in various cancer tissues, which suggested the role of survivin in cancer development. This study intended to find the degree of survivin expression making use of RT-PCR technology and to compare the expression pattern of survivin, caspase 3, and PARP.
METHODS
The cell lines known to have survivin expression such as HL60, Daudi, THP1, and colon cancer cell lines such as COLO 201, WiDr and breast cancer cell line ZR-75-1 were used for the positive control. For the negative control, normal colon tissues were included. The total RNAs from the frozen tissue of 6 normal colon, 36 specimens of colorectal cancer, and cell lines were used in RT-PCR. The 20 paraffin embedded tissues were used in immunohistochemical study in order to find out the degree of protein expression of caspase 3 and PARP. Western blotting was conducted on same tissues for caspase 3 as usual manners.
RESULTS
The survivin expression by RT-PCR techniques was found in the 22 cases (61.1%). As a result of the immunohistochemical staining, 13 cases (65%) in caspase 3, 17 cases (85%) in PARP showed reduced staining. In western blotting, 32 kDa inactive form of caspase 3 was expressed in 16 cases (80%), but the band of active split form was not found. No significant relationship was found between survivin expression and clinicopathologic data of colorectal carcinomas, and expression of caspase 3 and PARP.
CONCLUSIONS
These result suggest that apoptosis mechanism is depressed in colorectal cancer tissues and survivin plays a role in the inhibition of apoptosis of colorectal cancer. More profound study could confirm the apoptosis mechanism in tumorigenesis.

Determination of Rectal Afferents, Based on the Analysis of Cerebral Evoked Potentials Induced by Rectal Stimulation.: Seong, Moo Kyung , Choi, Hyun Joo , Park, Ung Chae , Cho, Joon; J Korean Soc Coloproctol. 2000;16(3):139-144.

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Abstract PDF: The rectum is a unique visceral organ, of which afferents are not so obvious. In anorectal surgery ablating the rectum and/or perirectal structure, this issue comes with significant meaning about whether to preserve patient's normal defecatory function, or not. So we planned this study to evaluate which nervous system concerns the afferents from the rectum.
METHODS
We recorded cerebral evoked potential (EPs) in 16 healthy male subjects after electrical and mechanical stimulation of the rectum, and compared their waving patterns regarding latencies and amplitudes of each peak with those occuring after electrical stimulation of the pudendal nerve.
RESULTS
The EPs after electrical stimulation of the rectum showed distinctly different waving patterns in comparison to those after electrical stimulation of the pudendal nerve. But the EPs after mechanical stimulation of the rectum showed very similar waving patterns with those after electrical stimulation of the pudendal nerve.
CONCLUSIONS
Rectal afferents of mechanical stimulation seem to be somatosensory, but those of electrical stimulation seem visceral. In that sense, sensory receptors of mechanical stimulation may lie in the perirectal structure, such as pelvic floor muscle and those of electrical stimulation lie in the rectum, itself.

Clinical Significance of Hyperplastic Polyps in the Distal Colon.: Hong, Boo Hwan , Kim, Jong Han , Ryu, Keun Won , Kim, Sun Han , Kim, Jin Ho , Moon, Hong Young; J Korean Soc Coloproctol. 2000;16(3):145-149.

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Abstract PDF: To determine whether hyperplastic polyps found in the distal colon are associated with proximal adenomas, and to judge whether patients with distal hyperplastic polyps found during sigmoidoscopy might benefit from full colonoscopy.
METHODS
We retrospectively analyzed 2333 consecutive patients who were examined with colonoscopy between January 1991 and December 1994.
RESULTS
247 of 2333 patients (10.6%) had one or more colonic polyps. The prevalence of adenomatous polyps alone was 72.5%, hyperplastic polyps 22.7%, and both 0.52%. The proportion of patients with distal hyperplastic polyps and proximal adenomatous polyps (4.4%) was not significantly different from the proportion of those without distal hyperplastic polyps (1.6%). Patients with distal adenomatous polyps, on the other hand, were significantly more likely to have proximal adenomatous polyps than those without distal adenomatous polyps.
CONCLUSIONS
Distal hyperplastic polyps are not strong predictors of risk for proximal adenomatous polyps. Based on the results of this study, we do not believe that finding a hyperplastic polyp during sigmoidoscopy justifies doing a full colonoscopy to search for proximal adenomatous polpys.

