Annals of Coloproctology

Volume 19(4); August 2003

Original Articles

The Effect of Photodynamic Therapy on Colon Cancer Cell Line.: Lee, Han Il , Choi, Dong Rak , Joo, Dae Hyun , Park, Ki Hyuk , Park, Sung Hwan , Yu, Yong Oon , Park, Ki Ho , Shin, Im Hee , Shin, Dong Gun , Kim, Jong Ki , Cho, Chang Ho , Kim, Jin Cheon; J Korean Soc Coloproctol. 2003;19(4):205-210.

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Abstract PDF: PURPOSE
Photodynamic therapy (PDT) is a relatively new technology for an alternative modality in the treatment of colorectal cancers. This study was conducted to identify the appropriate dosage and energy level for the photosensitizer as well as effect of PDT on colon cancer cells.
METHODS
Colon cancer cell line, COLO 205 (American Type Culture Collection, ATCC) was obtained from Korea Cell Line Bank (KCLB, Seoul, Korea). Cells were cultured on RPMI 1640 medium with 10% fetal calf serum, penicillin, and gentamicin. Cells were incubated at 37 C in a 5% CO2 air environment. Photosense (sulphonated aluminum phthalocyanine, AlPcS4, NIOPIK, State Research Center, Moscow, Russia) was used for the photosensitizer and Fireplace video-3 (Biospec, General Physics Institute, Moscow, Russia, 500 mW/cm2, 670 nm) was used for the light source. 1 104 cells were incubated in 96 well plates with different concentrations of aluminum phthalocyanine: 0.1, 0.3, 0.5 and 1micrometer for 24 hours then photoirradiation was performed at either 24 or 48 J/cm2. The time variations of the viabilities of cells of the four study groups and were measured by using MTT assay according to time were compared to those of the three control groups: control (no treatment), control (AlPcS4, no light), control (light, no AlPcS4), and the study groups (PDT) at one hour, 24 hours, 48 hours and 72 hours after PDT.
RESULTS
At, one hour after PDT, the viability of the cells was not changed in the control groups. Viabilities of 117, 40, 35, and 23% in the 24 J group and 76, 31, 52, and 48% in 48 J group were observed, respectively in order of increasing concentration with the value of 87~103% for the control group. 24 hours later, viability of control groups were not changed, By 24 hour after PDT, the viabilities of the control groups had not changed, but those of the 24 J/cm2 and 48 J/cm2 PDT study groups had decreased significantly to 62, 17, 16, and 18% and 24, 15, 13, and 13%, respectively (P=0.00). By 48 hours viability of the 24 J/cm2 and 48 J/cm2 PDT study groups were also significantly decreased being 103, 26, 13, and 13% and 50, 8, 8, and 9%, respectively (P=0.00). By 72 hours, viabilities were 84, 21, 21, and 30 % and 33, 20, 33, and 15%, respectively (P=0.00).
CONCLUSIONS
The PDT groups showed a marked cytotoxic effect compared to the control groups, and the effect appeared just after PDT and peaked in 48 hours. The minimum required concentration of the photosensitizer for effective cytotoxicity was at 0.3 micrometer either 24 or 48 J/cm2.

Review of the Pathology and Differential Diagnosis of Acute Appendicitis.: Kim, Jong Po , Son, Chang Mok; J Korean Soc Coloproctol. 2003;19(4):211-215.

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Abstract PDF: PURPOSE
Multiple methods are used to diagnose acute appendicitis. However, with the current practice, the negative laparotomy rate for acute appendicitis is from 15% up to 30%. This study was designed to evaluate various pathologies of the appendix and other intraabdominal organs of patients preoperatively diagnosed with acute appendicitis and to analyze clinically the difference between acute appendicitis and other intraabdominal inflammatory diseases.
METHODS
We reviewed the pathologic reports of 833 patients who underwent laparotomies for acute appendicitis from January 1997 to December 2001. We grouped these patients by pathology. Group I included patients with a negative appendectomy and no other intraabdominal pathology, group II included those with lesions within the appendix, and group III, those with intraabdominal lesions other than in the appendix. We also analyzed the age, sex distributions, the typical symptoms of appendicitis, the duration of symptoms, fever, and leukocytosis of 100 patients with typical appendicitis by random sampling to find the clinical differences that existed between pelvic inflammatory disease and cecal diverticular disease presented as appendicitis.
RESULTS
The diagnostic accuracy for acute appendicitis was 79.7%, and the negative appendectomy and negative laparotomy rates were 17.4% and 15.5%, respectively. The percents of patients in group I, II, and III were 10.4%, 82.6%, and 7.0%, respectively.
CONCLUSIONS
It is important to consider the possibility of various pathologies during diagnostic and operative procedures for an acute abdomen, especially one occurring in the right lower quadrant.

