Annals of Coloproctology

Volume 17(4); August 2001

Randomized Controlled Trial

Clinical Trial Comparing Pain and Clinical Function after Conventional Semi-open Milligan Hemorrhoidectomy vs Open Ultrasonic Dissector Hemorrhoidectomy.: Park, Chul Woon , Lee, Kil Yeon , Park, Ho Chul , Lee, Sang Mok , Lee, Kee Hyung , Yoon, Choong , Joo, Hoong Zae; J Korean Soc Coloproctol. 2001;17(4):159-163.

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Abstract PDF: PURPOSE
Hemorrhoidectomy is considered to be a painful operation, therefore some patients with symptomatic hemorrhoids conceal their symptoms to defer a much-needed surgical procedure. Patients who have undergone hemorrhoidectomy have experienced constipation or urinary retention due to postoperative pain. Several interventions have been used to relieve postoperative pain after hemorrhoidectomy. Nevertheless, the results are unsatisfactory. Hemorrhoidectomy with ultrasonic dissector have less thermal injury and can avoid ligation and suture. This study compared conventional semi-open Milligan hemorrhoidectomy with open ultrasonic dissector hemorrhoidectomy.
METHODS
One hundred patients with prolapsed symptomatic hemorrhoids were randomly assigned to semi-open Milligan (n=50) or open ultrasonic dissector (n=50) hemorrhoidectomy. Operation time, postoperative complication, hospital stay, degree and duration of postoperative pain, pain on bowel movement, and urinary retention were recorded and analyzed.
RESULTS
There was no significant difference in excised pile number. Operation time of open ultrasonic dissector hemorrhoidectomy was shorter than that of semi-open Milligan hemorrhoidectomy (P<0.05). The open ultrasonic dissector hemorrhoidectomy group resulted in less postoperative pain (P<0.05) and shorter duration of pain (P<0.05) and postoperative hospital stay (P<0.05) than semi-open Milligan hemorrhoidectomy. Urinary retention did not occur in both groups.
CONCLUSIONS
Despite the higher cost, open ultrasonic dissector hemorrhoidectomy results in less postoperative pain, shorter operation time and hospital stay than the conventional hemorrhoidectomy.

Original Articles

Clinical Presentation and Surgical Outcome in Patients with Solitary Rectal Ulcer Syndrome.: Choi, Hong Jo , Shin, Eung Jin , Hwang, Yong Hee , Weiss, Eric G , Nogueras, Juan J , Wexner, Steven D; J Korean Soc Coloproctol. 2001;17(4):164-170.

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Abstract PDF: PURPOSE
Solitary rectal ulcer syndrome (SRUS) is a poorly understood clinical condition and its scheme of treatment has not been defined yet. The aim of this investigation was to review the clinical spectra and outcome of various surgical treatments in patients with SRUS, thus to define more rational approach to the management of this ambiguous condition.
METHODS
The study population was composed of 49 patients, among whom 20 patients (18 females and 2 males; median age, 55) were diagnosed primarily as SRUS histopathologically (=primary SRUS). Reviewing all pathologic reports and slides from specimens resected surgically in patients with rectal prolapse, another 20 cases were diagnosed to be combined with SRUS. Other 9 patients included those who were diagnosed histologically as or to be combined with SRUS after the operation for an indication other than SRUS. The latter 29 cases (26 females and 3 males; median age, 72) were defined as secondary SRUS, and then differences in clinical features and outcome of surgical treatment between 2 groups were reviewed retrospectively. The median follow-up was 24 months (range, 5-49 months).
RESULTS
Ulcerative morphology was predominant in primary SRUS (70 percent), whereas erythematous (45 percent) and polypoid (34 percent) in the secondary ones. This difference in morphologic distribution between two groups was significant statistically (P=0.0025). No statistical difference was observed for symptomatologic distributions between two groups. The most common problem associated with evacuation was rectal bleeding in both groups (85 percent and 76 percent, respectively). In primary SRUS, clinical and defecographic studies revealed a rectal prolapse in 5 patients (25 percent), intussusception in 11 patients (55 percent), sigmoidocele (2 degrees) in 4 (20 percent), and paradoxical puborectalis contraction (PPC) in 3 (15 percent) to be combined. Beside rectal prolapse in secondary group, other defecographic findings associated with possible evacuatory problem included sigmoidocele (2 degrees) in 5 (25 percent), rectocele and intussusception in 2 (10 percent), respectively. Clinical improvement after surgery was obtained in 14 of 19 procedures (74 percent) in 17 patients with primary SRUS and 23 of 29 (79 percent) in secondary SRUS, the difference of which was not significant. Though statistically not significant, transabdominal rectopexy was superior to local excision for symptomatic relief in primary SRUS without overt prolapse (86 percent vs. 33 percent). Neither of changes in the percentage of symptoms before and after the operation between two groups showed significance. Clinical and pathologic variables were compared between two treatment result groups of 'improvement' and 'no improvement' and manifestations as tenesmus and digitation correlated with a poorer outcome after surgery (P=0.0065 and 0.02, respectively).
CONCLUSIONS
SRUS is rather a clinical condition associated with functional anorectal evacuatory disorders than an independent disorder. This study shows optimistic role of a surgical treatment against underlying functional disorders in the improvement of secondary SRUS. Proper surgical option, however, for treatment in variable clinical spectra of primary SRUS is still not established, which awaits a conclusion from extensive prospective randomized trials.

