Annals of Coloproctology

Volume 22(6); December 2006

Original Articles

Clinical Characteristics of Amebic Colitis as Diagnosed by using Colonoscopic Findings.: Moon, Gyoo , Park, Jong Beom , Paik, Chang Hee , Hur, Chang , Chang, Hee Chul , Kim, Hyun Shig , Park, Young Hee , Lee, Jung Dal; J Korean Soc Coloproctol. 2006;22(6):357-362.

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Abstract PDF: PURPOSE
Nowadays, with improvements in hygiene and in the sewage system, the prevalence of amebic colitis in Korea is declining. However, amebic colitis still occurs every year. We investigated the clinical features of current patients with amebic colitis and compared the results with those for a past endemic period in Korea.
METHODS
From June 2000 to June 2005, 10 patients were diagnosed in the Digestive endoscopy center of Song Do colorectal hospital as having amebic colitis. We evaluated their medical histories, clinical characteristics, and colonoscopic findings.
RESULTS
The male-to-female ratio was 1.5 : 1. The mean age was 38.4+/-11.4 years. The mean diagnostic period from occurrence of symptoms to diagnosis was 20.4+/-17.5 days. The clinical symptoms of amebic colitis were diarrhea (80%), bloody stool (70%), mucoid stool (60%), abdominal pain (50%), fever, weight loss, nausea, and fatigue. Seven patients (70%) had a history of travel, and six of those seven patients had taken trips abroad. The foreign areas of travel included India (50%), Indonesia (28.6%), and Japan (16.7%). The diagnostic methods were colonoscopic biopsies to detect trophozoites of Entameba histolytica (90%) and serologic tests for the anti-ameba antibody (10%). The most common colonic locations of the lesions were the cecum (80%) and the rectum (80%). Another was the ascending colon (30%); pan-colonic involvement was also seen (10%).
CONCLUSIONS
In the past, the cause of amebic colitis in Korea was poor hygiene. Nowadays, however, travel to amebiasis-endemic areas may be the most important cause. Therefore, the travel history of diarrheal patients is an important diagnostic factor in cases of amebic colitis and a differential diagnosis factor in cases of inflammatory bowel disease.

The P-pouch: a New Ileal Reservoir Used in Restorative Proctocolectomy.: Lee, Joobong , Yun, Sungpil , Oh, Nahmgun; J Korean Soc Coloproctol. 2006;22(6):363-370.

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Abstract PDF: PURPOSE
To evaluate the effectiveness of a P-pouch configuration with a reservoir and recycled segment in restorative proctocolectomy.
METHODS
There were 11 patients who underwent the P-pouch procedure. They were compared with healthy eight-control subjects. The P-pouch configuration was constructed using one firing of a 10 cm GIA stapler to form a 12-cm reservoir. Following that, the distal ileum (15+/-0.5 cm) was anastomosed to the proximal portion of the pouch. Pouch function was studied 23.3+/-4.4 months after ileostomy closure. We measured the frequency and amount of stool. The postprandial plasma peptide YY (PYY) response and the scintigraphic studies using 99m-Tc sulfur colloid were used to study transit.
RESULTS
In the patient group, daily stool frequency and volume were 5.2+/-0.3 and 423.5+/-23.7 g, respectively. Stool seepage and pouchitis occurred in 45.5 % and 9.1%. In contrast to other pouch procedures, the postprandial increment of plasma PYY was similar the P-pouch patients and healthy controls (P>0.05). The integrated increment of plasma PYY for 180 minutes following meals was also not decreased in 9-pouch patient group compared with the healthy controls (1,050.0+/-127.8 pmol/l vs. 1146.0+/-150.0 pmol/l, P>0.05). Small intestinal transit time for healthy controls and the patient group averaged 89+/-21 and 117+/-12 minutes (P>0.05). The capacity of the ileal pouch was 372+/-22 ml, and the efficiency of ileal reservoir evacuation was 76 %.
CONCLUSIONS
The P-pouch is a new and improved simple modification of the well-established J-pouch procedure, constructed using a single firing of a GIA stapler.