Prognostic Factors for Generalized Peritonitis Secondary to Colonic Perforation.: Kim, Hong , Lee, Kug Jong , Lee, Young Joo , Suh, Kwang Wook; J Korean Soc Coloproctol. 2003;19(4):216-220.

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Abstract PDF: PURPOSE
The prognosis following colonic perforation is generally regarded as worse than it is for upper gastrointestinal perforation. Moreover, the increasing incidence of colon cancer associated perforation is another reason for the present study of colonic perforation in the present study. We reviewed and analyzed various types of colonic perforations to determine which prognostic factors were still useful for the treatment of colonic perforation.
METHODS
Thirty six patients (mean age, 51.5; 24 males) with generalized peritonitis secondary to a colonic perforation were studied retrospectively. All the patients had undergone an exploratory laparotomy. The severity of the clinical condition was recorded according to the APACHE III scoring system for all the patients when they were first seen. Mortality and morbidity were analyzed for possible prognostic factors, such as age, type of operation, association with malignancy, and APACHE-III score.
RESULTS
Penetrating trauma was the leading cause of perforation (27.8%), and iatrogenic perforations accounted for 19.4% of the total. Among nontraumatic perforations, malignancy was the major pathology (25.0%). The sigmoid colon was the most frequent site of perforation. Types of surgical treatment varied according to the general conditions of the patients. In 22 patients, the operation was finished with primary closure alone. A colonic resection was performed in 14 patients, and a proximal diversion was performed in 19 patients (after either a resection or primary closure). Analysis of the various clinical variables showed that old age (>60), underlying malignancy, and the APACHE III score were significant prognostic factors for the surgical outcome.
CONCLUSIONS
These results suggest that penetrating injuries are still the main cause of colonic perforation and that iatrogenic and malignancy-related perforations are increasing. Among other variables, old age, underlying malignancy and the APACHE III score are significant prognostic factors for the surgical outcome.

Role of Anorectal Physiologic Studies for the Diagnosis and Treatment of Non- relaxing Puborectalis Syndrome.: Kim, Nam Hyuk , Hwang, Yong Hee , Choi, Kun Phil; J Korean Soc Coloproctol. 2003;19(4):221-228.

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Abstract PDF: PURPOSE
To assess the effectiveness of cinedefecography (CD), anal electromyography (EMG), and anal manometry (ARM) for the diagnosis of non-relaxing puborectalis syndrome (NRPR) and to compare the outcomes for patients after biofeedback therapy (BF).
METHODS
The clinical criteria used in this study for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. Patients who satisfied the clinical criteria were evaluated by use of anorectal physiology tests: CD, EMG, and ARM. The EMG criteria included failure to achieve a significant decrease in the electrical activity of the puborectalis (PR) during attempted evacuation. The ARM criteria included failure to achieve a significant decrease in intra-anal pressure during attempted evacuation. The CD criteria included either paradoxical contraction or failure of the PR to relax together with incomplete evacuation. Other possible etiologies for incomplete evacuation, such as rectal intussusception or rectocele, were excluded in all cases. Fifty-eight constipated patients diagnosed as having NRPR by at least one of anorectal physiolosic tests had more than one BF session. The outcomes for fifty-one patients (mean age, 44.8 years; male-to-female ratio, 22:29) were reported as either improved or unimproved at a mean follow-up of 12.7 (range, 2~30) months. The sensitivities, the specificities, and the positive and negative predictive values for the CD, EMG, and ARM diagnoses of NRPR were calculated to assess the diagnostic accuracy of each test and to identify predictors associated with the outcome of BF.
RESULTS
The sensitivities of EMG, CD, and ARM were 96%, 89%, and 85%, respectively (P>0.05). The positive predictive values of the three tests were 63% for EMG, 52% for ARM, and 51% for CD (P>0.05). The negative predictive values of the three tests were 90% for EMG, 43% for ARM, and 25% for CD (P<0.05). The specificities of the three tests were 38% for EMG, 13% for ARM, and 2% for CD (P<0.05). The positive predictive values the two-study-positive groups and the three-study-positive group were 63% for the EMG- and ARM-positive group, 61% for the CD- and EMG-positive group, 51% for the CD- and ARM-positive group, and 61% for the three-study- positive group (P>0.05).
CONCLUSIONS
A combination of the CD and the EMG tests is suggested for the diagnosis of NRPR.

