Annals of Coloproctology

Volume 13(1); March 1997

Original Articles

The Member's Opinion about Boardman System of Colorectal Disease (Tentative).: Shim, Min Cul; J Korean Soc Coloproctol. 1997;13(1):1-6.

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Abstract PDF: No Abstract available.

Human Papillomavirus Infection in Anal Carcinoma, Anal Condylomata and Rectal.: Kim, Toung Jin , Joo, Jae Hwan , Kim, Hyung Rok , Kim, Dong Yi; J Korean Soc Coloproctol. 1997;13(1):7-14.

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Abstract PDF: In order to examine the association of human papilloma virus(HPV) infection with anal carcinoma, the authors used polymerase chain reaction(PCR) and in situ hybridization technique to detect HPV DNA in formalin fixed, paraffin-embedded tissues from 46 anal carcinoma patients. At the same time, 28 condyloma accuminata specimens and 25 rectal adecarcinomas were examined for HPV DNA with in situ hybridization(ISH). By PCR analysis, using type specific primers and probes for HPV 6, 11, 16, 18 and 33, HPV type 16 DNA was demonstrated in 30(65.2%) of 46 anal carcinoma specimens, but HPV type 6, 11, 18 or HPV type 33 was not identified. HPV DNA Positivity was different according to the site of the anal carcinoma. In anal marginal squamous celt carcinoma, 3(27.3%) of 11 contained HPV DNA but 27(77.1%) of 35 anal canal carcinoma contained HPV DNA. Among the anal canal carcinomas, the cloacogenic carcinoma contained HPV DNA in 11(84.6%) of 13 and squamous cell carcinoma contained in 16(72.7%) of 22 specimens. Two of six local recurrences and three of nine lymph node metastases had HPV-16 DNA. When the anal carcinomas were analysed using ISH technique for HPV type 6, 11, 16, 18, the frequency of Positivity decreased to 4(11.4%) of 35 and stained only for HPV type 16/18. Among the 28 condyloma accuminata specimens, 24(85.7%) contained HPV DNA type 6/11 and only 2(7.1%) contained type 16/18 by ISH technique. In contrast to anal carcinoma, male was predominent in condyloma accuminata patient(82.1% of 28) and 6 patients were homosexual man. HPV DNA was not demonstrated in all the cases of rectal adenocarcinoma by ISH. We conclude that HPV infections are associated with the development of anal canal carcinoma but are not associated with adenocarcinoma of the rectum. In anal carcinomas, anal canal carcinoma is more closely associated with HPV infection than anal marginal carcinoma. Among the HPV types studied, type 16, 18 are more closely linked with malignant transformation.

Immunohistochemieal Study of Expression of nm23 and CD44 Protein in.: Shin, Dong Il , Lee, Kee Hyung , Yoon, Choong , Lee, Ju Hie; J Korean Soc Coloproctol. 1997;13(1):15-22.

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Abstract PDF: Gene expression of the nm23 and CD44 has been investigated in number of tumors, in cluding colorectal cancer, breast cancer, and hepatocellular carcinoma. This study was conducted to clarify the association between nm23 and CD44 protein expression and metastatic potential in human colorectal cancer. To elucidate the role of the nm23 and CD44 in human colorectal cancer, sections of formalin-fixed, paraffin-embeded tissue from 59 primary colorectal cancer were stained immunohistochemically against nm23 and CD44 proteins. Expression of the nm23 protein is not significantly correlate with Dukes'stage and recurrence. However, the expression of the CD44 protein is significantly higher in Dukes stage C as comparing with stage B.

Flow Cytometric DNA Analysis in Colorectal Cancer and Its Relationship to.: Choi, Dong Ho , Sohn, Tae Sung , Park, Young Buk , Baik, Hong Kyu , Nam, Young Soo; J Korean Soc Coloproctol. 1997;13(1):23-30.

