Annals of Coloproctology

Volume 16(4); August 2000

Original Articles

Changes of Nitric Oxide Synthase (NOS) Isozymes in Cultured Human Colon Carcinoma Cell.: Park, Jin Young , Kim, Cheong Yong , Lee, Byoung Rai; J Korean Soc Coloproctol. 2000;16(4):209-214.

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Abstract PDF: Nitric oxide (NO), the production of which is dependent on Nitric oxide synthase (NOS), has been shown to contribute to pathogeneses in various diseases. Recent investigations of NOS expression in tumor tissues indicate that NO may mediate one or more roles during the growth of human cancers. The aim of this study was to determine whether iNOS is expressed in human colon carcinoma cell lines and to determine the types of NOS isozymes in colon carcinoma cell lines with high and low metastatic potentials.
METHODS
We measured the expressions of iNOS and eNOS and the formation of nitrotyrosine which indicates peroxinitrate production in highly metastatic colon cancer cell (KM1214) and lowly metastatic colon cancer cell (KM12C) by Western blots.
RESULTS
The iNOS were detected in both KM1214 and KM12C by Western blot analysis. The expression of iNOS in KM1214 cells was significantly higher than in KM12C cells. The expression of iNOS was increased with lipopolysaccharide (LPS) in colon cancer cells but the rate of increase was higher in KM1214 cells than in KM12C cells.
CONCLUSIONS
In human colon carcinoma cells, iNOS is expressed in cancer cells and expression of iNOS is higher in highly metastatic colon cancer cells than in lowly metastatic colon cancer cells and iNOS expression may have some role in colon cancer metastasis.

Physiologic Characteristics and its Clinical Significances in the Patients with Pelvic Outlet Obstruction.: Park, Ung Chae , Chung, Soon Sup , Park, Seung Hwa; J Korean Soc Coloproctol. 2000;16(4):215-222.

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Abstract PDF: Current study was designed to assess the functional etiology of patients with pelvic outlet obstruction. Moreover, physiologic characteristics and theirs clinical significances were evaluated in the patients with ramified diagnosis.
METHODS
172 patients with pelvic outlet obstruction were performed 328 numbers of physiologic studies. These included cinedefecography (n=172), anal manometry (n=87), colonic transit time study (n=38), and anal EMG/PNTML (n=31). On the basis of physiologic findings, patient groups were categorized as rectocele (group I), nonrelaxing puborectalis syndrome (group II), anal dyschezia (group III), and rectoanal intussusception (group IV). The physiologic findings were compared between subgroup patients.
RESULTS
Incidence of categorized patients was 51.7% (group I, n=89), 22.7% (group II, n=39), 12.2% (group III, n=21), and 8.7% (group IV, n=15), respectively. The mean age of patients with group III were lower (p<0.05) than that of overall patients. The incidence of female patients was higher in group I and the incidence of male patients was higher in group II (p<0.0001). In cinedefecography, patients with group II showed smaller anorectal angle at strain (p<0.001), at dynamic change between rest and strain (p=0.002). In anal manometry, patients with group III showed higher mean resting pressures (p=0.001), higher maximum resting pressures (p<0.001), higher mean squeeze pressures, and higher maximal voluntary contraction (p=0.003) than those of patients with other group. In neurologic study, mean value of PNTML was 2.32 +/- 0.34 (range, 1.60~3.66) msec in overall patients. The size of rectocele was increased in proportion to patient's age (r=0.229, p<0.05), number of delivery (r=0.393, p=0.001), and degree of perineal descent (r=0.231, p<0.05). The degree of perineal descent was increased in proportion to patient's age (r=0.249, p<0.05).
CONCLUSIONS
Present series provided the diagnostic ramification of pelvic outlet obstruction by using the anorectal physiologic investigations. In addition to the function of puborectalis muscle, evacuation dynamics of anorectum should be emphasized. These findings could provide the fundamental information for guideline of future therapy in the patients with obstructed defecation.

Clinical and Physiologic Characteristics of Rectal Prolapse in Males.: Yoon, Seo Gue , Lee, Kwang Real , Cho, Kyung A , Hwang, Do Yean , Kim, Khun Uk , Kang, Young Won , Park, Weon Kap , Kim, Hyun Sik , Lee, Jung Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2000;16(4):223-230.