Laparoscopic Assisted Colectomy Versus Open Colectomy; Retrospective Case-Control Study.: Choi, Sung Il , Woo, Jong Gook , Chang, Nae Sung , Lee, Woo Yong , Chun, Ho Kyung; J Korean Soc Coloproctol. 2003;19(4):229-234.

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Abstract PDF: PURPOSE
Despite many reports on laparoscopic-assisted colectomies (LAC) over the past decade, the feasibility of their use in both benign and malignant disease of the colon is not clear. The purpose of this study was to evaluate the feasibility and safety of LAC for the treatment of colonic diseases.
METHODS
Between April 2000 and August 2002, we attempted a laparoscopic-assisted colectomy in 95 patients (LAC group). We excluded 3 patients who had converted to open surgery. The surgical outcomes were compared with 92 matched patients who underwent conventional open surgery during the same period (open group), focusing on the results of the surgery, postoperative recovery, complications and oncologic clearance. Between the two groups, there were no significant differences in age, Dukes stage, and type of resection.
RESULTS
There were 29 benign and 63 malignant diseases. The mean operating time for the LAC group and the open group were 167.9 and 95.1 minutes, respectively (P<0.00). However, the time taken for passing gas (40.4 hours vs 56.7 hours)(P=0.02) and the length of hospital stay (7.9 days vs 8.6 days) (P=0.07) were significantly shorter in the LAC group than in the open group. Nine patients in the LAC group had complications (9.7%): anastomotic site bleeding (4), chyle leakage (3), urinary retention (1), and ileus (1). All were treated conservatively. There were no differences in complication rates between the groups. The average number of harvested lymph nodes was 20.9 (2~64) in the LAC group and 21.5 (4~60) in the open group (P=0.49). The average distal resection margins were 3.7 (2.0~9.0) cm in the LAC group and 3.3 (1.0~5.0) cm in the open group (P=0.21) for an anterior resection and 3.2 (1.0~7.0) cm in the LAC group and 2.3 (0.7~7.0) cm in the open group for a low anterior resection (P=0.48).
CONCLUSIONS
This study showed that LAC had an advantage over open surgery in terms of earlier recovery. Oncological clearance (the number of lymph nodes removed and the resection margins) did not differ between the two procedures. Thus, LAC is a feasible technique in the treatment of colon disease with acceptable morbidity. However, long-term data from a randomized trial is needed.

Clinical Effects of Chemotherapy Combined with Interferon-alpha in Colorectal Cancer.: An, Chang Hyeok , Park, Sang Hyub , Kang, Won Kyung , Oh, Seong Tack , Kim, Jeong Soo , Jeon, Hae Myung , Yoo, Seung Jin; J Korean Soc Coloproctol. 2003;19(4):236-242.