Clinical Analysis of Total Colectomy for Chronic Idiopathic Constipation.: Lim, Sae Woung , Oh, So Hyang , Lee, Woo Yong; J Korean Soc Coloproctol. 2000;16(3):150-155.

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Abstract PDF: The aim of this study was to analyse clinical feature and outcome of patients following total abdominal colectomy and ileorectal anastomosis.
METHODS
All of 8 patients subjected to surgery during 5 year period from May 1995 to December 1999 were reviewed using retrospective method.
RESULTS
All patients had slow colonic transit and 7 patients (male to female, 1:1.6) with a mean age of 54 (range, 27~70) years underwent total abdominal colectomy and ileorectal anastomosis and one patient had right hemicolectomy. Major symptoms were abdominal pain and bloating and mean bowel action was 18.5 days, mean suffered time before operation was 26.3 years. Colonic transit study, defecography and rectal manometry were done in all cases. Pelvic floor dysfunction was combined in 5 patients. Median follow up was 2.7 years. There was one mortality case due to postoperative pneumonia and ARDS in a 70 year old patient. Except one mortality case, there was significant success rate, overall 71%.
CONCLUSIONS
Colectomy with ileorectal anastomosis produces a satisfactory outcome in the majority of patients undergoing surgery for chronic idiopathic constipation.

Etiology and Surgical Management of Fecal Incontinence.: Kim, Chang Nam , Chun, Ho Kyung , Yu, Chang Sik , Park, Sang Kyu , Kim, Sook Young , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(3):156-162.

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Abstract PDF: Fecal incontinence is a disabling condition with devastating psychosocial impact due to diverse etiology. This study was performed to assess various causes of fecal incontinence, clinical evaluation, and adequate surgical treatment.
METHODS
Eighty patients presenting fecal incontinence during July 1989 and June 1997 were included. They were evaluated by clinical parameters and physiologic tests including the defecography, electromyography, transanal ultrasonography, and anorectal manometry. Surgery was performed in 31 patients based on those evaluation. Pre- and post-operative comparison of manometric findings, clinical assessment, incontinence score, and the outcome of surgery were assessed. Mean postoperative follow-up was 22 (2~84) months.
RESULTS
Inappropriate anal surgery was the most common cause, and then injuries during delivery, trauma, rectal prolapse, and hysterectomy in descending order. Defecography was performed in 21 patients and mean values of anorectal angles were 115+/-15degrees at rest, 98+/-18degrees during squeezing, and 136+/-10degrees during push. Electromyography was performed in 8 patients showing pudendal neuropathy in 2, bilateral lumbosacral polyradiculopathy in 4, and normal finding in 2 patients, respectively. Transanal ultrasonography was performed in 33 patients and 22 among them showed finding of an injury of the anal sphincters. Surgery was performed in 31 patients due to anal sphincter damage, rectovaginal fistula, and anal stricture in descending order. Type of surgery was determined by respective cause: plication, triple repair (sphincteroplasty, anoplasty, perineorrhaphy), and posterior rectopexy in descending order. Nerve preserving graciloplasty was performed in a 12 year-old girl who had severe defect of the anal sphincters by traffic accident, showing sound recovery with a good functional outcome. Although there was no significant difference of manometric variables between pre- and post-operative periods, sphincter length, and maximum resting and squeezing pressure, revealed an increasing tendency postoperatively. According to the clinical assessment between pre- and post-operative periods, urgency to evacuate, soiling, sensation on defecation, and quality discrimination were significantly improved postoperatively (P<0.01). Incontinence score was markedly decreased from 10.6+/-6.1 during preoperative period to 2.9+/-4.7 during postoperative period (P<0.01). Eighty one percent of the patients undergone surgery experienced a significant symptomatic improvement.
CONCLUSIONS
According to the analysis of the causes of fecal incontinence, inappropriate anal surgery, injuries during delivery, and trauma were main causes. Adequate application of physiologic tests, such as, defecography, electromyography, transanal ultrasonography, and anorectal manometry, were helpful in determining treatment modality and types of surgery. We got satisfactory results with adequate surgery based on the physiologic tests.