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Abstract PDF: This study compares the sexual differences among rectal prolapse patients regarding the clinical and the physiologic characteristics with emphasis on males.
METHODS
The clinical data, functional status and operative records of 43 patients, who had completed both clinical and functional evaluations were collected in a prospective database and were analyzed according to sex. The functional status of the patients was evaluated by Wexner's constipation score (0~30), Wexner's incontinence score (0~20), anorectal manometry, and pudendal nerve terminal motor latency (PNTML).
RESULTS
The incidences of rectal prolapse in males (n=22) and in females (n=21) were similar. The age of onset for males was lower (mean standard deviation, 19.6 19.59 (50% in childhood) vs 52.0 20.75 years; p=0.001) and the duration of symptoms was longer (31.5+/-19.87 vs 12.5+/-14.31 years; p<0.001). Surgery in males was most commonly performed during the sexually active years (51.2+/-16.34 vs 64.5+/-13.19; p=0.006). The incidence of mucosal prolapse in males was higher (10/22 vs 4/17; p=0.065). The incidences and the severities of defecation difficulty in males and females were similar (n=12, mean Wexner score=8.4 vs n=12, mean Wexner score=9.9; p=NS) but, the incidences and the severities of fecal incontinence were lower in males (n=4, mean Wexner score=4.3 vs n=17, mean Wexner score= 14.2; p<0.001). The maximum resting pressure was higher in males (39.2+/-21.46 vs 26.3+/-19.98 mmHg; p=0.049), and the maximum squeezing pressure was better preserved (131.2+/-62.63 vs 67.5+/-37.99 mmHg; p<0.001). No significant difference existed in the PNTML. Female patients underwent abdominal resection rectopexy (n=6), perineal rectosigmoidectomy with lavatoroplasty (n=11), and Delorme's procedure (n=4), but all male patients preferred the perineal approach (rectosigmoidectomy with lavatoroplasty (n=8), Delorme's procedure (n=14)) for fear of sexual dysfunction after the abdominal approach.
CONCLUSIONS
These findings suggest that the mechanism for developing rectal prolapse in male and female may be different and that surgical treatment should be tailored to the patient.

A Role of Anorectal Physiologic Study for the Diagnosis of Chronic Constipation.: Kim, Seung Han , Hwang, Yong Hee , Choi, Kun Phil; J Korean Soc Coloproctol. 2000;16(4):231-238.

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Abstract PDF: To assess the role of anorectal physiologic study for the diagnosis of chronic idiopathic constipation.
METHODS
A retrospective study of 81 constipated patients (23 male, 58 female) of mean age 48 16.6 (16~83) years who had no abnormalities in colonoscopy, barium enema, and rectal exam was done. 81 patients underwent defecography and cine-defecography, of which 66 patients underwent anal manometry, 52 patients underwent colonic transit time study (CTT), and 27 patients underwent anal plug electromyography (EMG).
RESULTS
Nonrelaxing puborectalis syndrome (NRPR), rectocele, rectal intussusception, anal dyschezia, and sigmoidocele were observed in 27 (33.3%), 26 (32.1%), 14 (17.3%), 3 (3.7%), and 2 (2.5%) of the patients, respectively. Normal cinedefecography finding was observed in 21 (25.9%) patients. More than one abnormal finding was found in 11 (13.6%) patients. Abnormal findings included colonic inertia in 6 (11.5%) patients and pelvic outlet obstruction in 2 (3.8%) patients. Normal colon transit time was observed in 44 (84.6%) patients. Anal hypertonia was observed in 23 (34.8%) patients by anal monometry, of which 3 patients were diagnosed with anal dyschezia in cinedefecography. 13 (48.1%) patients were diagnosed with NRPR in anal plug EMG. The correlation rate between cinedefecography/EMG, defecography/CTT, and CTT/EMG were 81.5%, 61.5%, and 51.9% respectively in the diagnosis of NRPR. Sensitivities of the three tests were 72.7% for cinedefecography, 66.7% for EMG, and 7.7% for CTT in diagnosing NRPR (p<0.05). Positive predictive values of the three tests were 80% for anal plug EMG, 72.7% for cinedefecography, and 50% for CTT in the diagnosis of NRPR.
CONCLUSIONS
Defecography and EMG were complements each of the other in diagnosis of pelvic outlet obstruction especially NRPR, but CTT has no role.