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Abstract PDF: DNA flow cytometric analysis was performed on 42 colorectal cancers. DNA ploidy was diploid in 19 and aneuploid in 23 cases. There was no significant correlation between DNA ploidy and clinicopathological features such as primary site, histologic type, depth of invasion, lymph node metastasis, peritoneal seedings, lymphatic invasion and vascular invasion. In aneuploid group, which was divided into two groups, by the value of DNA index, there was no differences between two groups in prognosis and clinocoPathological features. Cumulative survival rates appeared to be more favorable in patients with aneuploid tumors than patients with diploid tumors, but the difference was not statistically significant.

The Value of the Expression of bel-2 and p53 in Colorectal Carcinomas.: Chang, Jeong Hwan , Clung, Ki Hwan , Kim, Kweon Chun , Kim, Cheong Yong; J Korean Soc Coloproctol. 1997;13(1):31-42.

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Abstract PDF: There are a lots of evidences that colorectal cancer arise as a result of multiple alterations of genes. Many attempts were made to understand the role of oncogenes and suppressor genes as a prognostic indicator, recently. Although histopathologic staging of tumor is the most important prognostic factor up to now, it is not enough to be used with full confidence. Apoptosis or programmed cell death represents a deletion of damaged or natural cell mechanism. The bel-2 proto-oncogene is known as a inhibitor of apoptosis that may allow accumulation and propagation of cells containing genetic alterations. Overexpression of bcl-2 probably plays a role in colorectal carcinogenesis. The aim of this study was to determine bcl-2 and p53 expression in colorectal carcinoma in correlation with apoptosis, clinical parameters, and histopathology, and to test their prognostic significance in patient with colorectal carcinoma. The bel-2 and p53 protein were identified by immunohistochemical staining using monoclonal and polyclonal antibody. The apoptotic index was detetermined by microscopic examination of hematoxyln and rosin-stained sections at x400. The materials subiected to this study were 54 paraffin-embedded colorectal carcinomas, which were collected randomly from January of 1992 to December of 1994 at Department of Surgery, Chosun University Hospital. Of 54 cases, 21 (38.9%) and 22(40.7%) showed positive expression of bel-2 and p53 protein respectively. Mean apoptotic index(AI) was 2.99% in colorectal carcinoma. Bcl-2 expression did not correlated with p53 expression or apoptotic index. Positive expression of p53 or AI was not correlate with any other clinical and pathologic parameters. An inverse correlation was found between bel-2 expression and increased tumor stage or Iymph node metastasis (P<0.05). In conclusion, these results suggest that bcl-2 expression is significant associated with early stage in colorectal carcinoma. But bcl-2 p53 and AI can`t be a independent prognostic factor in colorectal carcinoma. Further investigations to clarity its possible role in controlling the tumor decelopment and growth of colorectal carcinoma are needed.

The Relationship of AgNORs to the Survival Rate of Patients with Invasive.: Kang, Gu , Nam, Eun Sook , Shin, Hyung Sik , Kim, Soon Ran; J Korean Soc Coloproctol. 1997;13(1):43-50.

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Abstract PDF: Nucleolar organizer regions(NORs) are argyrophilic and have a loops of DNA that tran scribes to ribosomal RNA by RNA Polymerase I and are involved in formation of nucleolus. They are used in measuring proliferative activity of cells. Mean AgNORs count is increased or large and NORs are irregular in shape in malignant tumors. To examine the relationship of AgNORs to the survival rate of the patients with invasive colorectal adenocarcinoma, we counted mean AgNORs in 200 tumor cells and mean AgNORs#(mean AgNORs in counting AgNORs of the upper 40 nuclei after sorting AgNORs counts of 200 cell nuclei in descending order) after AgNOR staining using 45 cases of formalin-fixed, paraffin-embedded tissue surgically excised at Kang-Dong Sacred heart hospital. The survival rates were not related to age, sex, locations, differentiation, mAgNORs and mAgNORs# except Dukes'stages. There were only statistical significances in AgNORs# between high and low age group(p=0.0001), and between colon and rectum(p=0.005). But it is known that there could be different results according to staining time, fixation and preservation of tissues, counting methods in measuring AgNORs. There might be clinical usefulness of AgNOR if more cases are examined together with better tissue processing and staining methods.