Clinical Application of Continent Anal Plug in Bed-Ridden Patient with Intractable Diarrhea.: Kim, Jae Hwang , Shim, Min Chul , Choi, Byung Yon , Ahn, Sang Ho , Jang, Sung Ho , Shin, Hyoun Jin; J Korean Soc Coloproctol. 2000;16(3):163-170.

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Abstract PDF: Poor control of bowel movement in some bed-ridden patients with various causes such as stroke or spinal cord injury which causes fecal leakage and diarrhea, increases the risk of perianal excoriation, bed sores and is a burden on caregivers. PURPOSE: To evaluate the efficacy of fecal evacuation, prevention and treatment of skin complications in intractable diarrhea patients employing a new device.
METHODS
A continent anal plug (CAP: US Patent No. 5,569,216: Join Ent. Seoul, Korea) comprises an inner balloon surrounded by an external balloon both of which are mounted on a silicone tube containing a pair of air passages and an enema fluid inlet. The tube is secured in place in the rectum by the inflatable external balloon and is designed to drain fecal matter through a thin collapsible hose situated in the anal canal. Thirty two patients (21 male, median age 61 years, range; 28~76) were evaluated after fully informed consent. Median duration (range) was 12 (3~37) days.
RESULTS
CAP evacuated efficiently in those with loose or watery stools who only required once daily irrigation or not. Skin excoriations improved in 3~7 days. Minimal leakage was seen around the anus. There was no anorectal mucosal injury noted over 37 days. Conclusions: The CAP was an efficient method of treating patients with loss of bowel control and incontinence because it enabled controlled fecal evacuation and helped reduction of skin complications without causing anorectal mucosal injury.

Clinical and Physiologic Study of Encopresis.: Chung, Soon Sup , Kwon, Jae Bong; J Korean Soc Coloproctol. 2000;16(3):171-176.

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Abstract PDF: The pathophysiology of pediatric encopresis has been incomprehensible. The current study was designed to assess its clinical and physiologic findings. Moreover, outcome of treatment was evaluated.
METHODS
The clinical and functional findings of 18 patients (13 boys, 5 girls) were analyzed, retrospectively. Physiologic studies for cooperative child included anal manometry (n=12), cinedefecography (n=3), and PNTML (pudendal nerve terminal motor latency, n=1). For exclusion of the organic cause, barium contrast study was carried out in all case. Patients were categorized by leading symptom as constipation or incontinence. Physiologic findings and outcome of treatment were analyzed based on the categorized groups. Biofeedback therapy by using newly-developed anal sphincter control system (KONTINENCE CLINICAL(TM)) in my institute, was underwent a mean 4.1 (range, 2~12) sessions. The outcome was analyzed in the period of 5.4 (range, 1~33) months follow-up.
RESULTS
Patients were categorized as having constipation (group I, n=12) or incontinence (group II, n=6) group. In the manometric parameters, there were no statistical differences between the values of the mean resting pressure (RP), the maximum RP, and the maximum voluntary contraction between group I and II. In the cinedefecography, 3 of group I patients revealed as having the pelvic floor dyssynergia. The findings of PNTML were not specific in group II (n=1). Regarding to the therapeutic outcome, 8 of 10 patients were cured or improved.
CONCLUSIONS
There were no differences in the resting and squeeze profiles of manometric parameters between two groups. However, pelvic floor dyssynergia was identified in the cinedefecography of constipated group. Conventional and biofeedback treatment for encopretic children provides acceptable outcome.

Preoperative Staging of Rectal Cancer by CT & MRI.: Shin, Jong Keun , Lee, Sang Mock , Park, Ho Chul , Lee, Kee Hyung , Oh, Soo Myung , Yoon, Choong , Lee, Dong Ho; J Korean Soc Coloproctol. 2000;16(3):177-185.