Clinical Significance of CEA Level of Peripheral Vein, Inferior Mesenteric Vein, Bile, and Peritoneal Fluid in Sigmoid Colon and Rectal Cancer.: Lee, Ju Young , Kim, Cheong Yong , Kim, Jae Han , Park, Sang Heon , Park, Jung Hi , Byun, Joo Nam; J Korean Soc Coloproctol. 2000;16(4):239-245.

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Abstract PDF: Carcinoembriogenic antigen (CEA) was widely used as a marker for staging and detection of recurrence and metastases, and evaluation of response of radical opertion or chemotherapy in colorectal cancer patients.
METHODS
We examined 50 patients with sigmoid colon and rectal cancer patients who had a radical operation between 1994 May and 1995 April. We checked the level of CEA of peripheral blood preoperatively and postoperatively, and inferior mesenteric vein, bile of gall bladder and peritoneal fluid during surgery. We review clinical characters of the patients, and analyzed the importance of CEA level.
RESULTS
The mean CEA levels of peripheral blood (postoperation), inferior mesenteric vein, bile, peritoneal fluid were 5.35+/-2.65, 13.23+/-2.13, 9.23+/-1.65, 7.42+/-2.34 ng/ml respectlively. The mean CEA level of inferior mesentiric vein (13.23+/-2.13 ng/ml) was significantly higher than that of preoperative peripheral blood (8.13+/-2.34 ng/ml) (p<0.05). Falling of postoperative peripheral blood CEA level was also significantly lower than that of preoperative level (p<0.05).
CONCLUSIONS
Level of postoperative peripheral blood was related to recurrence rate and survival rate, but tumor size, tumor location, tumor differentiation, Dukes' stage were not related to the CEA level. Bile and peritoneal fluid CEA levels were related with the liver metastasis or local recurrence respectively. We suggest that CEA was useful indicator for evaluation, management, and prognosis of colorectal cancer not only preoperatively but also postoperatively.

Clinical Significance of the Colorectal Polyps.: Bae, Tae Seok , Jung, Ki Hoon , Lee, Joon Hee , Oh, Min Gu , Chung, Byung Ook , Bae, Sung Han , Ahn, Woo Sup; J Korean Soc Coloproctol. 2000;16(4):247-253.

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Abstract PDF: The aim of this study was to investigate the association of colorectal polyps with carcinoma of the colon and rectum.
METHODS
Between January 1995 and December 1998, 203 consecutive patients with 423 colorectal polyps retrospectively documented at the Department of General Surgery and College of Medicine in Dongguk University.
RESULTS
The peak age group of the colorectal polyp was in the fifth decades (33.5%). The proportions of malignant polyps were as follows: for size, 5.2% of polyps less than 1.0 cm and 19.5% of polyps larger than 1 cm (P<0.05); for morphology, 2.6% in polyps of Yamada type I, II and 18.5% in polyps of Yamada type III, IV (P<0.05); for location, 13.4% of the polyps located in rectum and sigmoid colon and 7.6% of the polyps located in descending to ascending colon (P>0.05); for number of polyp, 4.5% in cases of single polyp and 25.0% in cases of multiple polyps (P<0.05); for underlying histology, 9.2% in cases of tubular adenoma and 19.2% in cases of villous adenoma (p<0.05). The presence of distal adenomatous polyp was increased the risk of presence of the proximal adenomas (59.7%), whereas the presence of hyperplastic polyp did not (16.7%).
CONCLUSIONS
The malignant potential of colorectal polyps are correlated with size, histologic type, morphologic shape, multiplicity and distal location. The presence of hyperpalstic polyp should not be indication for colonoscopy because they are not associated with proximal adenoma when adjusting for patient characteristics and presence of distal adenoma.

Surgical Treatments and Clinical Outcomes of Sigmoid Colon Cancer Adherent to Other Organs.: Kim, Hee Cheol , Hong, Hyoun Kee , Lee, Dong Hee , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(4):254-259.

