Annals of Coloproctology

Volume 19(5); October 2003

Randomized Controlled Trial

Efficacy of Ligasure(TM) in a Hemorrhoidectomy: Comparison with Semi-open Hemorrhoidectomy.: Suh, Hae Hyeon; J Korean Soc Coloproctol. 2003;19(5):271-275.

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Abstract PDF: PURPOSE
Ligasure(TM) is a feedback-controlled bipolar diathermy originally devised to seal vessels and developed to weld tissue bundles. The tissue fusion mechanism consists of melting collagen and elastin, and the tissue welding property of Ligasure(TM) can be used in a hemorrhoidectomy. To confirm the efficacy of Ligasure(TM) in hemorrhoidectomies, I compared it with the conventional semi-open method.
METHODS
One hundred patients with grade III or IV hemorrhoids were randomly assigned to the Ligasure(TM) (n=50) or the conventional semi-open (n=50) hemorrhoidectomy group. The operation time, the postoperative analgesic requirement, the hospital stay, the time to return to normal life, and complications were prospectively recorded and analyzed.
RESULTS
There was no difference in sex and age between the two groups. The operation time was markedly shorter in the Ligasure(TM) group than semi-open group (10.8+/-4.0 versus 23.7+/-5.2 min; P<0.001). Although the hospital stay was not statistically different, the time to return to the normal life was shorter in the Ligasure(TM) group (9.5+/-3.8 versus 12.7+/-4.0 days; P<0.05). The requirement for postoperative analgesics within 48 hours (nalbuphine, 5mg) was not significantly different. In each group, an urinary retention was noted and treated with urinary catheterization. In Ligasure(TM) group, an anal stenosis was developed and was successfully treated with advancement flap surgery. In each group a secondary bleeding and a skin tag were noted. There was no wound infection or incontinence.
CONCLUSIONS
Ligasure(TM) hemorrhoidectomy reduces the operation time and the time to return to the normal life. If anal stenosis is to be prevented, careful attention is required to preserve the anal skin and mucosa. Ligasure(TM) is simple to use and is useful in the treatment of patients with grade III or IV hemorrhoids.

Original Articles

Comparison between an Interval Appendectomy and an Urgent Appendectomy for Patients of Periappendiceal Abscess.: Cho, Sung Wook , Kim, In Gyu , Lee, Bong Hwa; J Korean Soc Coloproctol. 2003;19(5):276-281.

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Abstract PDF: PURPOSE
Our goal was to compare the clinical course after an interval appendectomy with that after an urgent appendectomy in patients with localized periappendiceal abscesses confirmed by radiology.
METHODS
This study was a retrospective review of 57 consecutive patients who were treated between February 1999 and June 2003 for appendicitis complicated by periappendiceal abscess. For periappendiceal abscesses, 37 patients were treated with an urgent appendectomy, but 20 patients were treated initially non-operatively. Finally, 12 of those 20 patients underwent an interval appendectomy. Exclusion criteria were periappendiceal abscesses spreading to the whole abdomen diffusely, as confirmed by either abdominal CT or ultrasonography.
RESULTS
Interval appendectomies were performed in 12 (60%) of the patients in the 20 initial non-operative group. The complication rate for the 12 patients in the initial non-operative group who underwent an interval appendectomy was significantly lower than that for the 37 patients in the urgent appendectomy group (P<0.05). The duration of nothing by mouth (NPO) and the length of the hospital stay in the initial non-operative group with an interval appendectomy were also significantly lower than those in the urgent appendectomy group (P<0.05). The histopathologic finding for the interval appendectomy group was suppurative appendicitis in 9 of the 12 cases.
CONCLUSIONS
Initial non-operative treatment with an interval appendectomy has been relatively fewer postoperative problems than an urgent appendectomy in patients with localized periappendiceal abscesses in our study, and further study in more large series considered to be needed.

Gastrointestinal Stromal Tumors (GISTs) of the Colon and Rectum: Clinicopathological Analysis.: Kim, Eun Kyu , Lee, Ho Chang , Lee, Min Ro , Lim, Seok Byung , Kang, Sung Bum , Park, Kyu Joo , Kim, Woo Ho , Park, Jae Gahb; J Korean Soc Coloproctol. 2003;19(5):282-289.

