Annals of Coloproctology

Volume 22(1); February 2006

Original Articles

Hemorrhoidectomy Under Local Anesthesia after Pentothal Induction versus Spinal Anesthesia: a Concurrent Nonrandomized Prospective Study.: Kang, Choong Hoon , Lee, Sang Woo , Shin, Hyeon Keun , Jeong, Seung Kyu , Choi, Jai Pyo , Yang, Hyung Kyu; J Korean Soc Coloproctol. 2006;22(1):1-7.

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Abstract PDF: PURPOSE
The aim of this study was to evaluate the effectiveness of local anesthesia compared to spinal anesthesia and the usefulness of pentothal induction before infiltration of a local anesthetic agent.
METHODS
A concurrent non-randomized prospective study was conducted on 52 patients who underwent a hemorrhoidectomy. For the spinal anesthesia (SA) group (n=29), 0.5% heavy bupivacaine (Marcaine(R)), 5 mg (1 ml), was used, and for the local anesthesia (LA) group (n=23), pentothal, 3.3 mg/kg, was administrated intravenously prior to infiltration of a mixture of local anesthetics (2% lidocaine, 14 ml, with 0.5% bupivacaine, 7 ml).
RESULTS
There were no differences between the two groups in terms of operating time, postoperative pain, headache, urinary difficulty, nausea or vomiting, pain-free interval after operation, analgesic requirements, and patient's or surgeon's satisfaction. Postoperative ambulation was earlier in the LA group than in the SA group.
CONCLUSIONS
Local anesthesia after pentothal induction can be used effectively for a hemorrhoidectomy and may be a safe alternative to spinal anesthesia.

Clinical Significance of the Pecten Band in Hemorrhoids.: Lee, Je Seung , Ahn, Byeong Yul , Lee, Han Il; J Korean Soc Coloproctol. 2006;22(1):8-14.

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Abstract PDF: PURPOSE
The pecten band can be defined as a fibrous tissue on the lowermost part of internal anal sphincter and may cause anal outlet obstruction, but its role is debatable. We evaluated the functional roles of the pecten band in hemorrhoids patients.
METHODS
Three hundred sixteen hemorrhoids patients who underwent operations from January 1998 to April 2003 were analyzed for anal function according to presence or absence of a pecten band by using anorectal manometry and the constipation score.
RESULTS
The numbers of males and females were 167 and 149. The overall pecten band positive was 63.6% (201/316), and pecten band positive was 84.6% (33/39) in patients who had previous anal surgery while it was 60.6% (168/277) in patients who had no history of surgery (P= 0.002). Pure hemorrhoids patients showed an 18.3% positive rate while patients with hemorrhoids and other conditions, such as anal fissure, fistula, or stricture, showed a 95.7% positive rate (P=0.00). Maximal resting anal pressures (mmHg, Mean+/-SD) and constipation score were 78.9+/-24.7 and 7.88+/-3.8 in the positive group and 67.1+/-22.2 and 4.55+/-2.8 in the negative group (P=0.00, 0.00). Postoperatively, the constipation score decreased significantly from 7.25 to 2.82 (P=0.003).
CONCLUSIONS
The pecten band seems to be associated with anal outlet obstruction, and a pecten band releasing operation may be considered according to its presence or absence.

The Correlation between Quality of Life and Functional Outcome after Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis.: Yoon, Eyi Sang , Lee, Kil Yeon , Lee, Suk Hwan , Yoon, Choong; J Korean Soc Coloproctol. 2006;22(1):15-23.

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Abstract PDF: PURPOSE
The restorative proctocolectomy (RP) and ileal pouch-anal anastomosis (IPAA) has been accepted as the operation of choice for chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP). However, much is still unknown about the functional outcome and the quality of life (QoL) in patients undergoing RP. The aims of this study were to evaluate the functional outcome and the QoL in patients undergoing RP and to assess the correlation between functional outcome and QoL.
METHODS
The medical records of 20 patients who had undergone a RP for CUC (n=11) and FAP (n=9) from January 1993 to December 2003 were reviewed. The QoL was evaluated with the Korean version of Short Form 36 (SF-36) by telephone interview. The functional outcome was assessed by means of the Global Assessment of Function Scale (GAFS). The QoL of patients was compared with that of the general population matched for age and gender (n=107) with including the 7 men, the median age will be thought to be that of the 13 women.
RESULTS
There were 7 men (35%) and 13 women (65%), and the median age was 46 years. The QoL in patients undergoing RP was comparable to that of the healthy general population on all scales. The Physical Component Summary (PCS) was correlated significantly with the daytime and the nighttime incontinence (P<0.01). The Mental Component Summary (MCS) was correlated significantly with the daytime and the nighttime incontinence and the daytime bowel movement (P<0.05).
CONCLUSIONS
This study demonstrates that the QoL in patients undergoing RP is excellent and that the daytime incon tinence and the nighttime incontinence are significant factor influencing the QoL.