Results of Transanal Local Excision for Rectal Cancer.: Park, Kyu Joo , Park, Jae Gahb; J Korean Soc Coloproctol. 1997;13(1):51-62.

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Abstract PDF: Local excision for rectal cancer can yield comparable results to traditional radical operations in selected group of patients. We have retrospectively analyzed 32 cases of rectal cancer patients treated by transanal local excision for curative intent at the Department of Surgery, Seoul National University Hospital between 1990 to 1996. These 32 cases represent 4.1% of total rectal cancer patients treated during the same period. Mean age of the patients were 57.0+/-11.8 years. Median tumor size was 2 cm(mean : 2.4+/-1.1 cm), and the median distance from the anal verge to the lower margin of the tumors was 5 cm(mean : 5.1+/-1.7 cm). Deepest layer invaded by cancer was as follows: mucosa, 31.3%; submucosa, 56.3%; muscularis propria, 9.4%; subserosa, 3.1%. Sixty-nine percent of the patients had well differentiated tumors and 31% had moderately differentiated tumors, while none of the cancers were poorly differentiated. No patient received any adjuvant therapy. After a median follow-up of 21 (range: 1~83) months, no local recurrence occurred in any of the patients. Our results indicate that transanal local excision can be performed with favorable outcome in selected group of rectal cancer patients.

Pudendal Nerve Damage and Its Recovery in Vaginal Delivers.: Lee, Bang Jeon , Park, Jin Woo; J Korean Soc Coloproctol. 1997;13(1):63-70.

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Abstract PDF: We performed anorectal physiologic studies to evaluate the pelvic floor musculature and its innervation in 73 pregnant women(35 primiparous, 38 multiparous) who had been recruited into a study of pudendal nerve damage and its recovery in vaginal delivery as part of a prospective investigation. These women had all delivered by vaginal route with pros terolateral episiotomy. Pudendal nerve terminal motor latency was significantly increased 2~3 days after delivery but substantial recovery occurred in the first 2 months after delivery nearly to the pre-delivery value. Maximum average resting pressure was not affected by delivery. In contrast, maximum average squeeze pressure was decreased significantly 2~3 days after delivery and some recovery occurred in the first 6 months after delivery, which still remained significantly low relative to pre-delivery value. Perineal descent was significantly increased 2~3 days after delivery but substantial recovery occurred in the first 2 months after delivery, which still remained significantly low relative to pre-delivery value and thereafter no significant recovery was found. These results suggest pudendal nerve damage occurrs during vaginal delivery which recovers in the first 2 months after delivery but functional disturbance in pelvic floor sphincter muscuature persists thereafter, and we support avoidance of further vaginal delivery after previous damage to the innervation of pelvic floor sphincter musculature.

Pathogenesis and Treatment of Anal Outlet Obstruction: A clinical analysis of.: Kim, Jin Cheon , Lee, Han Il , Park, Sang Kwu , Yu, Chang Sik , Chung, Hee Won; J Korean Soc Coloproctol. 1997;13(1):71-76.

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Abstract PDF: Anal outlet obstruction(AOO), which was caused by various anal diseases, presented symptoms like acute or chronic constipation, obstipation, painful defecation and bleeding. We retrospectively reviewed these patients to identify underlying diseases, corresponding surgical treatment and outcome. From July 1989 to December 1995, 132 patients were operated for AOO at Asan Medical Center. Colonic inertia and other pelvic outlet obstructions such as rectocele, rectal intussusception, or Paradoxical puborectalis conraction were excluded from this study by history taking, physical examination, colon transit time study, manometry, and defecography. Male to female ratio was 1 : 1.2 and mean age was 45 and 44, respectively. Among 132 Patients, 57 cases(43%) had sing1e disease and remained 75 cases had combined two or more diseases. Hemorrhoids(90 cases) was the most common associated disease and then were anal stricture(59 cases), chronic anal fissure(29 cases), internal sphincter hypertonia(25 cases) and anal fistula(6 cases) in decreasing order. Either single or combined hemorrhoidectomy was performed in 85 cases, lateral internal sphincterotomy in 65 cases, anoplasty in 35 cases, rubber band ligation in 13 cases, manual anal dilatation in 10 cases. Postoperative complications were 7 cases of wound infection and one case of gas incontinence, that were subsided by conservative management. 119 patients(90%) showed complete improvement and twelve patients were partially improved from AOO. Only one patient did not respond surgical treatment due to anismus. As AOO is a comprehensive disease entity of frequent anal diseases, adequate surgery for respective patients mandatory to relieve discomfort.