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Abstract PDF: Sigmoid colon cancer occasionally attaches to the adjacent viscera. It is estimated that such attachment occurs in 6% to 12% of all patients with colon carcinoma without distant metastases. This study was performed to identify the parameters to distinguish direct tumor invasion to adjacent organs from simple inflammatory adhesion in sigmoid colon cancer and to clarify the difference of survival and recurrence pattern between two groups.
METHODS
Between 1989 and 1998, 415 patients underwent resection of sigmoid colon cancer in our clinic. Of these, 46 had tumors adherent to adjacent organs and confirmed as tumor direct invasion or simple inflammatory adhesion by pathologic examination. The mean age of 46 cases was 54.2+/-12.8 (mean+/-SD) years and median follow up was 21 (3~53) months.
RESULTS
Among the clinical and pathologic parameters such as symptoms and laboratory findings presenting bowel obstruction, serum CEA levels, preoperative radiological findings, tumor size, differentiation, and stage, there was no specific one that was correlated with direct tumor invasion or inflammatory adhesion. Almost all cases with adhesion to adjacent organ were treated by an en bloc resection including mutivisceral resection. The group with direct invasion had inferior disease free survival rate and overall survival rate comparing with simple inflammatory adhesion group.
CONCLUSIONS
In the situation that there was no valuable parameter suggesting direct tumor invasion, en bloc resection or multivisceral resection involving one tumor-free plane may be beneficial to the patients with sigmoid colon cancer adherent to adjacent organ.

The Significance of Serum Carcinoembryonic Antigen in Curative Surgery of Colorectal Cancer.: Lee, Mun Sub , Chung, Byung Ook , Jung, Ki Hoon , Seo, Jung Wook , An, Woo Sub , Bae, Sung Han , Oh, Min Gu , Lee, Jun Hee , Yang, Chang Hun; J Korean Soc Coloproctol. 2000;16(4):260-266.

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Abstract PDF: Carcinoembryonic antigen (CEA) in now the most widely used and the most useful marker for many cancers, including those of the colon, lung, pancreas, and breast. Also CEA is widely used for detection, staging, recurrence, and assessing the response to therapy in colorectal cancer.
METHODS
From 1992 to 1998 the clinical value of the pre- and postoperative serum levels of CEA who underwent curative surgery at Department of General Surgery, College of Medicine, Dongguk University KyungJu Hospital, in 140 s patient with colorectal cancer with abnormal levels of CEA (>or=5 ng/ml) was investigated.
RESULTS
The results are as follows: 1) The positive rate of preoperative CEA level was 47%, so preoperative CEA level measurement was not useful as screening test for colorectal cancer. 2) There was no significant association between abnormal CEA level and the location of tumor. 3) There was significant association between increased levels of preoperative serum CEA and lymph node metastases. 4) The incidence of preoperatively elevated CEA levels in Dukes stages A, B, C, and D was 0%, 27%, 63%, 71%, respectively. There was significant association between increased levels of the preoperative serum CEA and the progressive stages of colorectal cancers. 5) There was no significant association between abnormal CEA level and histologic differentiation of tumor. In addition, there was no significant association between abnormal CEA level and ploidy status of tumor. 6) The recurrence rate was 20% and 77% in patients with preoperative levels of CEA<5 ng/ml and >5 ng/ml, respectively. 7) The recurrence rate was 11% and 64% in patients with postoperative levels of CEA <5 ng/ml and >5 ng/ml, respectively. 8) Considering as normal CEA levels up to 5.0 ng/ml, sensitivity was found to be 77%, specificity, 80%, and predictive value of an elevated CEA concentration, 77%.
CONCLUSIONS
In conclusion, it is suggested that measurement of preoperative and serial postoperative CEA is very useful in assessing the prognosis and in detecting recurrences in colorectal cancer.

Flexible Rectal Stent for Obstructing Colonic Neoplasms.: Park, Je Hoon , Oh, So Hyang , Lee, Woo Yong , Choo, Sung Wook , Do, Young Soo , Chun, Ho Kyung; J Korean Soc Coloproctol. 2000;16(4):267-273.

