Annals of Coloproctology

Volume 14(1); March 1998

Original Articles

Clinical Characteristics of Korean Hereditary Nonpolyposis Colorectal Cancer.: Park, Young Jin , Park, Kyu Joo , Kang, Koo Jeung , Kim, Kwang Yun , Kim, Sung , Kim, Young Jin , Kim, Chung Young , Kim, Jin Pok , Kim, Jin Cheon , Oh, Nam Gun; J Korean Soc Coloproctol. 1998;14(1):1-9.

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Abstract PDF: Hereditary nonpolyposis colon cancer(HNPCC) accounts for 1~6% of colorectal cancer. Mutations in the DNA mismatch repair genes(hMSH2, hMLH1 and hPMS1, hPMS2 and hMSH6) are responsible for HNPCC. To evaluate the clinical characteristics of Korean HNPCC patients, analysis were performed on the 176 patients from 40 HNPCC families registered in the Korean Hereditary Tumor Registry. All the families in this study fulfilled the ICG-HNPCC criteria. The control group consisted of 1,204 patients of nonhereditary colorectal cancer operated at SNUH between 1991 and 1995. The mean age of patients at diagnosis was significantly lower than the control group (44.5 vs 56.1 years old). Thirty three percent of cancers were located proximal to splenic flexure compared to 23% in control group. Among the 71 patients whose pathological reports were available, 14 patients(20%) had synchronous colorectal cancer compared to 4% in control. Also 15 patients(21%) had synchronous adenomatous polyp and 3 patients had both the synchronous cancer and polyp. Thus, overall 26 patients (36%) had multiple colorectal cancer including polyp. The cancers in HNPCC patients were detected at significantly earlier stage than control(67% of HNPCC patients were Dukes A or B compared to 48% in control). Statis tically significant difference was not observed in tumor differentiation between HNPCC and control group. In terms of treatment, 64% of patients received an extensive surgery over subtotal colectomy between 1995~1997 compared to 31% in the period of 1991~1994. In this series, we confirmed that Korean HNPCC patients have similar characteristics with western countries in that an early age of onset, a proclivity for the proximal colon and excess of synchronous colorectal cancers. However, relatively low incidence of proximal colonic involvement and low rate of mucinous or poorly differentiated carcinoma differed from the reports from the western countries.

Expression of Tumor Metastasis Related Genes in Korean Colorectal Cancers and Cell lines.: Bae, Ok Suk , Suh, Seong Il , Chun, So Young; J Korean Soc Coloproctol. 1998;14(1):11-19.

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Abstract PDF: We studied the expressions of E-cadherin, MMP-7 and CD44V in colorectal cancer and their corresponding normal mucosa using RT-PCR. From the 26 patients whom a com parative study of clinical and histopathological data is available, MMP-7 and CD44V were significantly enhanced in cancer and their metastatic tissues, compared with their normal mucosa. E-cadherin did not reveal any difference between cancer and normal mucosa. The relashionship between these genes and colorectal cancer development can not be confirmed by this study, however CD44v and MMP-7 may be associated with metastasis of colorectal cancer.

A Preliminary Study on the Expression and Regulation of C-X-C Chemokine Genes in a Human Colon Epithelial Cell Line.: Yang, Suk Kyun , Kim, Ok Hee , Lee, Me Hwa , Park, Seon Me , Jung, Hwoon Yong , Hong, Weon Seon , Min, Young Il; J Korean Soc Coloproctol. 1998;14(1):21-26.

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Abstract PDF: Human colon epithelial cells secrete an array of proinflammatory cytokines that includes IL-8, MCP-1, GM-CSF, TNF alpha and IL-6. This response may serve to attract neutrophils and macrophags to the site of infection. In addition to IL-8 and MCP-1, the chemokine family contains other members, which, alone or in combination, can recruit and/or activate inflammatory and lymphoid cells. In this study, we asked whether colon epithelial cells express a broader array of chemokines than previously described. The colon epithelial cell line, Caco-2, was stimulated for 3h with IL-1 alpha, or was infected with Salmonella dublin. RNA was extracted and chemokine mRNA levels were determined by quantitative reverse transcription-PCR using internal RNA standards. Ex pression of GRO alpha, GRO beta, GRO gamma and IP-10 increased by bacterial infection or IL-l alpha stimulation. These data strongly support the notion that epithelal cells are an important and integral component of the host's natural immune system.

Multiple Primary Colorectal Cancer.: Lim, Yong Seok , Lee, Seok Hwan , Hong, Sung Wha , Yoon, Choong , Joo, Hoong Zae , Lee, Kee Hyung; J Korean Soc Coloproctol. 1998;14(1):27-34.

