Annals of Coloproctology

Volume 17(2); April 2001

Original Articles

Abdominal Sonography of Suspected Appendicitis.: Sim, Won Sup , Sim, Myungsuk; J Korean Soc Coloproctol. 2001;17(2):59-63.

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Abstract PDF: PURPOSE
To decrease the high negative appendectomy rate, in addition to the traditional history-taking, physical examination, and laboratory findings, additional sensitive and specific examinations are necessary. The authors conducted a study to evaluate the value of ultrasonographic examination in the diagnosis of acute appendicitis in patients with clinically suspected appendicitis.
METHODS
During 18 months from July 1, 1998 through December 31, 1999, a total of 290 patients were enrolled into the study. Altogether 110 abdominal sonographic examinations were performed by the staff radiologist, in all cases of clinically suspected appendicitis. The improvement of diagnostic accuracy was compared with the historical control group of 240 patients during the period of 18 months from January 1, 1997 through June 30, 1998.
RESULTS
Clinical diagnosis (without sonographic examination) was made in 180 patients (157 appendicitis, and 23 non-appendicitis). Negative appendectomy was performed in 24 patients. Sonographic diagnosis was made in 110 patients with clinically suspected appendicitis (91 appendicitis, and 19 non-appendicitis). Negative appendectomy was done in 9 patients. Nineteen patients without positive sonographic findings of appendicitis could be spared the negative appendectomy. Abdominal sonography for detecting acute appendicitis had a sensitivity of 100.0%, a specificity of 67.9%, an accuracy of 91.0%, a positive predictive value of 90.1%, and a negative predictive value of 100.0%. By adding ultrasonographic examinations in all cases of clinically suspected appendicitis, diagnostic specificity was increased significantly over the historical control group (P<0.01).
CONCLUSIONS
Although the value of meticulous history- taking, physical examination, and laboratory tests cannot be overemphasized, our experience suggests that patients with clinically suspected appendicitis should routinely undergo abdominal sonographic examinations, performed by experienced radiologists and surgeons, to further decrease the negative appendectomy rates.

Clinical Analysis of Complications in Abdominal Stoma Surgery.: Lee, Hun , Oh, Jae Hwan; J Korean Soc Coloproctol. 2001;17(2):64-68.

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Abstract PDF: PURPOSE
This study was undertaken to review the complications associated with ileostomy, colostomy construction and subsequent closure.
METHODS
We retrospectively reviewed 74 patients with ileostomy and colostomy closure from August 1, 1995 to June 30, 1999.
RESULTS
The complications of stoma construction occurred in 15 patients (20.3%) among 74 patients: skin problem in 10 cases, prolapse in 4 cases, and stoma necrosis, retraction and stenosis in 1 case, respectively. Factors such as age, underlying pathology, type of stoma did not contribute to the complications of stoma construction. Complications of stoma closure occured in 15 patients (20.3%): wound problem in 9 cases, enterocolitis in 4 cases and anastomotic leakage in 2 cases. With respect to stoma closure, only old age was associated with increased morbidity (P<0.05), rather than method of closure, time interval to closure, or type of stoma. Mean operation time for simple closure was 122.2 minutes and 204 minutes for resection and anastomosis. The mean hospital stay was 9.6 days for simple closure and 13 days for resection and anastomosis.
CONCLUSIONS
The morbidity associated with stoma construction and subsequent closure was appreciable. There were no specific risk factors influencing the complications of ileostomy or colostomy construction, but old age increased morbidity after closure.

Biofeedback Therapy for Patients with Rectocele.: Kim, Bong Soo , Hwang, Yong Hee , Choi, Kun Pil; J Korean Soc Coloproctol. 2001;17(2):69-75.