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Abstract PDF: Accurate staging of rectal cancer preoperatively is important to plan a proper treatment and to predict treatment results. For the preoperative staging of rectal cancer, computed tomography (CT), transrectal ultrasonography (TRUS), and magnetic resonance imaging (MRI) have been used, but the role of them remains controversial. This research was intended to compare and analyze the accuracy of CT and MRI in the preoperative staging of rectal cancer.
METHODS
From January 1998 to June 1999, sixty patients were studied by CT and MRI before their operations for rectal cancer in our institution, but two patients with local excision were excluded in N-staging as objects. The patients who had preoperative irradiation were also excluded in this study. Preoperative staging with CT and MRI were conducted by one radiologist according to 1997's TNM classification based on AJCC. On the results of pathological findings after operation, preoperative staging with CT and MRI were classified into T-staging and N-staging. Accuracy and agreement rate between pathological staging and preoperative staging by CT and MRI were compared and analyzed by Kappa value.
RESULTS
The accuracy of CT was 68 percent in T-staging, and 58 percent in N-staging, MRI showed accuracy of 82 percent in T-staging and 64 percent in N-staging. In the T-staging, the agreement rate between pathological staging and CT staging was 0.54 (95% confidence interval), while the agreement rate was 0.70 in MRI staging, resulting in a higher agreement rate with MRI than with CT. In the N-staging, the agreement rate between pathological staging and CT staging was 0.38, with a relatively lower agreement rate, while the agreement rate was 0.56 in MRI staging. In our study, MRI showed a higher agreement rate than CT.
CONCLUSIONS
In the future, more research should be conducted, but it can be conclued that in preoperative staging for rectal cancer, MRI using body arrayed coil has a better accuracy than CT. Subsequently MRI staging should be considered as a more useful investigation method before operation than CT.

The Influence of DNA Ploidy, Index and Lymph Node Status on Disease Free Survival in Patients with Colorectal Cancer.: Choi, Sun Keun , Jeong, Joo Hwan , Bae, Sun Young , Kwon, Young Sik , Hong, Kee Chun , Shin, Seok Hwan , Woo, Ze Hong; J Korean Soc Coloproctol. 2000;16(3):186-192.

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Abstract PDF: The DNA flow cytometric analysis in colorectal cancer has been studied for more than 10 years as an independent prognostic factor or a factor correlated with other preexistent prognostic factors, such as the depth of invasion, lymph node status, histologic differentiation, etc. To clarify the influence of DNA contents (DNA ploidy, DNA index) and lymph node status on disease free survival in colorectal cancer, we investigated the relationship between them, retrospectively.
METHODS
This study included 198 patients with curatively resected Dukes' stage A, B, and C colorectal cancer who had taken DNA flow cytometric analysis from June of 1996 to March of 1999 at Department of Surgery, Inha University Hospital.
RESULTS
In over all twelve-month disease free survival, there were 92.5% in DNA diploid and 74.3% in DNA aneuploid tumors. And so forth, there were 78.0% in positive and 91.9% in negative lymph node tumors. In the event of a DNA index greater and lesser than 1.15, the twelve-month disease free survival was 72.9% and 92.7%, respectively. These results were statistically significant (p<0.05). Therefore, patients with a negative lymph node, diploid colorectal cancer or DNA index lesser than 1.15 had a longer disease free survival than those with a positive lymph node, aneuploid one or DNA index greater than 1.15.
CONCLUSIONS
In conclusion, there seems to be a significant relationship between DNA contents and lymph node status on disease free survival. Thus, these factors are considered to be valuable in predicting the recurrence of colorectal cancer.

Survey on Satisfaction of Ostomate according to Colostomy Irrigation.: Choi, Sung Il , Lee, Kil Yeon , Ko, Young Gwan , Koh, Suck Hwan , Oh, Soo Myung , Yoon, Choong , Lee, Kee Hyung; J Korean Soc Coloproctol. 2000;16(3):193-197.

