Annals of Coloproctology

Volume 18(2); April 2002

Original Articles

Comparison of Clinical Differences between Colonic Obstruction and Non-obstruction Groups in Colon Surgery.: Sim, Woo Jung , Park, Yong Keum , Chi, Kyong Choun , Lee, Jung Hyo , Chang, In Taik , Kim, Sang Jhoon; J Korean Soc Coloproctol. 2002;18(2):65-72.

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Abstract PDF: PURPOSE
The purpose for this study is to compare the clinical differences of the two groups (ie. colonic obstruction and non-obstruction) in colonic surgery.
METHODS
A retrospective clinical analysis was done in 149 patients with colorectal disease who had been surgically treated from January 1995 to December 1997 at our institution.
RESULTS
1) The peak age of incidence was in the 7th. and 8th. decades (53.3%)in the obstruction group and 6th. and 7th. decades (54.3%) in the non-obstruction group, the sex ratio of male to female was higher in the obstruction group (2.00:1) than in the non-obstruction group (1.04:1). 2) The most common cause of colonic obstruction was malignant disease in both groups (75.4% in the obstruction group and 78.3% in the non-obstruction group). 3) The most frequent symptom and sign of the two groups were abdominal pain (36.8% and 2.6% respectively). 4) The most common location was cecum (24.6%) followed by sigmoid colon (22.8%) and rectum (15.8%) in the obstruction group, and rectum (40.2%) followed by ascending colon (15.2%), cecum (13.0%), and transverse colon (13.1 %) in the non obstruction group. 5) The right hemicolectomy was the most common procedure in the obstruction group (29.8%) while abdominoperineal resection was most frequently performed in the non-obstruction group (23.9 %). The surgical resection rate was 77.4% and 100% in obstruction group and non-obstruction group, respectively. 6) In the case of colon cancer, the stage of cancer (according to Modified Astler-Coller classification) was much higher in the obstruction group. An average 6.5 metastatic lymph nodes were found from 18.5 dissected lymph nodes in the obstruction group whereas 2.7 out of 13.9 lymph nodes in the non-obstruction group. 7) The postoperative complication rate of obstruction group were 21.4% whereas that of non-obstruction group were 15.0% respectively. The postoperative mortality rate was 14% in the obstruction group and 3.3% in the non-obstruction group. The complication rate and postoperative mortality of the obstruction group was higher than those of the non-obstruction group, especially in the malignant disesae group.
CONCLUSIONS
The results of our study indicate that the obstruction group has a different clinical course from the non- obstruction group and associated higher postoperative complication and mortality rate.

Difference between Genders in Patients with Obstructive Defecation: Analysis of 1,513 Defecograms.: Park, Duk Hoon , Yoon, Seo Gue , Yoon, Jong Seop , Lee, Jong Ho , Rhoe, Hee Jung , Moon, Min Joo , Kim, Hyun Shig , Lee, Jong Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(2):73-82.

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Abstract PDF: PURPOSE
The aims of this study were to find the difference in frequency between genders and to determine the correlation between age-related disease and other diseases in obstructive defecation.
METHODS
A consecutive series of 1,513 patients (343 males, 1,170 females) with obstructive defecation who undertook defecography and/or cinedefecography during 1 year period was analyzed.
RESULTS
The causes of obstructive defecation in males showed as spastic pelvic floor syndrome (SPFS) (48.3%), rectal prolapse (RP) (31.4%), descending perineum syndrome (DPS) (25.9%), enterocele or sigmoidocele (7.6%), and rectocele (7%). However, in females, the causes were rectocele (83.8%), DPS (49.2%), RP (37.6%), SPFS (32.5 %), and enterocele or sigmoidocele (11.2%). The SPFS was negatively correlated with enterocele or sigmoidocele, DPS, RP in both genders, but SPFS had no statistical correlation with rectocele. DPS was correlated with RP in both genders and with enterocele or sigmoidocele in females, but no statistical correlation was seen in males. The size of the rectocele showed a slight correlation with age in females (r=0.102, P=0.01). Age was correlated with rectal prolapse in females; however, it showed a negative correlation with SPFS in females.
CONCLUSIONS
The frequency of diseases causing obstructive defecation is different between genders. Age may not play a role in aggrevating the diseases causing obstructive defecation. Further pathophysiologic study of gender differences in patients with obstructive defecation is needed.