Analysis of the Results of Surgical Treatment Options for Ulcerative Colitis.: Park, Kyu Joo , Park, Gahb; J Korean Soc Coloproctol. 1997;13(1):77-96.

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Abstract PDF: The surgical options for ulcerative colitis have developed rapidly in recent years, with emphasis on improving the quality of life by preservation of voluntary defecation and continence while eradicating the disease. In this paper, we have retrospectively analyzed 29 patients with pathologically proven ulcerative colitis who underwent surgical treatment at the Department of Surgery, Seoul National University Hospital between 1980 and 1996. We sought to correlate the changing patterns of the surgical management with their outcomes. The mean age at the time of definitive surgical procedures was 36.7(+/-11.9), and median duration of follow-up was 26 months. The final surgical procedures performed in these patients were ileal J pouch-anal anastomosis (14), total proctocolectomy with either end (7) or continent ileostomy (4), total colectomy with ileorectal anastomosis (1) or Hartmann procedure (2), and partial colectomy (1). Since 1993, we have been performing ileal pouch-anal anastomosis(IPAA), which was performed in all patients except two (one with toxic colitis and the other with disseminated colon cancer). In two patients who underwent partial colectomy and were available for follow-up, there was recurrence of symptoms related to ulcerative colitis. All 11 patients who received total proctocolectomy with either end or continent ileostomy experienced at least one postoperative complication, and 5 required reoperations for management of these complications. Tn particular, 3 out of 7 patients who received total proctocolectomy with continent ileosotmy required removal of the pouch due to pouch related complications. There were two postoperative deaths due to septic complications. On the other hand, while 8 out of 14 patients who received IPAA experienced postoperative complications, all were resolved with conservative management and none required reoperation. The function of ileal J pouch was assessed in 13 Patients at a median duration of 10 months (range : 3~27 months) after restoration of pouch continuity. The mean stool frequency per 24h was 7.6(+/-2.1) and mean nocturnal stool frequency was 1.6(+/-1.5). None of the patients had major incontinence while 7 had occasional spotting of mucous. The remaining 6 patients had normal continence. Only one patient needed antidiarrheal medication and 5 followed a strict diet. Confirmed pouchitis occurred in only one patient. All of the patients who received IPAA were satisfied with their bowel status and the operation. Our results confirm that IPAA is an acceptable surgical option for the management of ulcerative colitis.

The Treatment Of Fistula-in-ano in Infants.: Cho, Hang Jnn , Kim, Toung Kyun , Kim, Do Sun , Lee, Doo Han , Kang, Yoon Sik; J Korean Soc Coloproctol. 1997;13(1):97-100.

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Abstract PDF: The authors performed a retrospective review to find out optimal treatment plan in infantile fistula-in-ano. There were seventy-one patients in a 2-year period. All were male and other clinical characteristics were similar to previous reports. The onset in 60 patients(97%) of the cases was in the first 1 year of alee, especially in the first 3 months(52%). We investigated patterns of disease progression in multiple-lesion cases(19cases 29%). In 5 out of 9 cases of which we could identify the patterns, new lesion developed from 1 month to 4 months after index lesion. Fifty Patients underwent fistulotomy under principle of early surgical intervention, No recurrence was found except 2cases who needed second operation during 30 months of median follow-up(23~48 months). In 21 patients whose parents did not want operation, we performed simple drainage and followed-up. Six out of 12 patients who could be communicable had no fistula-related symptoms from 20 months to 31 months. This suggests that simple drainage has therapeutic effect in some portion of infantile abscess. We conclude that simple drainage should be initial treatment of choice in infantile perianal abscess. We suggest that definite operation for recurrent abscess and fistula with relatively mild symptoms should be delayed until 1-year of age because of interval ccurrence of multiple lesions and therapeutic effect of simple drainage.