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Abstract PDF: The colostomy may cause considerable discomfort as well as surgical, psychological and esthetic problems. The ostomates probably suffer most from fecal incontinence, even though many attempts have been made to eliminate the problems related to the spontaneous colonic emission. Hence the aims of this study are to survey ostomates' satisfaction with colostomy irrigation.
METHODS
This medical survey attempts to assess the degree of satisfaction that ostomates are satisfied with the quality of their lives and the extent to which they are affected in doing their jobs and sexuality. The survey was conducted for 146 ostomates, who responded to the questionnaire at the 3rd & 4th Workshop for Stoma Rehabilitation for Ostomates in 1998 and 1999 developed by the Department of Surgery, Kyung Hee University Hospital. The irrigation group was formed with 66 cases (45.2%) and the non-irrigation group 80 cases (54.8%). In assessment of the satisfaction of sexuality, the irrigation group was composed of 37 cases (male: 22 cases, female: 15 cases) and the non-irrigation group 48 cases (male: 30 cases, female: 18 cases).
RESULTS
It is found out that the ratio of male to female is 1.5:1 (97:59) and by the age distribution, the ostomates in their 50's and 60's constitute 67.1%: by the cause of stoma operation, malignancy consists of 133 cases (91.1%), Inflammatory Bowel Disease (IBD) 6 cases, the others 7 cases. As for the degree of the satisfaction of ostomates for their life quality, it is found that 52 cases (78.9%) of the irrigation group and 71 cases (88.8%) of the non-irrigation group (p<0.05) reveal dissatisfaction. As for the degree of the satisfaction of the ostomates for the extent to which they are affected in doing their social activities, dissatisfaction is revealed in 52 cases (78.9%) in the irrigation group and in 64 cases (80.0%) in the non-irrigation group (p>0.05). As for the degree of the satisfaction of the ostomates for the sexuality in male, dissatisfaction is revealed in 13 cases (59.1%) of the irrigation group and in 23 cases (76.7%) of the non-irrigation group (p<0.05). In the case of female, the dissatisfaction is observed in 8 cases (53.3%) of the irrigation group and in 13 cases (72.2%) of the non-irrigation group (p<0.05).
CONCLUSIONS
This medical survey clearly shows high dissatisfaction rates especially in the non-irrigation group, and the better significant satisfaction was shown in the quality of life and sexuality between the male and the female in the irrigation group. Therefore, colostomy irrigation may be an effective method for the management of colostomy.

Anastomotic Stricture after Colorectal Stapled Anastomosis.: Hong, Hyoun Kee , Jeong, Choon Sik , Lee, Dong Hee , Kim, Hee Cheol , Yu, Chang Sik , Park, Sang Kyu , Kim, Sook Young , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(3):198-203.

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Abstract PDF: INTRODUCTION: Stapled anastomosis in the rectal cancer surgery has been already proven as a safe technique, maintaing secure suture and saving times compared to handsewn anastomosis. With the advancement of stapling device, the incidence of anastomotic leakage has decreased significantly. However, developement of anastomotic stricture has become a major postoperative complication. PURPOSE: An analysis of the clinical features and the predisposing factors of anastomotic stricture was made to identify its pathogenesis and to determine adequate procedure.
METHODS
We analyzed 49 patients (8.1%) with the rectal stricture among 608 patients, undergone stapled anastomosis for the rectal cancer surgery at Asan Medical Center from Jan 1993 to Dec 1998. Rectal stricture was defined when index finger or colonoscope could not pass the anastomotic site (high grade), or could pass with difficulty(low grade). RESULTS: Underlying general diseases, e.g., DM, hypertension and cardiovascular disease was associated more frequently in patients with anastomotic stricture (20.4%) than patients without (10.8%) (P<0.05). The rate of postoperative major complications in patients with stricture was 22.4%, while that of anastomotic leakage was 6.1%. Development of anastomotic stricture was not associated with operative methods, age, anastomosis level, and postoperative radiotherapy. In patients with stricture, 34 patients (69.4%) were asymptomatic, and 15 patients were symptomatic. In treating symptomatic rectal stricture, only five patients performed dilation manually or by the Hegar dilator.
CONCLUSIONS
Rectal stricture after stapled anastomosis might be associated with underlying diseases, and correlated with prolonged sanguinous drainage and ileus. Meticulous management of underlying disease and complete hemostasis during operation appear to be important to reduce the rate of rectal stricture.

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