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Abstract PDF: Acute lower gastrointestinal obstruction due to colorectal neoplasm is a common clinical problem, which frequently requires emergency operation. Morbidity and mortality associated with emergency operation is relatively high, and almost all requires a multi-stage operation. Recently flexible rectal stent has been emerged as an alternative for the management of acute lower gastrointestinal obstruction due to colorectal neoplasm. Thus we analyzed the results of flexible rectal stent treatment for acute lower gastrointestinal obstruction due to colorectal neoplasm.
METHODS
From June 1996 to May 1999 47 patients with acute malignant lower gastrointestinal obstruction were included in this study, medical records of these patients were reviewed retrospectively.
RESULTS
Of 47 patients 19 were male and 28 were women, with a mean age of 57.3 years (33~77 years). Male to female ratio was 1:1.47. Causes of acute intestinal obstruction were as follows: rectal cancer, 17 patients; sigmoid colon cancer, 18 patients; descending colon cancer, 3 patients; ascending colon cancer, 1 patient; stomach cancer, 5 patients; gall bladder cancer, 1 patient; and uterine cervix cancer, 1 patient; and ovarian cancer, 1 patient. Stent insertion was indicated as palliative treatment in 22 patients and preoperative decompression in 25 patients. Successful stent insertions were achieved in 40 patients (85.1%). Stent insertion was successful in 20 patients (91.0%) among the 22 patients treated for palliation. Stent insertion was successfully achieved in 20 patients (80.0%) among the 25 patients. Stent insertion failure was observed in 7 patients (14.9%). Stent failed due to the complete obstruction, 3 patients; long segmental lesion, 1 patient; anatomic abnormality, 1 patient; multiple lesions, 1 patient, and ultra-low rectal lesion, 1 patient. Colonoscopy-assisted stent insertion was performed in 5 patients. Post-stent complications occurred in 12 patients among the 40 patients (30.0%): stent migration, 8 patients; expansion failure, 2 patients; fecal incontinence, 1 patient; and malposition, 1 patient. The interval between stent insertion and operation was from 1 to 30 days with a median of 7 days. Elective operations were performed as follows: anterior resection, 6 patients; low anterior resection, 7 patients; Miles' operation, 3 patients; sigmoid colostomy, 3 patients; and transverse colostomy, 1 patient. Mean distal resection margin of specimen was 2.3 cm. No postoperative complication was seen.
CONCLUSIONS
Multi-stage operation can be avoided with flexible rectal stent without increasing postoperative complications. Complication rate was relatively high in patients whom stent were inserted for palliative intent. Combined colonoscopy increased the successful rate in difficult cases. Immediate operation should be considered for the patients with long segmental lesion, multiple lesions, ultra-low rectal lesion, and when perforation is suspected.

Fournier's Gangrene in a Boy of Three Years Old.: Lee, Do Sang , Sung, Gi Young , Song, Moo Hyung , Kim, Wook , Park, Il Young , Won, Jong Man; J Korean Soc Coloproctol. 2000;16(4):274-278.

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Abstract PDF: Fournier's gangrene is a rare disease characterized by an aggressive necrotizing fascitis of perineum and genitalia which is caused by mixed bacterial infection. The cornerstone of therapy consists of immediate recognition, wide debridement of devitalized tissues, antibiotic therapy, search for the primary source and occasionally urinary and fecal diversion. Although Fournier's gangrene has been reported in almost all ages, most cases have been reported in adults and occurrence in children is very unusual. Despite advancement in management, morbility and mortality remain significantly high. We report a case of Fournier's gangrene in a boy of 3 years old preceded by diarrhea and upper respiratory tract infection.

Colon Cancer and Polyposis Associated with Colonic Tuberculosis.: Han, Myoung Sik , Kim, Jee Soo , Kim, Wan Soo , Jang, Hyuk Jai , Kang, Gil Hyun; J Korean Soc Coloproctol. 2000;16(4):279-283.

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Abstract PDF: Tuberculosis can involve any part of the gastrointestinal tract but 80~90% of patients present the disease in the ileocecal region. The cases of colon cancer coexisting with colonic tuberculosis are relatively rare and ascending colon is the predominant site of the combined disease. A 46-year-old man, without specific past medical or family history, showed multiple colonic polyps and ulcers on colonoscopic examination. After surgery, the surgical specimen disclosed adenocarcinoma in the ascending colon, eleven adenomatous polyps throughout the colon, and multiple tuberculous ulcers in the entire colon. Tuberculosis of terminal ileum was also accompanied. The association of colonic tuberculosis and colon cancer with multiple polyps in this case may have been coincidental. The preoperative colonoscopic examination and pathologic diagnosis by frozen section during operation are necessary for the adequate treatment.

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