Comparison of the Result of Restorative Proctocolectomy and Ileal Pouch-anal Anastomosis in Familial Adenomatous Polyposis and Ulcerative Colitis.: Park, Sun Jin , Lee, Gil Yeon , Lee, Kee Hyung , Koh, Suck Hwan , Hong, Sung Wha , Oh, Soo Myung , Yoon, Choong; J Korean Soc Coloproctol. 2001;17(4):171-176.

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Abstract PDF: PURPOSE
The aim of this study was to compare the early postoperative results and the long-term outcome of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) in familial adenomatous polyposis (FAP) and ulcerative colitis (UC).
METHODS
Thirty patients that underwent IPAA for either FAP (14 patients) or UC (16 patients) at Kyung-Hee University Hospital between January 1987 and December 1999 were studied retrospectively. Either handsewn or stapled anastomosis technique was used in IPAA. Most patients (12 patients in FAP, 16 patients in UC) had a two-stage operation with temporary diverting loop ileostomy and two patients with FAP had a one-stage operation without temporary ileostomy.
RESULTS
One patient in the UC group died from sepsis after operation (n=16, 6.25%), but no patients in the FAP group died. Overall operative complications appeared in two patients (14.3%) and four patients (25%) with FAP and UC, respectively. At follow-up (mean, 47.3 months), pouchitis was developed in four patients with UC, but no patients with FAP. The mean daytime stool frequency was 4.5 stools per day in FAP patients and 5.8 stools per day in UC patients (P=0.031), but night-time stool frequency was similar between two groups (1.2 and 1.4 in FAP and UC, respectively; P>0.05). Daytime fecal incontinence was noticed in two patients (14.3%) with FAP and four patients (26.7%) with UC. Night-time fecal incontinence was noticed in three patients (21.4%) with FAP and six patients (40.0%) with UC.
CONCLUSIONS
FAP patients tolerated the operation better and had less long-term disability than did UC patients. This suggested that the long-term outcome of IPAA procedure may depend on the primary disease rather than the procedure itself.

Passage Pattern of the Colon during Colonoscopy Based on the 'Axis-Maintaining and Bowel-Shortening Method'.: Kim, Hyun Shig , Park, Won Kap , Park, Jong Beom , Hwang, Young Jun; J Korean Soc Coloproctol. 2001;17(4):177-180.