Manometric Investigation of Anorectal Dysfunction in Patients with Progressive Systemic Sclerosis.: Choi, Hong Jo , Lim, Hyun Sung , Park, Ki Jae , Chung, Won Tae , Lee, Sung Won; J Korean Soc Coloproctol. 2002;18(2):83-88.

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Abstract PDF: PURPOSE
The aim of this study was to investigate the anorectal function in patients with progressive systemic sclerosis (PSS), thus to define the clinical role of anorectal manometry in the earlier diagnosis of anorectal involvement of PSS.
METHODS
Seventeen consecutive patients (all females) with PSS were evaluated with anorectal manometry by the stationary pullthrough technique using the 8-channel hydraulic capillary infusion system for anorectal function. Functional parameters of the manometry were compared between patients with PSS and 20 normal control subjects, matched for age and sex.
RESULTS
The mean resting pressure over the high pressure zone (HPZ) in patients with PSS was significantly lower than that in the control group (70.8 3.4 mmHg vs. 81.5 3.2 mmHg: P=0.046). The HPZ in patients with PSS was also significantly reduced compared with that in the control (1.5 0.1 cm vs. 2.5 0.1 cm: P=0002). The rectoanal inhibitory reflex (RAIR) was detected in only 10 patients (59%) in the PSS group, but was present in all except one (95%) in the control (P=0.022). More interestingly, RAIR in patients with PSS responded at a higher volume of the air insufflated than that in the control (74% vs. 30% at 20 cc, 21% vs. 30% at 30 cc, and 0% vs. 40% at 50 cc, respectively: P=0.031). Other functional parameters, including maximal squeeze pressure, minimal sensory and maximal tolerable volume of the rectum, and rectal compliance were not significantly different between two groups.
CONCLUSIONS
Anorectal involvement reflected by the anorectal manometric dysfunction may be rather an earlier event in patients with PSS. An awareness to perform an anorectal manometric study in every case of PSS may be necessary for earlier subclinical detection of anorectal involvement by the disease.

Laparoscopic Suture Rectopexy for Rectal Prolapse.: Yoon, Seo Gue , Kim, Khun Uk , Noh, Khun Young , Lee, Jung Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(2):89-94.

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Abstract PDF: PURPOSE
This study was undertaken to eveluate the early results of the laparoscopic suture rectopexy in the treatment of rectal prolapse.
METHODS
From May 1999 to July 2001, laparoscopic suture rectopexy (LSR) was successfully performed in 26 patients and the results were compared to those of 5 patients with open suture rectopexy (OSR) and 6 patients with open resection rectopexy (ORR). Preoperative and postoperative functional assessment included Wexner's incontinence score, constipation score, and anorectal manometry.
RESULTS
Immediate postoperative morbidity was minimal in all groups. Bowel function was resumed significantly sooner (P=0.001), the numbers of the analgesics injection were significantly fewer (P<0.001) and postoperative hospital stay was significantly shorter (P<0.001) in the LSR than in the open groups. Postoperatively, the anal resting and squeezing pressures increased slightly and Wexner's incontinence score decreased significantly in all groups of patients. Constipation score decreased slightly in all groups of patients after surgery. There was one mucosal prolapse recurrence after surgery in the LSR.
CONCLUSIONS
Laparoscopic suture rectopexy for rectal prolapse can be performed safely. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Functional results are obtained similarly with both approaches.

Psychiatric Investigation by Using the Minnesota Multiphasic Personality Inventory in Patients with Chronic Constipation.: Park, Ung Chae , Yoo, Young Bum , Kim, Jong Jun , Nam, Beom Woo; J Korean Soc Coloproctol. 2002;18(2):95-103.