Risk Factors and Oncologic Impact of Anastomotic Leakage after Rectal Cancer Surgery.: Jung, Sang Hun , Yu, Chang Sik , Choi, Pyong Wha , Kim, Dae Dong , Hong, Dong Hyun , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(6):371-379.

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Abstract PDF: PURPOSE
Anastomotic leakage (AL) is a serious and life-threatening complication following rectal cancer surgery. The impact on long-term oncologic outcome in patients with AL is not clear. The aim of this retrospective study was to evaluate the risk factors of AL and its impact on long-term prognosis after rectal cancer surgery.
METHODS
We investigated 1,391 patients who underwent primary resection and anastomosis for rectal cancer between January 1997 and August 2003. Operations were performed as follows: AR (n=164), LAR (n=898), uLAR (n=329). Standard procedures in our clinic were mesorectal excision according to tumor location and autonomic nerve preservation. Median follow-up period was 40.1 months (2~96 months).
RESULTS
AL rate was 2.5% (n=35). Gender (male), age (>60 years) and uLAR were independent risk factors in multivariate analysis (HR: 3.03, 95% CI: 1.18~7.22; HR: 2.42, 95% CI: 1.12~7.83; HR: 2.68, 95% CI: 1.08~7.09, respectively). Local recurrence in the AL group was significantly higher than that in the non-AL group (P<0.05), but there was no significant difference in multivariate analysis (P=0.14). Systemic recurrence between both groups was not statistically different. The 5-year overall survival rate was significantly lower in the AL group than in the non-AL group (55.1% vs 74.1%, P<0.05) and the cancer- specific survival rate was lower in the AL group than in the non-AL group (63.0% vs 78.3%, P=0.05).
CONCLUSIONS
Age, gender, and anastomotic level were risk factors for AL after rectal cancer surgery and anastomotic leakage was associated with a poor survival.

Lung Metastasis of Colorectal Cancer.: Kim, Pyong Su , Moon, Sun Mi , Hwang, Dae Yong; J Korean Soc Coloproctol. 2006;22(6):380-386.

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Abstract PDF: PURPOSE
The lung is the second most common site of metastasis of colorectal cancer. Pulmonary resection of lung metastasis of colorectal cancer has been reported a 5-year survival rate of 9~57% variably. Therefore we have tried to assess the clinical patterns of lung metastasis from colorectal cancer and to evaluate prognostic factors.
METHODS
A retrospective study was performed on 76 patients who presented with colorectal cancer with pulmonary metastasis between Jan. 1993 and Dec. 2001. Follow up period was 2~92 months.
RESULTS
53 patients had developed pulmonary metastasis after curative resection of colorectal cancer, 27 patients of these cases showed isolated lung metastasis and 12 patients underwent pulmonary resection. The number of patients with single pulmonary nodule was 7 and they showed higher survival rate than those of multiple nodules (2-year survival rate: 80% vs. 33.3%, P=0.0325). The patients with normal serum CEA level showed higher survival rate than those with elevated serum CEA level (median survival-71 months vs. 32 months, P=0.0123) in 53 patients who had developed pulmonary metastasis after curative resection of primary tumor. The number of patients of TNM stage IV with synchronous lung metastasis was 23. And serum CEA level and the number of metastatic site had affected the survival in these cases.
CONCLUSIONS
The serum CEA level could be prognostic factors in pulmonary metastasis of colorectal cancer. And pulmonary resection for selected patients may improve the survival rate especially in the case which the number of metastatic nodule was only one.

Trend of Clinicopathologic Characteristics of Colorectal Cancer in Asan Medical Center: a 15-Year Experience.: Choi, Pyong Wha , Jung, Sang Hun , Kim, Jung Rang , Yu, Chang Sik , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(6):387-395.