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Abstract PDF: PURPOSE
This study was undertaken to investigate the clinicopathological features of GISTs (gastrointestinal stromal tumors) of the colon and rectum.
Method
At Seoul National University Hospital from Jan. 1994 to Dec. 2002, 11 patients were diagnosed as having GISTs, leiomyomas, or leiomyosarcomas of the colon and rectum. For those 11 patients, immunohistochemical staining for CD117 (c-kit) was undertaken in order to differentiate true GISTs from leiomyomas and leiomyosarcomas. Ten patients were positive for CD117 (c-kit) and were finally diagnosed as having GISTs. Then, we retrospectively analyzed the clinical and the pathological features of those 10 cases and investigated the recurrence of disease and the survival.
RESULTS
Colorectal GISTs accounted for 0.3% of all colorectal malignancies (10 cases/2,964 cases). The male- female ratio for the 10 patients with GISTs was 8:2, and the median age was 56.5 (34~75) years. The locations of the tumor were the rectum in 9 cases (90%) and the ascending colon in 1 case. The most common symptoms were decreased stool caliber and GI bleeding (3 cases, respectively). A curative-intent resection was possible in 8 cases. There were two cases of recurrence after curative resection (25.0%). The median survival period of the 10 patients was 33.5 (2~70) months. The median tumor size was 7.5 (5~20) cm, and the median number of mitosis per 50 high-power fields was 36.5 (8~123). There was a statistically significant correlation between size and mitotic count (r=0.942, P=0.001).
CONCLUSIONS
Colorectal GISTs are very rare disease entities (0.3% of the colorectal malignancies). However, all colorectal GISTs were classified as malignant based on their sizes and mitotic counts in our study. For introduction of STI-571 in the treatment of colorectal GISTs and for further study, accurate diagnosis of GISTs by special immunohistochemical staining (c-kit) is very important in differential diagnosis of primary gastrointestinal mesenchymal tumors and recurred leiomyosarcomas.

Clinical Analysis of T4 Colorectal Cancer with Adhesion to Adjacent Organs.: Cho, Mun Hyeong , Joo, Jai Kyun , Ryu, Seong Yeob , Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 2003;19(5):290-298.

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Abstract PDF: PURPOSE
A colorectal cancer (CRC) is defined as T4 when the tumor directly invades other organs or structures and/or perforates the visceral peritoneum. The purpose of this study was to evaluate the results of a surgical approach and to determine the significant prognostic factors for tumor resectability and survival in patients with advanced T4 CRC.
METHODS
A total of 61 patients with T4 CRC with adjacent organ adhesion, who received multivisceral resections at Chonnam University Hospital, Korea, between Jan. 1990 and Dec. 2001, were analyzed retrospectively.
RESULTS
Cancer invasion to contiguous organs was present in 51 (83.6%) of the 61 patients who received a multivisceral resection and was absent in 10 (16.4%). Postoperative rates of complications and death were 22.9% and 4.9%, respectively, in the 61 patients. Lymph-node (LN) metastases were presented in 25 patients (41.0%). The 5-year survival rate (5 YSR) was 22.2% in patients with LN metastases, but was significantly higher (66.7%) in patients without LN metastases. The 5 YSRs for the 61 patients according to the AJCC cancer stage (TNM classification) were as follows: stage II (66.7%), stage III (46.4%), and stage IV (0%).
CONCLUSIONS
T4 CRC without distant metastases requires multivisceral en-bloc resection of any organ or structure to which the primary tumor is adhered. The presence of LN metastases at the time of surgery is one of the significant factors with a poor prognosis in T4 CRC.

The Postoperative Impact of Co-morbidity in Colorectal Cancer Surgery.: Suh, Hee Seok , Lee, Kang Hong , Kim, Hee Cheol , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2003;19(5):299-306.

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Abstract PDF: PURPOSE
Co-morbidity is the presence of co-existing or additional diseases during the initial diagnosis. It may be used as a prognostic indicator for the postoperative outcomes in most cancers, including colorectal cancers. The impact of respective co-morbidities in colorectal cancer surgeries were evaluated to identify their outcomes regarding complications and hospital stay.
METHODS
The medical records of 2,242 colorectal cancer patients, who had had curative operations between Jan. 1997 and Dec. 2001, were reviewed to evaluate the prevalence of co-morbidities. All co-morbidities were adequately evaluated and managed preoperatively.
RESULTS
Co-morbidities were observed in 789 out of the 2,242 (35.2%) patients. Hypertension was the most frequent (340, 15.2%), with diabetes (210, 9.4%) and cardiovascular diseases (124, 5.5%) following. Early stages (0~II) were more frequently associated with co-morbidities, compared to late stages (III~IV) (P<0.001). Hypertension and cerebrovascular diseases were significantly associated with postoperative complications (P<0.05). Postoperative complications occurred in 578 out of the 2242 (25.8%) patients: e.g., ileus (10.2%), voiding difficulty (4.4%), wound problems (4.3%), etc. Pulmonary complications occurred more often in patients with cerebrovascular diseases, hypertension, and asthma. Wound complications were observed in patients with hypertension, cerebrovascular diseases, chronic obstructive pulmonary disease, and chronic renal failure (P<0.05). Patients with more than one co-morbidity were closely associated with frequent postoperative co-mplications (P<0.05). However, comorbidities did not seem to affect the duration of the postoperative hospital stay.
CONCLUSIONS
Postoperative complications frequently occur in colorectal cancer patients with specific co- morbidities, especially in those with more than one. An adequate management of the co-morbidities preoperatively leads to a good outcome.