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Abstract PDF: PURPOSE
During colonoscopy, smooth insertion of the colonoscope is an important basic procedure. However, it is not necessarily easy. An understanding of the passage patterns of the colon is helpful for colonoscopy. In this study, the authors aimed to contribute information that could be useful to effect a smooth and effective introduction of the colonoscope.
METHODS
The authors performed 7,560 colonoscopies from May 2000 to December 2000. All cases were performed without using sedatives or analgesics. Out of those 7,560 cases, 2,289 cases, which were performed by one colonoscopist, were selected, excluding those with incomplete colonoscopy, those with a history of bowel resection, those with poor bowel preparation, those with advanced disease, such as inflammatory bowel disease, cancer, etc., and those with conditions that could markedly affect colonoscopy. Those 2,289 cases were classified as 4 patterns according to the passage patterns through the colon during colonoscopy:pattern A, passage is possible using right torque and pull-back; pattern B, bowel-shortening is possible at the peak point of the sigmoid colon; pattern C, bowel-shortening is possible at the transverse colon because of a markedly redundant sigmoid colon; and pattern D, pattern is difficult to specify. Those 2,289 cases were also analyzed regarding age. As to age, they were divided into two groups, those under the 6th decade and those of the 6th decade or older.
RESULTS
The most common pattern was pattern A, comprising 71.3%; next was pattern B, 19.7%. There was no significant difference in distribution of the passage patterns between the two age groups (P>0.05).
CONCLUSIONS
Ninety-one percent (91%) of the cases were patterns A and B. An understanding of the passage patterns will be helpful for smooth insertion of the colonoscope. The 'axis-maintaining and bowel-shortening method' is a useful and effective approach to colonoscopy.

Clinical Significance of Colonoscopy in Patients with Benign Anorectal Disease.: Kim, Kyung Bo , Park, Hyun Chul , Oh, Jae Hwan; J Korean Soc Coloproctol. 2001;17(4):181-186.

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Abstract PDF: PURPOSE
Benign anorectal disease will often cause great concern to the patient and the practitioner about a more proximal colon pathology. The aim of this study is to evaluate the significance of routine colonoscopy for patients with benign anorectal disease.
METHODS
A retrospective analysis of 108 patients with benign anorectal disease who had undergone colonoscopic examination from April 1997 to August 1998 at Gil Medical Center was done.
RESULTS
The mean age of all patients was 43 years; the male-to-female ratio was 1:1.1. The diagnoses of anorectal disease were hemorrhoids in 84 cases, anal fissures in 13 cases, chronic anal pain syndrome in 6 cases, anorectal fistulas in 5 cases, and other in 9 cases. There were 37 patients (34.3%) with 53 abnormal findings:14 tubular adenomas, 11 inflammatory polyps, 4 hyperplastic polyps, 1 tuberculous colitis, 1 angiodysplasia, 6 diverticula, 6 nonspecific ileitis or colitis, 2 melanosis coli, 2 rectal ulcers, 2 ileal ulcers, and 3 other diseases. Among them, clinically significant lesions, such as neoplastic lesion, tuberculous colitis and angiodysplasia, were detected in 12 patients (11.1%). Because the lesions in 7 patients of the 12 patients were within the reach of sigmoidoscopy, only 5 patients (4.6%) needed a colonoscopic examination. In regard to neoplasms, patients presenting with anal bleeding and old age were not found to have a higher frequency of neoplasia. Also, the specific type of anorectal disease was not associated with an increased risk for colorectal neoplasia (P>0.05).
CONCLUSIONS
Sigmoidoscopy is a more acceptable primary diagnostic tool in patients with benign anorectal disease, but in patients with gastrointestinal symptoms, a high risk for colorectal cancer, suspicious inflammatory bowel disease, or fear of cancer, selective colonoscopy will be needed.

Manometric Assessment after Ileal Pouch- Anal Anastomosis.: Yu, Chang Sik , Kim, Hee Chul , Park, Sang Gyu , Kim, Sook Young , Cho, Young Gyu , Hong, Hyun Ki , Kim, Jin Cheon; J Korean Soc Coloproctol. 2001;17(4):187-192.