Anal Fistula in Crohn's Disease.: Lim, Seok Won , Lee, Chul Ho , Lee, Kwang Real , Yu, Jung Jun; J Korean Soc Coloproctol. 1997;13(1):101-109.

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Abstract PDF: Crypt glandular infection theory is accepted as an explanation of anal fistula's major cause. However, the pathogenesis of an anal fistula in Crohn's disease is different from that of a conventional anal fistula because a Crohn's anal fistula is caused by ulceration which, in turn, is caused by transmural inflammation of the rectal wall due to Crohn's disease. The difficulty with operating on anal fistulas in Crohn's disease lies in the fact that healing of the wound is inhibited because of continuous inflammation of the anorectal tissue due to Crohn's disease. Hence, there is a high possibility of incontinence due to sphincter muscle injury. Especially, because almost all Crohn's disease patients have frequent defecation and diarrhea, the patients will suffer more if incontinence occurs. Nowadays, even with increased understanding of the etiology of Crohn's disease, new medications, and aggressive surgical approaches, the result of treatment is still not satisfactory. Recently, since Korean eating habits have changed to include more western-style food in the diet, inflammatory bowel disease, such as Crohn's disease, is expected to increase. Consequently, the number of cases of anal fistulas in Crohn's disease is also expected to increase. The authors reviewed 20 confirmed cases of anal fistulas in Crohn's disease, which were treated from January 1993 to December 1995 at Song-Do Colorectal Hospital. The results are as follows: 1) Anal fistulas in Crohn's disease were present in 20(0.6%) of the 3378 cases of anal fistulas treated during the time period considered. 2) The male to female ratio for these 20 cases was 2: 1, and the most Prevalent age group was the 3rd decade, followed by the 2nd decade, the 4th decade, and the 5th decade in that order. 3) Three cases of anal fistulas whose origins could be explained by crypt glandular infection theory and which did not involve the rectum healed, although the healing was delayed. 4) Seventeen cases of anal fistulas whose origins could not be explained by crypt glandular infection theory and which involved the rectum did not heal after the operation. he results of the study show that anal fistulas whose origins can be explanined by crypt glandular infection theory and which do not involve the rectum can be cured by conventional fistula surgery. However, perirectal fistulas whose origins can not be explained by crypt glandular infection theory and which involve the rectum do not heal. Because there is the possibility of incontinence after a conventional operation, it is suggested that, in the cases of perirectal fistulas in Crohn's disease, better results, although not completely satisfactory, can be obtained by long-term seton drainage and diversion colostomy.

Case Report

A Clinical Analysis of 429 Cases of Hemorrhoids.: Jang, Tong Seog , Kim, Jae Jun; J Korean Soc Coloproctol. 1997;13(1):111-120.