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Abstract PDF: PURPOSE
A retrospective study was performed to provide an overview of changes over time by age, stage, tumor location, and surgical therapy of colorectal cancer over the past 15 years.
METHODS
We analyzed the cases 6,314 colorectal cancer patients who underwent surgery at Asan Medical Center between January 1990 and December 2004. The period was divided into three periods: 1990 to 1994, 1995 to 1999, and 2000 to 2004. We analyzed trends over time for stage, resectability, and demographic factors of colorectal cancer over the past 15 years.
RESULTS
The mean age of the patients in the periods from 1990 to 1994, from 1995 to 1999, and from 2000 to 2004 were 57.1 (21~89), 57.4 (14~91), and 58.9 (15~91) years, respectively, showing an increasing tendency over time (P<0.001). The male-to-female ratios were 1.2 : 1, 1.3 : 1, and 1.6 : 1, repectively, and this male preponderance has been more marked in recent years (P=0.003). There was no change in tumor location over time. The ratios of early cancer to advanced cancer were 0.06 : 1, 0.09 : 1, and 0.11 : 1, respecfively, showing an increasing tendency over time (P=0.002). The curative resection rate increased over time (P<0.001). The non-curative resection rate was higher and the non-resected rate was lower in the period 2000 to 2004 than in the period 1990 to 1999 (P<0.001). The ratios of the lowest anterior resection to the abdominoperineal resection were 0.06 : 1, 0.49 : 1, and 1.02 : 1, respectively. With decreasing tendency of abdominoperineal resection, the lowest anterior resection rate has increased gradually over time (P<0.001).
CONCLUSIONS
Etiologic studies are necessary to understand the male preponderance in colorectal cancer, and multi-center studies should be conducted to understand the changing trend of colorectal cancer in Korea.

Oncological Outcome after Abdominoperineal Resection for Low Rectal Cancer.: Oh, Seung Yeop , Lee, Ho Won , Suh, Kwang Wook; J Korean Soc Coloproctol. 2006;22(6):396-401.

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Abstract PDF: PURPOSE
Literature shows that low rectal cancer, that especially undergoing abdominoperineal resection (APR), is worse than mid or high rectal cancer. Two reasons have been proposed: diverse lymphatic channels in the low rectum, and technical difficulty in performing the APR. By comparison with the results reported in representative literature, we tried to find out whether low rectal cancer is really worse oncologically than high rectal cancer.
METHODS
For 133 patients who underwent an APR from 1995 to 2005, we examined the pathological characteristics of the cancer, the recurrence, the metastasis, the survival rates, and the prognostic factors.
RESULTS
The patient distribution according to stage was 15.9% in stage I, 33.6% in stage II, and 50.4% in stage III. The overall 5-year actuarial survival rate (5SR) of patients undergoing a curative resection (n=113) was 74.6%. Local pelvic recurrence was found in 11.5% of the patiennts, and systemic metastasis was noted in 14.2%. Among several prognostic variables, lymph node metastasis, the number of metastatic lymph nodes, adjuvant chemotherapy, and the distance between the tumor border and the dentate line were significant factors. In the multivariate analysis, lymph node metastasis was the most significant prognostic factor.
CONCLUSIONS
It is true that a curative resection in low rectal cancer is difficult due to the anatomy of pelvis, so knowledge of the anatomic features of the pelvis and surgical skill are important. definitely, acceptable oncological results can be attamed if the rule of curative resection is obeyed. We also found that lymph node involvement was the most significant prognostic factor in low rectal cancer.

Accuracy of Magnetic Resonance Imaging in Predicting TNM Staging and Circumferential Resection Margin Compared with Pathologic Assessment on Whole-mount Section in Rectal Cancer.: Kim, Young Wan , Kim, Nam Kyu , Min, Byung So , Pyo, Juyon , Kim, Hogeun , Cha, Seung Hwan , Kim, Myong Jin , Baik, Seung Heuk , Lee, Kang Young , Sohn, Seung Kook , Cho, Chang Hwan; J Korean Soc Coloproctol. 2006;22(6):402-410.