Clinical Analysis of 40 Patients with Familial Adenomatous Polyposis (FAP).: Lee, Young Chan , Kim, Nam Kyu , Baik, Seung Hyuk , Lee, Kang Young , Sohn, Seung Kook , Cho, Chang Hwan; J Korean Soc Coloproctol. 2006;22(1):24-28.

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Abstract PDF: PURPOSE
This study was carried to find the clinical characteristics of incidence and the phenotype of familial adenomatous polyposis (FAP).
METHODS
This retrospective analysis was performed on 40 patients who were diagnosed as having FAP and who underwent surgery due to FAP from June 1985 to April 2005. The operative method, extra-colonic symptoms, and number of polyps were analyzed.
RESULTS
From June 1985 to April 2005, 0.65% (40 patients) of all surgically treated colon-cancer patients were diagnosed as having FAP. Seventeen patients had familial history, and 23 patients were neither aware of any familial history nor had taken any tests. The primary symptoms were hematochezia, diarrhea, mucous discharge, constipation, and abdominal pain, but 5 patients had no specific symptoms. The mean age was 38.0 years. A total colectomy with ileostomy was performed in 19 cases, a total colectomy with ileorectal anastomosis in 2 case, and a total proctocolectomy with ileal J pouch anal anastomosis in 17 cases. One case was only diagnosed as having a FAP without surgical treatment, and one cases had palliative surgery due to carcinomatosis. Thirty-five cases had more than one hundred polyps, and 5 cases had less than one hundred polyps with a higher mean age of 62.2 (50~74) years and having no familial history. Extracolonic manifestations, were congenital hypertrophy of the retinal pigment epithelium, submandibular tumor, thyroid cancer, and intraabdominal desmoid tumor. The polyps could develop in other organs, such as the stomach or the duodenum. Because they can progress to cancer, a gastroduodenoscopy needs to be done. As for result, 17 cases underwent endoscopic gastroduodenoscopy, and among them, 9 cases had multiple adenomas.
CONCLUSIONS
FAP has been considered as a rare disease. Because of its association with early development of colorectal cancer, measures for early detection of the disease and for identification of other family members at risk should be performed. Furthermore, early prophylactic treatment should be undertaken to reduce the incidence of cancer in these conditions. For early detection and better outcome, clinical and radiological examination and treatment for extracolonic manifestations and extracolonic tumor (thyroid cancer, desmoid tumor, medulloblastoma, hepatoblastoma) are necessary.

A Subtotally Divided End-loop Colostomy for Unresectable Rectal Cancer.: Park, Yonghoe , Yang, Kwangho , Cho, Yonghoon , Kwak, Hisuk , Sin, Jinyong , Oh, Nahmgun; J Korean Soc Coloproctol. 2006;22(1):29-33.

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Abstract PDF: PURPOSE
Divided end-loop colostomy is recommended in some cases of unresectable rectal cancer or anal incontinence, because a conventional loop colostomy is difficult to managing due to bulky stoma volume for a long period. In such case of the divided end-loop colostomy, severe inflammation may occur at the stoma site by poor conditions of the patient so that cause to be retracted or detached, and distal loop may be disrupted. To avoid these problems, we designed subtotally divided end-loop colostomy and studied its clinical effectiveness retrospectively.
METHODS
About a 3 cm diameter, round skin incision as presumed colostomy size was made at the left lower abdomen, and entered the abdominal cavity by splitting the rectus muscle fibers. The caudal side of colon can be identified by confirming the fusioned taenia at the rectosigmoid colon level. After pulling out the colonic loop, the distal colon far from the lesion was subtotally divided by a GIA staple or manual suture, which cut obliquely 80% or 90% from the antimesenteric side of the distal loop while maintaining the 10% or 20% mesenteric side of the colonic loop. Then an end-loop colostomy is matured with a small fistularization of the distal loop as the undivided mesenteric side of colon.
RESULTS
In 8 cases, subtotally divided colonic loop using a GIA staple. But in 9 cases, divided manually because of makedly thickened, edematous colonic wall resulting from prolonged obstruction. There were several mild complications, i.e. transient dermatitis in 5 cases, transient bulky stoma due to edema in 4 cases, mild retraction of stoma in 2 cases, and mild prolapse of stoma in 1 case. There were no major functional abnormalities during the follow-up period.
CONCLUSIONS
Although we need to get further clinical experiences, the subtotally divided end-loop colostomy seems to be a useful alternative surgical procedure for unresectable rectal cancer.