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Abstract PDF: PURPOSE
Current study was designed to understand the personality and emotional composition of patients with chronic constipation. Specifically, the personality differences were evaluated in the ramified subgroups based on the physiologic characteristics.
METHODS
Forty patients (31 females and 9 males) of a mean age of 48 (range, 16~86) years underwent the MMPI among 310 patients with chronic constipation. MMPI (Minnesota Multiphasic Personality Inventory) profiles were utilized for psychologic assessment for all patients prior to making diagnosis. Three validity scales of MMPI included L (Lie scale), F (Infrequency scale), K (Suppressor scale). Ten clinical scales included HS (hypochondriasis), DP (depression), HY (hysteria), PD (psychopathic deviant), MF (masculinity- feminity), PA (paranoia), PT (psychasthenia), SC (schizophrenia), MA (mania), SI (social introversion). On the basis of findings with use of anorectal physiologic studies, subgroups were categorized as patients with rectocele (A1, n=22), patient without rectocele (A2, n=18), patients with nonrelaxing puborectalis syndrome (B1, n=10), patients without nonrelaxing puborectalis syndrome (B2, n=30). The MMPI profiles were compared between subgroup patients.
RESULTS
In overall patients, mean scores for scales HS, DP were elevated as compared with mean profiles (60~65 and 45~55, respectively). Male patients showed higher mean scores for scale SI than those of female patients (male vs. female; 63.5 vs. 53.9, P<0.05). A1 group showed higher mean scores for PD scale than those of A2 group (A1 vs. A2; 57.4 vs. 49.8, P=0.01). B1 group showed higher mean scores for DP scale than those of B2 group (B1 vs. B2; 67.5 vs. 59.8, P<0.05).
CONCLUSIONS
Present series provided that the MMPI is a valuable tool for assessing the psychologic functioning of patients with chronic constipation. It has revealed a different personality and emotional composition in the subgroup patients based on the anorectal physiologic studies. An aspect of social introversion, psychopathic deviant and depression should be emphasized. These findings can provide the fundamental information for guideline of future diagnostic evaluation and therapy in the patients with chronic constipation.

Clinical Results of Transanal Endoscopic Microsurgery (TEM).: Chung, Jun Chul , Choi, Sung Il , Lee, Doo Suk , Chang, Weon Young , Noh, Sang Ik , Oh, So Hyang , Lee, Woo Yong , Chun, Ho Kyung; J Korean Soc Coloproctol. 2002;18(2):104-109.

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Abstract PDF: PURPOSE
Local treatment of rectal tumors have become an alternative to the classic radical operation. However, conventional transanal procedures are limited to tumors located in the lower rectum and the precision of the excision is restricted by the limitation of the surgeon's visualization during the procedure. This report will present our surgical management and functional results after TEM, a new minimally invasive technique for the treatment of rectal tumors.
METHODS
From December 1994 to January 2000, 136 patients underwent TEM. All patients were evaluated preoperatively with sigmoidoscopy or colonoscopy with biopsy. The indications for TEM were benign rectal tumors and T1 and T2 malignant rectal tumors with well or moderately differentiation. All patients were followed up 1 month postoperatively and every 3 months thereafter.
RESULTS
The mean operation time was 56.5 minutes (25~150 minutes) and the mean postoperative hospital stay was 3.6 days (2~10 days). On the basis of the postoperative evaluations, 56 of the 136 patients proved to have benign tumors while the remaining 80 patients had malignant tumors. One hundred thirty five patients were removed with adequate resection margins. One patient had cancer cell involvement at the resection margin. There were no serious complications. After a mean observation time of 29 months (12~42 months), there were five noted recurrences. Functional results were excellent; 24 of the 136 patients complained of impaired continence or defecation disorders in a review one month postoperatively. These problems improved during the first 6 months after the surgery.
CONCLUSIONS
We feel that TEM is an adequate method for removal of benign rectal tumors, and properly selected early rectal cancers.

Anorectal Cancer Undetected at the Time of Hemorrhoidectomy.: Kang, Sung Bum , Heo, Seung Chul , Jung, Seung Yong , Choi, Hyo Seong , Park, Kyu Joo , Park, Jae Gahb; J Korean Soc Coloproctol. 2002;18(2):110-114.