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Abstract PDF: PURPOSE
The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for rectocele.
METHODS
Twenty four female patients (mean age 43.8 years) with rectal emptying difficulties and a rectocele greater than 2 cm at defecography were evaluated before hand with a standardized questionnaires, immediately after biofeedback therapy, and at follow up. Defecography, manometry, colon transit studies and electrophysiology were also analyzed.
RESULTS
Follow up (mean 7.2; range 2~17 months) results were evaluated by an independent observer in 20 patients. At the end of biofeedback, 22 (92 percent) patients felt improvement in symptoms, including 13 (54 percent) with symptomatic relief. At follow-up, 14 (70 percent) patients felt improvement in symptoms, including 3 (15 percent) with complete relief of symptoms. There was a significant reduction in difficult defecation (from 79 to 29, 40 percent, from pre-biofeedback to post-biofeedback, at follow-up respectively; P<0.001, P<0.05), sensation of incomplete defecation (from 96 to 46, 60 percent; P<0.001, P<0.005), laxative use (from 54 to 25, 30 percent; P<0.05), enema use (from 21 to 0,0 percent; P<0.05), anal pain (from 21 to 0, 5 percent; P<0.05) and digitation (from 21 to 4, 5 percent). Normal spontaneous bowel movement was significantly increased from 50 percent pre-biofeedback to 83 post-biofeedback (P<0.05), 65 percent at follow-up. Abdominal pain (P<0.05) and digitation (P<0.05) related to poor results. High mean squeeze pressure (P<0.001) and high maximum squeeze pressure (P<0.05) on pre-biofeedback manometry were also related to a poor outcome. Age, duration of symptoms, parity, number of sessions of biofeedback, gynecologic surgery history, and rectocele size at defecography had no prognostic value. Anismus and colonic inertia did not influence the outcome of biofeedback.
CONCLUSIONS
Biofeedback is an effective treatment option for patients with obstructed defecation due to rectocele.

Comparison of C-anoplasty and House Shaped Advancement Flap in Anal Stenosis.: Yang, Hyung Kyu , Kim, Sang Hee , Ryu, Kwang Seok , Choi, Jai Pyo , Na, Jai Woong , Ban, Jai Min; J Korean Soc Coloproctol. 2001;17(2):76-83.

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Abstract PDF: PURPOSE
The surgical treatment of anal stenosis includes internal sphincterotomy, rotaton flap and advancement flap according to the stenosis degree, recently, Christensen performed house shaped advancement flap and reported fair results. We compared and analyzed the surgical methods and results in patients with moderate and severe anal stenosis who underwent house shaped advancement flap and C-anoplasty.
METHODS
We have performed this study with 6 cases using the house shaped advancement flap and 6 cases using the C-anoplasty. The out come was assessed by clinical characteristics, surgical method, operation time, duration of hospitalization, healing time, postoperative complications, results.
RESULTS
The average operation time was 38 min in those house shaped advancement flap cases and 63 min in C-anoplasty cases. The average time of hospitalization was 6 days and 9 days, respectively, and the average time of healing was 28 days and 46 days, respectively. In those house advancement flap cases, surgery could be done in 2 directions at the same time in 4 cases and 3 directions in 2 cases; as for those C-anoplasty cases, surgery could be done in 1 direction in 4 cases and 2 directions in 1 case. Two complications were observed in C-anoplasty, one flap infection and one flap necrosis, and in house shaped advancement flap, no complication was observed.
CONCLUSIONS
House shaped advancement flap have several advantages compared to the C-anoplasty, and since house shaped advancement flap could be performed in 2 to 3 directions or even 4 directions at the same time, the anus could sufficiently expanded in severe anal stenosis patients. The house shaped advancement flap might be one of the good method in treating anal stenosis.

Laparoscopic-assisted Colorectal Resection in Malignant Polyps and Benign Disease.: Kang, Jung Gu , Kim, Nam Kyu , Yun, Seong Hyeon , Park, Jea Kun , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2001;17(2):84-90.