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Abstract PDF: PURPOSE
In advanced colorectal cancer, 5-Fluorouracil (5-FU) and Leucovorin (LV) have been used as a standard chemotherapy regimen. 5-FU is a popular chemotherapeutic drug for colorectal cancers and LV is the most effective modulator of 5-FU. Recently, some studies using Interferon (INF) combination therapy with 5-FU to enhance the anti-tumor effect of 5-FU have been performed. The outcomes were reportet to be better than those of studies using single agent therapy. However, the clinical effect of a combination therapy with INF is still controversial. So that, we performed this study to understand the advantages of INF combination therapy in advanced colorectal cancers in the Korean population.
METHODS
We recruited patients who had been diagnosed with for colorectal cancers and received operations and postoperative adjuvant chemotherapy in Uijongbu St. Mary's hospital, from July, 1995, to June, 1999. The patients were divided into two groups; control group treated with the Mayo clinic chemotherapy regimen of 5-FU plus LV, and study group treated with additional INF-alpha to 5-FU-LV combination treatment. We evaluated the clinical outcomes such as the overall survival rate, the recurrence rate, and the chemotoxicity between two groups.
RESULTS
In comparison of 5 year survival rates of two groups for each stage of the colorectal cancer, those of stage B2 were 90.9% in the control group and 80.0% in the study group. For stage C patients, the values were 80.2% in control group and 52.5% in the study group. The overall 5-year survival rates of the control group and the study group regardless of stages were 77.1%, and 63.4%, respectively. The 5-year disease-free survival rates for stage B2 were 82.8% in the control group and 72.9% in the study group. For stage C patients, those were 42.6% in the control group and 34.4% in the study group. The recurrence and metastatic rates were 19.2% (local recurrence; 2, metastasis; 12) in the control group and 36.1% (local recurrence; 3 metastasis; 27) in the study group. The overall incidences of chemotoxicity were 24.7% in the control group and 31.3% in the study group.
CONCLUSIONS
There was no evidence that chemotherapy using 5-FU and LV combined with INF-alpha in advanced colorectal cancer patients was more effective than the Mayo regimen of 5-FU and LV. More large scale clinical studies are warranted to evaluate the efficacy of additional INF therapy in colorectal cancer patients.

Impact of Body Mass Index on Surgical Outcomes of Laparoscopic Colorectal Cancer Resection.: Joh, Yong Geul , Kim, Seon Han , Yoon, Jin Seok , Chung, Choon Sik , Lee, Dong Keun; J Korean Soc Coloproctol. 2003;19(4):243-247.

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Abstract PDF: PURPOSE
The purpose of this study was to determine whether obesity increases the risk of performing a laparoscopic resection for colorectal cancer.
METHODS
Prospectively collected data were obtained for 103 patients who had undergone laparoscopic resection for colorectal cancer from September 2001 to August 2002. Patients who had had a previous abdominal operation, a total colectomy or an additional surgical procedure at the time of colon resection were excluded from the analysis. The patients were divided into two groups based on body mass index (BMI kg/m2): the normal group (BMI <25) and the obesity group (BMI 25). Intraoperative blood loss, operative time, conversion, length of hospital stay and complications were analyzed.
RESULTS
Nineteen patients (25%) were obese. Operation time (183.2 min vs 202.1 min) and the blood loss (98.2 ml vs 168.2 ml) were significantly increased in the obese patients, but hospital discharge after surgery (11.7 days vs 11.9 days) and the morbidity rate (8.5% vs 5.3%) were not different between the groups. Conversion to the an open precedure occurred with one obese patient, but that was not related to obesity. In the analysis of the low anterior resection, blood loss (94.6 ml vs 186.6 ml) was significantly higher in obese patients, but no statistically significant differences existed for other surgical outcomes between the two groups.
CONCLUSIONS
A laparoscopic resection for colorectal cancer can be safely performed in obese patients.

Change of Anorectal Function after Low Anterior Resection for Rectal Cancer.: Yun, Min Young , Choi, Sun Keun , Bae, Sun Young , Hur, Yun Suk , Lee, Kun Young , Kim, Sei Joong , Ahn, Seung Ick , Hong, Kee Chun , Shin, Suk Hwan , Kim, Kyung Rae , Woo, Ze Hong; J Korean Soc Coloproctol. 2003;19(4):248-253.

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Abstract PDF: PURPOSE
The anorectal function after a low anterior resection for rectal cancer recovered progressively by 6 12 months after the operation, but the mechanisms and the recovery process are not well understood. The aim of this study was to correlate postoperative anorectal function after low anterior resection with physiologic parameters.
METHODS
Sixty-seven patients who underwent a low anterior resection for rectal cancer were studied. The control group was consisted of normal persons. Anorectal physiologic studies were conducted for 6 months postoperatively by using defecographys, anorectal manometry and electomyogram of pudendal nerve.
RESULTS
The postoperative anorectal function was gradully improved with time. Defecograms showed that the resting, squeezing, and straining anorectal angles were not significantly increased. Anorectal manometry showed that the threshold volume and the urgency volume were not significantly decreased but the maximal tolerable volume was decreased remarkably. The maximal resting pressure significantly decreased but the maximal squeezing pressure were not. The pudendal nerve electromyograms were not significantly different between the two groups. The patients were divided by based on the anastomosis level. The short anastomosis group showed more impairment in the urgency volume and the maximal resting pressure than that of the long anastomosis group.
CONCLUSION
The neorectal volume and the level of anastomosis were important for changes in the anorectal function after a low anterior resecton. Gradual improvement of symptoms resulted from a resected rectal adapted to a neorectal volum.