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Abstract PDF: PURPOSE
Functional derangement in bowel movement after ileal pouch-anal anastomosis (IPAA) is not infrequent. It results from several mechanisms mainly decreased rectal reservoir capacity and rectal sensation. Anal sphincter or pelvic nerve damage during surgery contributes physiological changes, also. This study was performed to evaluate manometric changes after IPAA and compare them with functional outcomes regarding anastomotic technique.
METHODS
Forty seven (M:F=23:24) patients who underwent IPAA and manometric assessment were enrolled. Pathological diagnoses of them were 32 ulcerative colitis, 12 familial adenomatous polyposis, and 3 hereditary non-polyposis colorectal cancer. Every pouch was constructed in J shape, 15cm length. Pouch-anal anastomosis was performed by 27 hand-sewn and 20 double stapling technique. Diverting ileostomy was performed in 30 cases (64%) and closed 2-3 months after IPAA. Manometry was performed preoperatively and 3 to 6 months interval, postoperatively. Twenty two patients underwent full manometic assessment pre- and post-operatively. The others did it either pre or postsoperatively. Functional outcome was investigated at the median follow-up period 25 (2-54) months. Statistical analysis was performed by using Chi- square and Fisher's exact test. Significance was assigned to a P value of <0.05.
RESULTS
Maximum resting pressure (MRP) was significantly decreased postoperatively (85.2 vs. 60.6 mmHg; P=0.002). This phenomenon could be observed throughout the follow-up period. However, the difference was getting smaller as times went by. Rectoanal inhibitory reflex (RAIR) was identified 96% preoperatively, and only 22% postoperatively (P=0.000). Rectal compliance was decreased at the time of ileostomy closure, and improved remarkably since 6 months after closure. In comparison of manometric findings according to anastomotic technique, MRP in hand- sewn group was significantly decreased (52.3 vs. 77.0 mmHg; P=0.003). RAIR could be identified more frequently in double stapled group (31.6 vs. 15.4%; P>0.05). Postoperative stool frequency and incontinence rate were not different between two groups. Thirty one percent of patients revealed night time seepage. MRP of this seepage group was significantly lower than the other group (67.9 vs. 48.4 mmHg; P=0.038).
CONCLUSIONS
Characteristic changes of manometric findings after IPAA were summarized as decrease of MRP and disappearance of RAIR. Rectal compliance was significantly improved since 6 months after IPAA or ileostomy closure. Decrease of MRP was more remarkable in hand-sewn group. However, we could not find any difference in functional outcomes between two anastomotic techniques. MRP was a crutial factor for postoperative seepage.

The Effect of Tumor Manipulation on Serum Carcinoembryonic Antigen Levels in Colorectal Cancer Patients.: Kim, Yong Hoon , Bae, Ok Suk , Park, Hyo Won , Park, Sung Dae , Chun, Dong Suk; J Korean Soc Coloproctol. 2001;17(4):193-197.

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Abstract PDF: PURPOSE
Tumor cells can be shed into a venous blood stream by manipulation of tumor during surgery, resulting metastasis to distant organs from the primary tumor. In order to elucidate the effect of early lymphovascular dissection prior to tumor mobilization, we studied the difference in carcinoembryonic antigen (CEA) values of tumor draining veins before and after tumor mobilization.
METHODS
Blood samples were taken from the tumor draining veins of sixteen patients during operations. The lymphovascular dissection was performed before the tumor mobilization, and the main draining vein from the tumor was isolated and the proximal end was ligated and blood samples were taken, then the tumor mobilization was made. Just before the removal of the tumor, we took the second sets of blood samples from the same sites.
RESULTS
There were no significant differences in CEA values between peripheral blood (1.8+/-1.2 ng/mL) and tumor draining veins before the tumor mobilization. The mean CEA value of draining veins after the tumor mobilization (14.3+/-11.9 ng/mL) was significantly higher than that of draining veins before the mobilization (2.2+/-2.1 ng/mL)(P<0.001).
CONCLUSIONS
Theses results suggest that early lymphovascular dissection procedures before tumor mobilization can reduce the opportunity of tumor cell dissemination into draining vein.

Clinical Usefulness of PET Scan during Follow up after Curative Resection for Colorectal Cancer.: Lee, Kang Young , Kim, Seong Min , Park, Jae Kun , Kim, Nam Kyu , Lee, Jong Doo , Min, Jin Sik; J Korean Soc Coloproctol. 2001;17(4):198-202.