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Abstract PDF: PURPOSE
Laparoscopic colorectal procedures are widely used for benign disease but controversial for malignant disease. In early colorectal cancer, laparoscopic colectomy can be performed safely on the basis of oncologic principles. The purpose of this study is to evaluate the safety and effectiveness of laparoscopic-assisted colorectal resection for malignant polyps and benign disease.
METHODS
Twenty five patients submitted to surgical treatment between Oct. 1996 to June 2000 were reviewed retrospectively.
RESULTS
Malignant polyps comprized 7 cases whose resection margins were all positive for cancer cells after endoscopic polypectomy and benign diseases in 18 cases (benign polyp: 7, diverticular disease: 4, submucosal tumor: 4 etc.). The common sugical procedures were anterior or low anterior resection (7 cases) and segmental resection (6 cases). There was no conversion to an open surgery. In malignant polyps, pathologic results revealed early cancer with no lymph node metastasis. There was no operative mortality. Postoperative recovery was uneventful except 2 cases (9.0%) of complications, which were, prolonged ileus in one patient and subcutaneous emphysema in another patient.
CONCLUSIONS
Laparoscopic-assisted resection can be recommended as a safe and effective procedure for treatment of colonic malignant polyps and benign disease.

Temporary Indwelling of Self-expandable Metal Stent may Obviate the Need of Staged Operation for Malignant Colonic Obstruction.: Kim, Bong Wan , Lee, Kwang Jae , Kim, Jin Hong , Suh, Kwang Wook; J Korean Soc Coloproctol. 2001;17(2):91-96.

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Abstract PDF: PURPOSE
Staged operation employing temporary enterostomy is still the standard treatment of malignant colonic obstruction (MCO). Expandable metal stent has been used for the palliation of unresectable gastrointestinal obstruction. We applied this metal stent technique to the MCO to achieve temporary alleviation of the obstruction so that the bowel preparation and one-stage operation were enabled. In this study we examined the efficacy of temporary indwelling of metal stent to obviate the need of staged operation in the treatment of MCO.
METHODS
From December 1998 to January 2001, 35 MCO patients were treated. Patients had typical symptoms of colonic obstruction such as abdominal pain and distension. When they were admitted, an self-expandable metal stent was introduced under the guide of flexible colonoscopy. For three days, formal bowel preparation (both chemical and mechanical) were followed. With regard to achievement of bowel preparation, postoperative complications and hospital stay, these 35 patients were compared with control group (N=20) of patients who underwent two staged operations for MCO.
RESULTS
The tumor locations were upper rectum (N=10), sigmoid colon (N=22) and left colon (N=3). Metal stent slipped off in one patient. Double contrast barium enema was possible in 34 patients. One stage operation was performed in all patients. Anastomotic complications were not observed in both groups. Intraabdominal abscess requiring reoperation was noted in one patient in each group. Wound infection was noted in 3 (8.6%) stent patients whereas 16 (80%) patients had wound complication in the control group (P<0.05). Mean hospital stay was 12.2 days in stent group and 29.4 days in control group (P<0.05).
CONCLUSIONS
Even though our series is limited in patient number, these data suggested that temporary indwelling of self-expandable metal stent may obviate the need of staged operation in the treatment of MCO.

Clinical Study of Mucinous Colorectal Carcinoma.: An, Chang Hyeok , Kang, Won Kyung , Park, Seung Chul , Hong, Min Kwang , Lee, Do Sang , Oh, Seong Taek , Jeon, Hae Myung; J Korean Soc Coloproctol. 2001;17(2):97-102.