Case Report

Hirschsprung's Disease in Adults.: Park, In Ja , Yu, Chang Sik , Yu, Sang Hwa , Lee, Kang Hong , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2003;19(4):254-259.

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Abstract PDF: Hirschsprung's disease is a disorder caused by the absence of ganglion cells in the colon and rectum. It has an incidence of 1 in 5000 births, the majority diagnosed and treated in the neonatal period due to symptoms of intestinal obstruction. Persistence of Hirschsprung's disease into adulthood is very rare. In such patients, prolonged periods of constipation are a common problem. For the diagnosis, a colon study and anorectal manometry are performed, and the presence of the disease is confirmed by an excisional biopsy proving the absence of the ganglion cell in Auerbach and Meissner's plexus. Although various surgical procedures have been performed, there is no obvious optimal choice for treatment of Hirschsprung's disease in adolescents and adults. We experienced two cases of Hirschsprung's disease, confirmed by a rectal biopsy, in 20-year patients. Prior to a definitive operation, a sigmoid loop colostomy was performed due to severe dilatation of the left colon and rectum. Six months later, one patient was treated using Duhamel's procedure, and the other by using a proctosigmoidectomy and coloanal anastomosis. No postoperative complications were observed, and the patients had bowel movements three to four times a day. Despite its infrequent incidence, adult Hirschsprung's disease should be suspected in patients who have had lifelong constipation. Several successful surgical treatments have been used for treatment of patients with adult Hirschsprung's disease. In our cases, the functional results of Duhamels' procedure and of a proctosigmoidectomy with coloanal anastomosis were satisfactory.

Review

Biofeedback Therapy in Patients with Functional Evacuation Disorders.: Park, Ung Chae; J Korean Soc Coloproctol. 2003;19(4):260-269.

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Abstract PDF: Biofeedback therapy has emerged as a useful adjunct for patients with functional evacuation disorders over the past decade. The goals of biofeedback retraining may vary and could depend on the underlying dysfunction. In patients with obstructive defecation, the goals are to relax the anal sphincter, improve rectoanal coordination, and improve sensory perception. Methods of biofeedback therapy varied widely between centers. However, no difference was described when EMG-based biofeedback was compared to manometry-based biofeedback, or when visual or auditory feedback was given. In regards to biofeedback adjuncts, including sensory retraining with either an intrarectal balloon, a portable home-training unit or both can be practicable. There are inconsistencies in the literature regarding the patient selection criteria for biofeedback treatment. The patient group is not homogeneous. Different case selection, different regimens and different methods of biofeedback may explain the variability in success rate. Quality research that would assist in predicting outcome is still lacking. Although no specific denominator could possibly be assigned to correctly predict the overall outcome of therapy, biofeedback is not successful in all patients with outlet obstructed constipation. Results with success rates is ranging from 8.3 percent to 100 percent. The treatment of constipation by biofeedback has been viewed with some skepticism as the low success rate may simply be a placebo effect. The majority of scepticism to therapeutic outcome are derived from entry criteria for treatment. Lower success rates have been described when entry criteria were broadened. Prebiofeedback clinical findings which are presupposed to prognostic relevance are age, gender, duration of symptoms and presence of rectal pain, lower motor neuron disease, and psychiatric problems. I feel strongly that informations about the predictive factors are vital to all physicians either performing or recommending biofeedback to their patients. If biofeedback could be undertaken according to specific criteria, we, colorectal surgeon will save a fruitless endeavour, one would expect more improvements in more patients. Additional well-designed controlled trials are needed to establish the clinical and physiologic factors.

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