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Abstract PDF: No abstract available.

Adenocarcinoma Associated with Anal Fistula.: Kang, Sung Bum , Heo, Seung Chul , Jung, Seung Yong , Choi, Hyo Seong , Park, Kyu Joo , Park, Jae Gahb; J Korean Soc Coloproctol. 2002;18(2):115-120.

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Abstract PDF: PURPOSE
Although adenocarcinoma associated with anal fistula is rare, missed diagnosis may result in progression of the tumor and poor outcome. This study is aimed to determine the clinical features of adenocarcinoma associated with anal fistula.
METHODS
The medical records of 8 (0.4%) cases associated with anal fistula, out of 1978 anorectal adenocarcinoma treated at Seoul National University Hospital between 1979 and 2000, were reviewed.
RESULTS
The median age at diagnosis of cancer was 57 years (range, 39 to 62 years) and sex ratio was 7 to 1 with male predominance. The median duration of anal fistula before diagnosis of cancer was 8.5 years (range, 4 to 30 years). Major symptoms at diagnosis of cancer were perianal pain (38%) and discharge (38%). Perianal mass was palpable in all patients. All patients except for one case, in which palliative T-colostomy was performed due to extensive invasion despite preoperative radiation therapy, were treated with abdominoperineal resection: 4 in curative resection and 3 in palliative rsection. There were 4 (50%) in stage IV, 3 (38%) in stage III, and 1 (12%) in stage II. On median follow-up of 16 months (range, 3 to 72 months), systemic recurrences of 2 cases at lung or intraperitoneal cavity and 1 local recurrence at posterior vaginal wall were developed after curative resection.
CONCLUSIONS
Adenocarcinoma associated with anal fistula had the history of long-standing anal fistula and perianal mass on physical examination. These tumors were detected at advanced stage and their outcomes were poor. Therefore, in the anal fistula combined with long-standing history or perianal mass, a high index of suspicion for malignancy is necessary and a generous biopsy of fistulous tract should be performed to rule out concomitant adenocarcinoma.

Prognostic Significance of p53, nm23 and VEGF Expression in Primary and Hepatic Colorectal Cancer Metastases Following Surgical Resection.: Kim, Nam Kyu , Park, Jae Kun , Lee, Kang Young , Kim, Ho geun , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2002;18(2):121-127.

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Abstract PDF: PURPOSE
The aim of this study is to analyze a correlation between related molecular markers and prognosis after curative resection for primary and hepatic metastasis for colorectal cancer.
METHODS
A total 63 patients who have been resected curatively for primary and metastatic colorectal cancer between 1989 and 2000. All patients were completely followed up and recurrence and survival rates were analyzed. All paraffin embedded tumor tissues in primary and metastatic tumors were used for microtissue array and immunohistochemical staining of p53, nm23 and VEGF.
RESULTS
Mean follow up period was 30.9 months. Recurrence was noted in 39/63 (61.9%) and 5 year survival rates was 27.7%. 5 year survival rates according to protein expression in primary tumor: p53+/-: 24.6% vs 27.3%, nm 23 +/-: 17.6% vs 38.9%, VEGF +/-: 38.8% vs 21.6% (P=0.16, 0.06, 0.9, respectively). 5 year survival rates according to protein expression in metastatic tumor, p53 +/-: 18% vs 59.2%, nm 23 +/-; 38.2% vs 15.8%, VEGF +/-: 38.8% vs 21.6% (P=0.03, 0.35, 0.96, respectively). A patients recurred within 1 year after surgery (group I, N=23) were compared with patients who recurred 1 year after (group II, N=16). nm23 expression in primary tumor in each group of patients: ; 15/23 (65.2%), : 4/16 (25 %), : 8/23 (34.8%), : 12/16 (75%), respectively (P= 0.013). But, p53, VEGF expression in primary tumor showed no statistical significance. nm23 expression in metastatic tumor revealed no statistical significance between two group of patients.
CONCLUSIONS
p53 expression in metastatic tumor and nm 23 expression in primary tumor can predict poor prognosis after curative resection for primary and metastatic colorectal cancer. Molecular marker expression in primary and hepatic colorectal cancer can give us a reliable prognostic values.