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Abstract PDF: PURPOSE
The clinical influences of mucinous colorectal carcinomas are still controversial. Some previous reports have suggested that mucinous carcinomas of colorectum affect more young patients, involve the more proximal colon, are more advanced at diagnosis, show increased incidence of local and distant metastasis, and have a worse prognosis than adenocarcinoma. We evaluated the clinicopathological aspect of mucinous colorectal carcinoma.
METHODS
A retrospective review of colorectal cancer patients treated between January 1990 and December 1998 was undertaken. Eight-hundred-fifty patients were operated for colorectal cancer during the period, among them seven- hundred-eighty-two patient records were available for this study. Sixty-two patients (7%) could be classified as mucinous carcinoma as defined by more than 50% of mucin- secreting pattern on histological examination. The age and sex distribution, primary location of tumor, modified Dukes' classification at diagnosis, recurrence rates and 5-year survival of mucinous carcinoma patients were compared with those of adenocarcinoma patients. Survival was calculated according to Kaplan-Meyer, and the differences were compared using the log-rank test.
RESULTS
The sex ratio of mucinous carcinoma was 2.05: 1, whereas 1.32: 1 in adenocarcinoma. The age distribution of mucinous carcinoma showed orderly 60s (30.7%), 50s (17.7%), 40s (17.7%) similar to adenocarcinoma. The sites of the mucinous carcinoma were 22 (35.5%) in the rectum, 21 (33.9%) in the right colon, 6 (9.7%) in the transverse colon, whereas for adenocarcinoma 250 (37.0%) in the rectum, 137 (20.3%) in the sigmoid colon, 114 (16.9%) in the ascending colon. The stage of primary tumor at diagnosis was as follows: In mucinous carcinoma, 5 stage B1 (8.1%), 13 B2 (21.0%), 33 C2 (53.2%), 11 D (17.7%). In adenocarcinoma, 20 stage A (3.0%), 61 B1 (9.0%), 210 B2 (31.1%), 15 C1 (2.2%), 250 C2 (37.0%), 120 D (17.7%). Three-year and five-year disease free survival rates were similar, but slightly higher in patients with adenocarcinomas. Mean survival time was also similar, 45.5+/-38.1 months in the mucinous carcinoma group and 45.6+/-33.4 months in the adenocarcinoma. Five-year survival was 65.6% and 68.1% in patients with mucinous carcinomas and adenocarcinomas, respectively; but the difference was not statistically significant. The recurrence rates were 41.9% and 22.3% in patients with mucinous carcinoma and adenocarcinoma, respectively with statistical significance (P<0.005). Local recurrence was more frequent in the mucinous carcinoma than in the adenocarcinoma significantly.
CONCLUSIONS
Our study suggested that mucinous colorectal carcinoma showed decreased survival, although having no statistical significance and increased recurrence rates with statistical significance compared with those of adenocarcinoma. So, we recommend aggresive surgical treatment and careful follow-up in mucinous colorectal carcinoma.

Case Reports

Two Cases of Adult Intussusception.: Chae, Gyeong Rae , Cheon, Heui Doo , Tae, Hyong Jin , Kim, Cheol Seung , Lee, Kwang Min , Ju, Myong Jin; J Korean Soc Coloproctol. 2001;17(2):103-107.

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Abstract PDF: Intussusception can develop at any age but about 95% of patients are children under 2 years-old. Adult intussusception is a rare condition. Unlike children, nearly all adults with intussusception have a lead point such as benign or malignant small bowel tumors, intestinal tuberculosis, or Meckel's diverticulum. First case is a 48-year-old male who was admitted with 2 days of diffuse abdominal cramping pain and no other associated gastrointestinal symptoms. Barium enema revealed ileocolic intussusception with a round cecal mass after barium reduction. An ileocecectomy was performed electively. The pathologic report was cecal cyst, which was an intraluminal structure with an epithelial lining of colonic mucosa. The second case, a 53-year-old male, was admitted with 1 week of diffuse abdominal cramping pain and watery diarrhea. Barium enema revealed ileocecal intussusception. Emergency surgery (ileocecectomy), revealed a polypoid small bowel mass. The pathologic report was lipoma. Recently, we experienced two cases of adult intussusception and report these cases with a brief review of the literature.

A Case of Granular Cell Tumor in the Perianal Region.: Hwang, Do Yeon , Song, Seok Kyu , Lee, Jong Ho , Kim, Hyun Shig , Lee, Jong Kyun , Lee, Jung Dal , Kim, Kwang Yun; J Korean Soc Coloproctol. 2001;17(2):108-111.

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Abstract PDF: Since granular cell tumor was first described by Abrikossoff in 1926, it has been known as a rare disease. The histogenesis of this tumor is still controversial, but the origin is thought to be from a Schwann cell. About one third of the tumors occur in the tongue, and uncommonly in the perianal region. We report a case of granular cell tumor that developed in the perianal region. The tumor grew slowly for 5 years and was removed by a local excision. This tumor showed positive staining with neuron-specific enolase (NSE).

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