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Abstract PDF: The clinical analysis was made on 429 patients with hemorrhoids who have been dmitted and operated at the department of Surgery, Soonchunhyang University Hospital,from January, 1986 to December, 1995 and the statistical interpretation was made to get the interval changes between the 1st half of period (1986-1990) and the 2nd half of period (1991-1995). The results were as follows: 1) The average distribution rate of hemorrhoids among benign anal diseases including hemorrhoids, fistula in auto, fissure in auto, and perianal abscess in the past one decade was 44.9% and the rate of the 2nd half(49.2%) was higher than one of the 1st half(41.2%). 2) The sex ratio of male to female was 1.65: 1 and the peak incidence was at 30s in age. In the 2nd half period the number of female patients and patients in 20s & 30s of age decreased but the number of patients in 40s of age increased. 3) 27 Patients had one hemorrhoidectomy and 3 Patients, two hemorrhoidectomies before. The average interval inbetween two different hemorrhoidecomies was 11 years involving 8.5 years of the 1st half and 13.2 years of the 2nd half. 4) The frequent symptoms were mass(34.6%), pain(26.1%), and bleeding(25.1%) but there was no interval change between the 1st half and the 2nd half. 5) The patient was first seen between 1 and 5 years after symptom development with 30.1% in frequency and the patients in the 2nd half came to hospital sooner. 6) The ratio of internal, mixed, and external type was 60.9.34:5.1 and there was no interval change. 7) The predominant location of hemorrhoids were right posterior(38.5%), left lateral(33.6%), right anterior(29.8%) and left posterior(23.8%) and there was no interval change. 8) The third grade of hemorrhoids was most frequent(52.4%) with no interval change. 9) The most of patients were operated by semi-open hemorrhoidectomy with mainly modified Nesselrod method and the number of open hemorrhoidectomies in the 1st half was larger than in the 2nd half. The most common associated anal surgery with hectorrhoidectomy was lateral internal partial sphincterotomy. 10) The associated anal diseases with hemorrhoids were skin tag(11.6%), anal fistula(6.1%), anal fissure(5.4%), and anal polyp(5.1%) in the order of frequency. There was no interval change. 11) The most common method of anesthesia for hemorrhoidectomy was the caudal anewthesia(79.2%) but hemorrhoidectomy incidence under the local anesthesia was only 0.5%. There was no interval change. 12) The common post-hemorrhoidectomy complications were urinary retention(7.7%), edema(7.5%), and bleeding(2.6%) in the order of frequency with no interval change. 13) The duration of hospitalization was between 4 to 7 days(42%) and the mean time was 8.78 days. The number of patients of the 2nd half was smaller than the number of patients of the 1st half in 7 days of admission.

Original Articles

Laser Surgery To The Circumferential Hemorrhoids.: Kim, Kwang Chul , Lee, Hruck Sang; J Korean Soc Coloproctol. 1997;13(1):121-130.

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Abstract PDF: BACKGROUND
This study was undertaken to evaluate the treatment of circumferential hemorrhoids using the CO2 laser.
METHOD
Five hundred seventy-two consecutive patients with circumferential hemorrhoids(411 males, 161 females) had hemorrhoidectomy performed with CO2 laser under caudal or epidural anesthesia during the 2 year-period between July 1994 and June 1996. The follow-up period was a minimum of 3 months after hemorrhoidectomy. The standard Milligan-Morgan open technique was used for most full three-quadrant hemorrhoidectomies. For the excision of necessary piles, "core-ablation" technique was employed.
RESULTS
The postoperative pain lasted for an average of 2.10 days. Comlications of hemorrhoidectomy included Postoperative skin tags, bleeding, wound infection, delayed wound healing, urinary retention and anal fistula in only a few of the cases, none of which caused any long-term problems.
CONCLUSIONS
These results indicate that CO2 laser hemorrhoidectomy is feasible and safe provided it is used with care, and that it seems to cause no significant alteration in anorectal physiology.

Sigmoid Volvulus in Young Males.: Chae, Gi Bong , Jeong, Gi Hoon , Moon, Hong Toung; J Korean Soc Coloproctol. 1997;13(1):131-136.

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Abstract PDF: Volvulus of the colon is a twisting of a redundant segment of the colon about it's narrow mesentery and sigmoid volvulus is the most common type. In many developing counteries this disorder is a common cause of obstruction of the intestine and in the western hemisphere it occurs in elderly patients who often have significant coexisting disease. This disorder may spontaneously reduce and recur as a chronic problem, but more frequently it becomes acute by obstruction, which may lead to strangulation and gangrene with high mortality if not treated promptly. Recently We have experienced 5 cases of signmoid volvulus, which were all in their twenties and had surgical operation. They had the triad of abdominal pain, distention, and absolute constipation. Plain abdominal roentgenogram was diagnostic in all cases The first line of treatment was nonoperative decompression with rigid sigmoidoscopy and successful in four of five. One Patient had emergency Hartman operation and other four had elective sigmoid resection with primary anastomosis.

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