Case Report

Cases of Postoperative Mesenteric Panniculitis.: Park, Sung Dae , Bae, Ok Suk; J Korean Soc Coloproctol. 2002;18(2):128-132.

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Abstract PDF: Mesenteric panniculitis is a rare inflammatory condition of mesenteric adipose tissue in which the mesentery is replaced with fibrosis. The frequent symptoms of mesenteric panniculitis are palpable mass, abdominal pain and gastrointestinal obstructive symptoms. In the majority of cases, its course is self-limiting and the prognosis is favorable. 3 cases of mesenteric panniculitis are described that presented with obstructive symptoms of gastrointestinal tract, which occurred in 2 weeks following colectomy of colonic tumors. And reviewed the symptomatology, pathology, treatment, and outcome of this disorder.

Original Article

A Case of Idiopathic Megacolon Associated with Sigmoid Volvulus.: Yeom, Joo Jin , Choi, Ji Hun , Kim, Ji Woong , Kim, Sang Wook , Kim, Tae Hyeon , Choi, Suk Chae , Lee, Jung Gyun , Yun, Ki Jung , Nah, Young Ho; J Korean Soc Coloproctol. 2002;18(2):133-136.

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Abstract PDF: Megacolon is an uncommon condition in which the bowel is persistently of increased diameter and it is always associated with long-standing constipation. Two main groups are recognized according to whether or not ganglia are present in the intermuscular plane of the rectal wall. Their complete absence, even along a short segment of rectum, denotes Hirschspurung's disease. If ganglia are present, the dilated bowel may be secondary to some predisposing factor such as a stricture, a congenital anorectal abnormality, a cauda equina lesion etc. In other instances, however, there may be no apparent organic reason as to why the bowel should be so dilated. This latter condition is termed "idiopathic megacolon". We report the case of one female patient with idiopathic megacolon. During medical treatment, she was complicated with a sigmoid volvulus, we performed subtotal colectomy and cecorectal anastomosis and she improved without any complication.

Case Report

Surgically Correctable Fecal Incontinence Associated with Traumatic Duhamel Operation: A Report of Three Cases.: Yoon, Wan Hee , Choi, Jeong Hun; J Korean Soc Coloproctol. 2002;18(2):137-140.

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Abstract PDF: We present 3 cases of fecal incontinence associated with traumatic injury during Duhamel procedure. Three male patients suffered from persistent fecal soiling and incontinence for more than 7 years after definitive surgery for Hirschsprung's disease by a pediatric surgeon. They showed grade 4 frequent major soiling, mild patulous anus, and flattening of the anorectal angle due to traumatic injury of the external sphincter and puborectalis muscle on the posterior midline of the anorectal junction. On Parks postanal pelvic floor repair procedures, the incontinent symptoms were abated, anatomic changes were normalized, and postoperative Kirwan classification scales were markedly improved from grade 4 to grade 1. Patients with fecal incontinence after Duhamel operation for Hirschsprung's disease may have a traumatic injury of the anal sphincter. Careful physical and laboratory examinations should be performed for the confirmation of traumatic injury in these patients, and Parks postanal repair could be the treatment of choice for the correction of incontinence.

Review

Surgical Treatment of Anal Fistula.: Jun, Soo Han; J Korean Soc Coloproctol. 2002;18(2):141-146.

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Abstract PDF: Most anal fistulas are either intersphincteric or low transsphincteric and are treated by fistulotomy with a few recurrence and minimal risk of incontinence. In high and complicated fistulas, fistulotomy should not be used because of a high chance of incontinence. High transsphincteric or suprasphincteric fistulas, anterior fistulas in female, patients with coexisting inflammatory bowel disease, elderly patients with poor sphincter function, multiple simultaneous fistulas, or patients with multiple prior sphincter injuries need alternative technique to minimize the incidence of incontinence. The alternative techniques include seton placement, advancement flap closure, muscle filling procedure, fibrin glue, etc. depending on the status of fistula and patients. The various sphincter sparing techniques used widely are reviewed.

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