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Abstract PDF: PURPOSE
The aim of this study is to assess the potential role of PET in patients with unexplained rising CEA levels after curative resection of colorectal cancer or for differential diagnosis of the result by conventional radiologic study.
METHODS
18 patients with abnormal CEA levels and normal results of conventional methods of tumor detection and 7 patients who needed differential diagnosis after conventional X-ray were studied with PET. The PET results were compared with pathologic findings or conventional radiologic and clinical follow-up for 6 months.
RESULTS
PET showed increased uptake in 17 of 25 patients. Using PET in 18 patients with elevated carcinoembryonic antigen levels, 12 patients showed increased uptake of FDG. Among them, 11 positive findings were turned out to be a true recurrence and there was one false positive finding. Six patients with elevated carcinoembryonic antigen levels showed normal PET scan. But conventional X-ray or repetition of PET confirmed the recurrence in 2 patients among them. Using PET in 7 patients for differential diagnosis of conventional X-ray, 3 patients showed hot uptake of FDG and all of them were turned out to be a true recurrence. There were no abnormal findings in 4 patients but one patient among them showed a hepatic recurrence. It was confirmed by abdominal MRI. Overall, sensitivity was 82.4% and specificity was 87.5% CONCLUSIONS:When conventional examinations are normal except CEA elevation or equivocal, PET is a valuable imaging tool for the detection of recurrence.

Significance of Subclassification of Depressed-Type Early Colorectal Cancer Based on Growth and Development.: Kim, Hyun Shig , Park, Won Kap , Park, Jong Beom , Kang, Yong Won , Lee, Jung Dal , Kim, Kwang Yun; J Korean Soc Coloproctol. 2001;17(4):203-208.

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Abstract PDF: PURPOSE
Recently it became obvious that some early cancers which appeared to be polyp lesions had actually originated from depressed-type lesions. The aim of this study was to clarify both the characteristics of depressed- type early colorectal cancers compared with protruded- or flat-type ones and the significance of a subclassification of depressed-type early cancers.
METHODS
The authors experienced 248 early colorectal cancers from 1996 to 2000. We classified those cancers into protruded, flat, and depressed types based on growth and development. Further, we used Kudo's classification to subclassify the depressed-type cancers into three sub-types, IIc, IIa+IIc, and Is+IIc. We analyzed the 248 cases with emphasis on size, type, sub-type, and submucosal cancer (sm) rate.
RESULTS
The sm rate of the depressed cancers was 81.8% (18/22) and was significantly higher than those of the protruded (30.5%) or the flat (38.5%) types (P<0.05). The sm rate of the depressed lesions not larger than 10 mm was 70% (7/10) and that of the lesions from 11 mm to 20 mm was 91.7% (11/12); there were no depressed cancers larger than 20 mm in diameter. The sm rate of the type IIa+IIc plus type Is+IIc lesions was higher than that of type IIc lesions (93.3%, 14/15 vs. 57.1%, 4/7). Endoscopic resection was done in 74.2% of all early colorectal cancers.
CONCLUSIONS
The sm rate of depressed-type early colorectal cancers was 82%, and no depressed cancers were larger than 20 mm in diameter, suggesting that by the time a depressed-type cancers had become larger than 20 mm in size, it had already progressed into an advanced cancer. Thus, it is very important to detect depressed-type cancers in an early stage. Moreover, it is imperative to differentiate type IIa+IIc and type Is+IIc from polyp lesions and to manage them cautiously because their sm rate is higher than that for type IIc lesions.

Case Report

Two Cases of Tailgut Cyst.: Lee, Hun , Oh, Jae Hwan , Cho, Seung Yeon , Yang, Dal Mo , Ha, Seung Yeon; J Korean Soc Coloproctol. 2001;17(4):209-212.

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Abstract PDF: Tailgut cysts in retrorectal or presacral space are rare and the derivatives of the embryonic post-anal gut. It is thought to arise from vestiges of embryonic hindgut. The lesions were usually multicystic and lined by a variety of epithelial types, including ciliated columnar, mucin-secreting columnar, transitional, and squamous epithelium. Tailgut cyst has been found in men and women of various ages but is more common in women and is usually associated with middle age. They may be the source of the chronic perirectal symptoms and rarely undergo malignant change, so early diagnosis and accurate evaluation is important. Complete surgical resection should be considered because of a long term risk of malignant change. We report two cases of tailgut cyst.

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