Self-expandable Metallic Stent for the Management of Acute Malignant Large-bowel Obstruction.: Park, Yoon Ah , Lee, Kwang Hun , Lee, Sun Il , Sohn, Seung Kook; J Korean Soc Coloproctol. 2006;22(1):34-40.

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Abstract PDF: PURPOSE
The purpose of this study was to review our experience with the use of self-expandable metallic stents as the initial interventional management for acute malignant large-bowel obstruction.
METHODS
The records of 35 patients who underwent placement of a colonic stent for acute malignant obstruction at our institution between January 2003 and December 2004 were reviewed.
RESULTS
Stents were placed for palliation in 19 patients and as bridge to surgery in 16 patients. Technical success of stent placement was achieved in all patients (100%), but clinical failure occurred in two patients due to limited expansion of the metallic stent. One of them who had clinical failure underwent an emergency operation, and the other needed no further procedure because of his death. Complications occurred in 4 patients (12%), including one pelvic abscess associated with colon perforation, two minor bleedings, and one anal pain. All the patients in the bridge-to-surgery group underwent an elective colon resection without stoma. In the palliative group, stent reocclusion was observed in three patients during the follow-up (median: 65 days; range: 27~440 days), two of which were managed by reinsertion of a stent. In the remaining patients, the stent was patent until death or the last follow up date (median: 65 days).
CONCLUSIONS
Placement of a self-expandable metallic stent is a safe and effective procedure for immediate decompression of acute malignant large-bowel obstruction. It provides a chance of elective surgery for patients with resectable disease, as well as relief of symptoms for those with unresectable disease.

Comparison of Self-Expanding Metallic Stenting with Emergency Surgery as First-Management for Obstructing Primary Left-sided Colorectal Cancer.: Park, Ji Won , Lee, Min Ro , Hong, Chang Won , Yoon, Sang Nam , Park, Hyoung Chul , Kim, Se Hyung , Han, Joon Koo , Park, Kyu Joo , Park, Jae Gahb; J Korean Soc Coloproctol. 2006;22(1):41-46.

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Abstract PDF: PURPOSE
Emergency surgery has been a conventional treatment for malignant large-bowel obstruction, but is associated with high morbidity and mortality. Recently, self-expanding metallic stents (SEMS) have provided a new modality as palliation or bridge therapy for patients with obstructing colorectal cancers. The purpose of the present study is to evaluate whether SEMS is useful in patients with malignant large bowel obstruction.
METHODS
Between January 1999 and June 2004, 63 patients were treated for primary obstructing left-side colorectal cancer at the Department of Surgery, Seoul National University Hospital. 32 patients were managed firstly with SEMS (stent group), and 31 patients underwent an emergency operation (emergency surgery group). Clinical data were retrospectively reviewed. The results, including perioperative outcome and survival, were compared between the two groups.
RESULTS
Clinicopathological parameters, including age, gender, ASA grade, tumor location and stage, were similar between the two groups. The rate of one-stage operations was significantly higher in the stent group (52% vs 13%; P=0.004). The stent group was associated with a lower rate of stoma formation (48% vs 87%; P=0.004), a shorter length of hospital stay (19 days vs 26 days; P=0.048), and fewer complications (7% vs 30%; P= 0.035). The overall and the disease-free survival rates were similar between the two groups (P=0.973, 0.126). The stent group was associated with fewer surgeries needed, shorter length of hospital stay, and fewer complications.
CONCLUSIONS
Stenting with SEMS is useful in managing malignant large-bowel cancer with obstruction and may be better than traditional open surgery.