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Abstract PDF: PURPOSE
Recently, magnetic resonance imaging (MRI) has become the preferred diagnostic tool for preoperative assessment of TNM staging and circumferential resection margin (CRM) in patients with rectal cancer. The aim of this study is to evaluate the accuracy of preoperative MR imaging in the prediction of T, N stage and CRM compared with pathologic results on whole- mount sections.
METHODS
Thirty-five consecutive patients with rectal cancer were enrolled between Dec. 2005 and Apr. 2006. 1.5-T MR imaging, was performed, and pathologic results were investigated on whole-mount sections. The agreement between MR imaging and pathologic examination for the assessment of T, N stage and status of CRM were analyzed using kappa statistics.
RESULTS
The accuracy of MR imaging compared with pathologic assessment of T stage was 82.9% (kappa=0.56), and that of N stage was 74.3% (kappa= 0.31). Of the MR imaging planes, the oblique axial plane showed the most accurate prediction of CRM, regardless of tumor position within the circumference of the rectum. The accuracy of MR imaging in the oblique axial plane for predicting the CRM was 81.0% (kappa=0.62) in anterior and posterior rectal tumors and 71.4% (kappa=0.43) in laterally located rectal tumors. With a different CRM criteria for the measured distance in MR imaging, the accuracy of the 2-mm CRM criterion was 77.1% (kappa=0.53).
CONCLUSIONS
MR imaging in predicting T stage showed fair agreement according to kappa statistics. Of the MR imaging planes, the oblique axial plane provided the most accurate CRM information compared with pathologic examination. The actual measured distance of the CRM in MR imaging can be applied to the pathologic CRM.

Comparison between Responder and Non- responder of Oxaliplatin Chemotherapy for Metastatic Colorectal Cancer.: Cho, Min Mi , Bae, Ok Suk , Baek, Seong Kyu , Lee, Tae Soon , Park, Sung Dae; J Korean Soc Coloproctol. 2006;22(6):411-417.

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Abstract PDF: PURPOSE
The purpose of this study was to evaluate the clinicopathological significance of responders with metastatic colorectal cancer treated with oxaliplatin chemotherapy.
METHODS
A total of 52 patients with unresectable metastatic colorectal cancer were enrolled for treatment between March 2000 and August 2005. Patients received first line chemotherapy consisted of oxaliplatin 85 mg/m2 or 130 mg/m2 as a 2-hour infusion on day 1, concurrently with leucovorin (LV) 20 mg/m2 as a bolus infusion on day 1~5, followed by continuous infusion of 5-fluorouracil (5-FU) 425 mg/m2 on day 1~5. This treatment was repeated in 2 or 3 week intervals. All responses were assessed after 4 cycles of therapy by independent radiologic experts and categorized into two groups: responder (major reduction of tumor) and non-responder group (no change or progression of the tumor.
RESULTS
The response rate was 51.9 percent (27/52 patients). There were no significant differences in clinicopathologic parameters between two groups. The decrease of CEA value after chemotherapy was significantly more frequent in the responder group than in the non-responder group.
CONCLUSIONS
We could not find any clinical differences between the two groups, but these results suggest that oxaliplatin chemotherapy has a beneficial effect on tumor shrinkage and serum CEA value can be an indicator for tumor response of oxaliplatin in advanced colorectal cancer.

Clinical Characteristics of Synchronous Multiple Colorectal Cancer.: Kang, Jung Gu , Kim, Dong Hyun , Kim, Chang Hee , Lee, Sang Hyuk , Choi, Yun Jung; J Korean Soc Coloproctol. 2006;22(6):418-423.