Pulmonary Metastases after Curative Resection in Patients with Colorectal Carcinomas.: Park, In Ja , Kim, Hee Cheol , Lee, Gang Hong , Yu, Chang Sik , Kim, Tae Won , Chang, Heung Moon , Kim, Dong Kwan , Park, Seung Il , Kim, Jin Cheon; J Korean Soc Coloproctol. 2003;19(5):307-313.

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Abstract PDF: PURPOSE
Pulmonary metastases from colorectal carcinomas have been reported to occur in 10% of all patients who undergo a curative resection. A number of studies have reported aggressive treatments, including lung resection, for pulmonary metastases that appear to prolong the survival in selected cases. The aim of this study was to assess the clinical characteristics, and the prognostic factors of pulmonary metastases, as well as the outcomes after resection of the pulmonary metastases.
METHODS
A retrospective study was performed on 104 patients who presented with primary pulmonary metastases without metastases in other organs after a curative resection for a colorectal carcinoma between January 1994 and December 2000 at Asan Medical Center. Pulmonary metastases were diagnosed by using serial changes in the chest X-ray and the CT. Univariate (log-rank) and multivariate (Cox's model) analyses were employed to identify the prognostic factors.
RESULTS
The mean interval between colorectal resection and pulmonary metastases (disease-free interval) was 22 (range: 4~64) months. Fifty-eight of 104 patients had pulmonary metastases originating from rectal cancer. More than half of the patients (55.7%) had bilateral multiple metastases. Fifty-six of 104 patients underwent chemotherapy, 28 conservative therapy, and 20 a pulmonary resection with the extent of the resection varying from a wedge resection of the metastatic nodule to a lobectomy. Prolonged survival was associated with serum CEA levels at the diagnosis of the metastases (P=0.02) and with the type of treatment (P<0.01).
CONCLUSIONS
The s-CEA level at the diagnosis of the pulmonary metastases appears to be a reliable predictor of survival in patients with pulmonary metastases from colorectal cancer. Resection of the pulmonary metastasis in colorectal cancer may significantly prolong survival. Thus, aggressive therapy, including surgery, should be considered for pulmonary metastatic tumors in selected groups.

Surgical Treatment of Recurrent Colorectal Cancer.: Koo, Gwang Mo , Park, Sang Su , Yoon, Jin , Kim, Il Myoung , Yu, Byoung Uk , Yang, Dae Hyun , Cho, Ik Hang; J Korean Soc Coloproctol. 2003;19(5):314-321.

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Recurrent colorectal cancers have important and difficult diagnostic and treatment problems. The purpose of this study is to evaluate the rationale and the efficacy of surgical re-treatment for patients with recurrence following curative surgery for colorectal cancer.
METHODS
From January 1991 to December 2002, we experienced 60 (20.9%) patients with recurred colorectal cancer among 287 patients who had curative operations in our hospital. These 60 patients were divided into three groups. Patients in group 1 had curative-intent resections, patients in group 2 had palliative resections, and patients in group 3 had conservertive treatment. The groups consisted of 17 (28.3%), 10 (16.7%) and 33 (55.0%) patients, respectively. We analyzed retrospectively those groups for any recurrence pattern and for survival.
RESULTS
Of the 60 patients with recurrent colorectal cancer, in 20 (33.3%) patients the cancer recurred in the colon, and in 40 (66.7%) it recurred in the rectum. Local recurrence was seen in 9 (15.0%) patients, liver metastasis in 25 (41.7%), and pulmonary metastasis in 13 (21.7%). The 1- and 3-, and 5-year survival rates were 86.5%, 31.7%, and 15.9%, respectively, for group 1, 33.3%, 0%, and 0% for group 2, and 28.9%, 4.4%, and 4.4% for group 3. The median survival period was 31 months for group 1, 8 months for group 2, and 7 months for group 3.
CONCLUSIONS
Although evaluation was difficult owing to the small number of patients with recurrent colorectal cancer, a significant difference in survival rates was observed between the treatment groups. On the basis of these results, we think that curative-intent aggressive surgery for recurrent colorectal cancer in appropriately selected cases can clearly prolong survival when compared with palliative resections and conservative treatment.