Pattern of Recurrences and Metastases according to Regional Lymph Node Metastasis of Colorectal Cancer.: Park, In Ja , Kim, Hee Cheol , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(1):47-53.

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Abstract PDF: PURPOSE
We aimed to verify the pattern of recurrences or metastases of primary colorectal cancer according to regional lymph node metastasis and to use it for follow up.
METHODS
A study was undertaken of 537 stage II and III patients who had undergone a resection of colorectal cancer between July 1989 and December 2002 and who had been identified as having a recurrence during follow up and of 439 stage IV patients who had undergone a resection of the primary tumor during the same period and who could be evaluated for regional lymph node status. Patients were classified into two groups according to regional lymph node status: no lymph node metastasis (214) and lymph node metastasis (762). Univariate and multivariate (Cox's model) analyses of recurrence were employed to identify differences. Statistical significance was assigned to a P value of <0.05.
RESULTS
In the lymph-node-metastasis group, female, poorly differentiated, and infiltrating type cancer were dominant. The patterns of recurrence were hematogenous in 729 cases (74.7%), local recurrence in 101 cases (10.3%), peritoneal seeding in 107 cases (11.0%), and lymph node recurrence in 116 cases (11.9%). Hematogenous metastasis was the most common type of metastasis or recurrence in both groups. Compared with the no-lymph-node-metastasis group, the rates of lymph node recurrence (P<0.01) and local recurrence (P=0.02) were much higher in the were more frequent lymph-node-metastasis group. Local recurrence was frequent in rectal cancer, and the location of the primary tumor greatly influenced on local recurrence. Therefore, lymph node recurrence was strongly influenced by regional lymph node metastasis.
CONCLUSIONS
The pattern of recurrence differed according to the characteristics of the primary tumor. Especially, in the lymph-node-metastasis group, lymph node and local recurrences were more common than they were in the no-lymph-node-metastasis group. Therefore, lymph node metastasis should be considered for follow up.

Case Reports

A Case of Acute Appendicitis Associated with Enterobius Vermicularis.: Kim, Do Hyoung , Cheon, Joon Sung , Kim, Jeong Goo , Lee, Dong Ho , You, Young Kyoung , Lee, Hye Kyung , Ahn, Chang Joon; J Korean Soc Coloproctol. 2006;22(1):54-57.

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Abstract PDF: Enterobius vermicularis is one of the common parasites in the world. The infestation rate of Enterobius vermicularis is higher in children than in adults. Moreover, the egg-positive rate of Enterobius vermicularis is higher in the mentally retarded population. We report the case of a ten-year-old, mentally retarded boy, who was diagnosed as having acute appendicitis associated with Enterobius vermicularis.

Diverticula of Appendix Associated with Chronic Abdominal Pain: A case report.: Shin, Il Yong , Ahn, Chang Joon , Cheon, Joon Sung , Kim, Jeong Goo , Lee, Dong Ho , You, Young Kyoung , Lee, Hye Kyung; J Korean Soc Coloproctol. 2006;22(1):58-61.

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Abstract PDF: The incidence of an appendiceal diverticulum in instance of appendectomies has been reported to range from 0.004 to 2.1 percent. It is known that diverticulum of the appendix leads to diverticulitis, appendicitis, or perforation. Recently in the literature, appendiceal diverticulum without inflammation has been reported as a possible cause of chronic abdominal pain. We report the case of a 40-year-old man with appendiceal diverticula associated with chronic abdominal pain.

Neutropenic Enterocolitis after Chemotherapy for Colon Cancer.: Chun, Jung Woo , Hong, Seong Woo , Chang, Yeo Goo , Lee, Hye Kyoung , Lee, Hyucksang; J Korean Soc Coloproctol. 2006;22(1):62-65.

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Abstract PDF: Neutropenic enterocolitis is observed in approximately 10~46% of patients with acute leukemia, as well as in patients with other diseases, like acquired immunodeficiency syndrom (AIDS), that lead to profound neutropenia. Patients who become neutropenic after combined chemotherapy are at special risk of developing neutropenic enterocolitis. With the recently increasing numbers of patients with solid tumors treated with high-dose chemotherapy, the frequency of this disease is expected to increase. However, this disease has been rarely reported in patients with colon cancer treated with leucovorin and 5-fluorouracil for adjuvant chemotherapy. We report a case of neutropenic enterocolitis after a treatment of 5-fluorouracil and leucovorin for sigmoid colon cancer.

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