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Abstract PDF: PURPOSE
Colorectal cancer might have a synchronous cancer or polyps. Diagnosis of synchronous cancer is important for surgical treatment. The purpose of this study is to review the clinicopathological characteristics of synchronous multiple colorectal cancers.
METHODS
A retrospective analysis was performed with 16 patients with synchronous multiple colon cancer out of 625 colorectal cancer patients who underwent surgical treatment from March 2000 to December 2005.
RESULTS
The incidence of synchronous multiple colon cancer was 2.6%, and 1.9% in case of exception of Tis. The incidence of synchronous polyp was 62.5% in synchronous multiple colorectal caner and higher than 29.6% in single colorectal cancer. Numbers of the lesions were from 2 to 4, and total number of lesions were 35. Preoperative diagnostic rate of multiple colorectal cancers was 46.7% with colonoscopic examination. 18.8% of synchronous cancers were detected during intraoperative examination. Microscopically, ulcerative type was most common (62.9%), moderately differentiated type was common (84.8%). In TNM stage, advanced stage was common and stage III was 43.8%. T3 was the most common lesion in T stage among all lesions in synchronous cancer. Relatively small lesions of less than 2 cm were common (48.3%). Synchronous cancers were common in distal part of colorectum. Operations were carried out from segmental resection, to total or subtotal colectomy in case of multiple involvement of colon by cancer. During the follow up, one case was died postoperative 22 months due to cerebrovascular attack.
CONCLUSIONS
Synchronous multiple colon cancer was important for decision of extent of surgical resection. In this study, preoperative diagnostic rate of multiple colorectal cancers was 42.9%. So, index of suspicion about synchronous multiple colorectal cancers in preoperative and intraoperative stage is major key to improve the detection rate of synchronous lesion and appropriate resection.

Case Reports

Benign Solitary Cecal Ulcer Accompanied by Massive Lower Gastrointestinal Tract Hemorrhage.: Park, Jong Ik , Park, Sang Su , Kang, Sung Gu , Shin, Dong Gue , Yoon, Jin , Kim, Il Myung; J Korean Soc Coloproctol. 2006;22(6):424-427.

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Abstract PDF: A benign cecal ulcer is an uncommon lesion. The etiology remains unknown, and there are no pathognomonic lesions or symptoms. Lower gastrointestinal tract hemorrhage secondary to benign cecal ulcer is the most common complication. Herein, the case of a 24-year-old man with a benign cecal ulcer presenting with a massive lower gastrointestinal tract hemorrhage requiring transfusion until a exploratory laparotomy and right hemicolectomy, is reported with a review of the literature. Surgical intervention is warranted if malignancy is suspected or if the patient has signs of uncontrollable hemorrhage, perforation, or peritonitis.

Internal Hernia in Adult Patients: Transmesenteric Hernia and Internal Hernia through a Defect of the Broad Ligament.: Lee, Sang Myong , Lee, In Kyu , Lee, Yoon Suk , Kang, Won Kyung , Ahn, Chang Hyeok , Lee, Do Sang , Jung, Seung Eun , Chang, Suk Kyun; J Korean Soc Coloproctol. 2006;22(6):428-431.

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Abstract PDF: An internal hernia is a rare disease that causes bowel obstruction. It is difficult to diagnose because the symptoms and the signs are the same as those for other obstructive diseases of the bowel. Early diagnosis and management are essential, and early surgical management may reduce complications such as ischemia, and strangulation. We experienced two cases of internal hernias. One patient underwent a laparotomy, and had a transmesenteric defect with a herniated and strangulated small bowel segment. The other patient underwent a laparoscopic surgery, and we found that the left broad ligament had a focal defect with a herniated small bowel segment. An internal hernia is an uncommon disease, and its differentiation from other obstructive diseases of the bowel is difficult. However, the clinician should consider that the internal hernia might be the cause of the bowel obstruction, especially in patient with no previous history of intra- abdominal surgery. Early diagnosis can improve the clinical outcome through early surgery.

A Retrorectal Neurofibroma Resected by Transsacral Approach.: Cho, Bu Goan , Ahn, Byung Kwon , Lee, Seung Hyun , Baek, Sung Uhn , Chang, Hee Kyung; J Korean Soc Coloproctol. 2006;22(6):432-435.

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Abstract PDF: Tumors in the retrorectal area are rare. Surgical approaches to retrorectal tumors include posterior, anterior, or combined approaches. We have encountered a case of a 56- year-old woman with a retrorectal tumor. She had a solid tumor, 3 cm in size, in the posterior midline rectum 7 cm above the anal verge. The tumor was successfully resected by using a posterior (transsacral) approach with a partial sacrectomy and was diagnosed as being a neurofibroma. There were no postoperative complications.

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