Detection of Cytokeratin 19 and 20 in Portal Bloods in Right Colon Cancer Patients.: Kim, Hong , Kim, Bong Wan , Kim, Hye Jin , Suh, Kwang Wook; J Korean Soc Coloproctol. 2003;19(5):322-326.

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Abstract PDF: PURPOSE
We planned this prospective study to detect tumor cells in portal venous blood during a curative operation for colon cancer and to identify its clinical implications.
METHODS
From August to December 1998, we collected portal venous blood (10 ml) during curative operations on 20 patients with colon cancer. Cytokeratin (CK) 19 and 20 transcripts were amplified using a reverse transcriptase-PCR assay. As a negative control, 10 ml of portal blood from 10 patients who underwent benign surgery were assayed. The HCT-116 colon cancer cell line was used for the positive control. All patients were closely followed until May 2003 (mean follow-up: 55 months).
RESULTS
CK 19 was positive in 17 (85.0%) patients, and CK 20 was positive in 6 (30.0%) patients. However, CK 19 was also detected in 8 (66.7%) control patients, whereas CK 20 was negative in all control patients. CK 20 was found to be more relevant to the pathologic stage. During the follow-up period, liver metastases were found in 3 patients (50%) who had shown CK 20 in their portal bloods.
CONCLUSIONS
CK 20 is found to be more specific than CK 19 in the detection of epithelial cells from portal blood. Moreover, CK 20 is related to the stage and was predictive of hepatic metastases in 50% of the patients with colon cancer. With further accumulation of cases, the prognostic significance of CK 20 for hepatic metastases may be better evaluated.

Accuracy of Preoperative Staging of Rectal Cancer: Comparative Study of Transrectal Ultrasonography and Computerized Tomography.: Cheon, Seung Hui , Lee, Suk Hwan , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2003;19(5):327-333.

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Preoperative assessment of the depth of invasion in the rectal wall and of lymph node metastases is very important in determining the treatment modality in rectal cancer. The purposes of study were to evaluate the accuracy of transrectal ultrasonography (TRUS) in preoperative staging of rectal cancer and to compare that accuracy with the accuracy for computed tomography (CT).
METHODS
We reviewed 59 patients who were diagnosed as having rectal cancer and who had been staged by using TRUS and CT preoperatively. Ultrasonographic tumor (uT) and nodal (uN) stage and computerized tomographic tumor (cT) and nodal (cN) stage were entered into the database prospectively. The accuracy of each staging was compared with the pathologic staging. The accuracy, the sensitivity, the specificity, the positive predictive value, and the negative predictive value of each diagnostic test were calculated. Chi- square tests were conducted to identify the factors influencing the accuracy.
RESULTS
The accuracies of TRUS and CT in assessing the depth of invasion were 66.1% and 62.5%, respectively. The accuracies of TRUS and CT in assessing the nodal involvement in patients treated with radical surgery were 70.4% and 63.6%, respectively. For detection of fat infiltration, the sensitivities were 97.4% for TRUS and 76.3% for CT. The specificities were 45.0% for TRUS and 55.6% for CT. The sensitivities for detection of lymph node involvement were 59.3% for TRUS and 42.9% for CT. The specificities were 81.5% for TRUS and 85.2% for CT. The gross appearance of the tumor had a significant influence on the assessment of the depth of invasion (P=0.015). In 9 out of 77 patients (11.7%) could not be performed the TRUS examination due to obstruction or the location of the tumor.
CONCLUSIONS
In spite of some limitations, TRUS is considered a very useful tool in the preoperative assessment of the depth of invasion and of the lymph node involvement in rectal cancer. However, CT examination is mandatory to overcome the limitations of TRUS in the preoperative diagnosis of rectal cancers.

Review

DRG(Diagnosis Related Group) Payment System.: Kang, Yoon Sik; J Korean Soc Coloproctol. 2003;19(5):334-338.

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Abstract PDF: No abstract available.

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