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Abstract PDF: To assess the clinico-pathological characteristics of patients with multiple primary colorectal cancer, 458 patients who underwent curative surgery and being followed-up at our institution between Jan. 1987 and Dec. 1993 were evaluated in this study. The median follow-up period was 42 months. Synchronous cancer was defined as distinct lesions separated by a distance of greater than 4cm with the invasion of the tumor below the muscularis mucosa at the time of diagnosis or within 6 months after initial treatment, and metachronous cancer was defined as the development of colon cancers more than 6 months after the initial treatment without evidence of the recurrence or metastases from primary tumor. There were 29 cases of multiple primary colorectal cancer(6.3%). Eighteen cases(3.9%) of them were synchronous, 11 cases(2.4%) were metachronous cancers. Seven cases(1.5%) were related to 5 hereditary non-polyposis colorectal cancer(HNPCC) families. During the follow-up period, 11 patients(2.4%) developed cancers in other organs. Adenomatous polyps were identified 14 cases of 29 patients with multiple primary colorectal cancers(48.3%), compared to 43 cases(10%) in 429 patients with solitary colorectal cancer(p<0.01). After initial curative surgery, there were 8 recurrences in 29 patients with multiple primary colorectal cancers(23.6%), compared to 100 recurrences in 429 patients with solitary primary colorectal cancer(23.3%)(p>0.05). In aspect of family history, there was close-relationship with this regarding in the group of multiple primary colorectal cancers. However, authors were unable to make analysis this regarding in the group of solitary primaries because of lack of the information. Conclusively, authors guess the frequent association of the adenomatous polyps in multiple primary colorectal cancers as the evidence of the adenoma-carcinoma sequence. In addition, authors emphasized the importance of the total colonoscopic examinations in pre-and post-operation in order to make diagnosis of the multiple primary colorectal cancers and paying attention as to the family history of colorectal cancer patients because we have good therapeutic results after operation of early stage in synchronous cancers and co-existent adenomatous polyps.

Palliative Resection for Incurable Colorectal Cancer.: Kim, Dae Hwan , Baek, Moo Jun , Park, Nae Kyung , Lee, Moon Soo , Song, Ok Pyung; J Korean Soc Coloproctol. 1998;14(1):35-40.

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Abstract PDF: Despite a recent trend toward increased screening and public awareness for colorectal cancer, 30% of patients present with incurable disease. This study was designed to identify objective criteria that might help surgeons decide which patients with incurable colorectal cancer will benefit from palliative resection. Among 33 patients considered incurable colorectal cancer, twenty one patients underwent palliative resection and twelve patients had bypass surgery. Incidence of postoperative complication after palliative resection was 61.9%(13 cases), and after bypass surgery was 58.3%(7 cases). Among patients treated by palliative resection, one patient required reoperation for postoperative bleeding. The operative mortality after palliative resection was 19%(4 cases), and after bypass surgery was 25%(3 cases). The median survival was 11.4 months for patients treated by palliative resection, and was 9.7 months for patients treated by bypass surgery. These results show that palliative resection can be done safely and effectively in patients with incurable colorectal cancer. We believe this approach improved the quality of the remaining life in these patients.

Microsatellite Instability and hMSH2 Gene Mutations in Sporadic Colorectal Cancers.: Jeon, Hae Myung , Oh, Seung Tack , Kim, Jeong Soo , Chang, Suk Kyun , Kim, Jae Sung; J Korean Soc Coloproctol. 1998;14(1):41-49.

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Abstract PDF: Microsatellites are short nucleotide repeat sequences present throughout the human genome. Alterations of microsatellites, comprising extra or missing copies of these se quences, have been termed microsatellite instability(MSI, genetic instability, replication errors, RER(+) phenotype). To date, at least four genes involved in DNA mismatch repair, hMSH2, hMLH1, hPMS1 and hPMS2, are thought to account for the observation of microsatellite instability in tumor from Hereditary nonpolyposis colorectal cancer (HNPCC) patients. The genetic defect responsible for the MIN+ phenotype in sporadic colorectal cancer, however, has yet to be clearly delineated. The purpose of this study was to determine the presence of MSI in sporadic cancer and to correlate its occurrence with clinicopathological parameters, we have studied six microsatellite loci by use of polymerase chain reaction amplification and denaturing polyacrylamide gel electrophoresis. We found that 20%(9 of 46 cases) sporadic colorectal cancers showed RER at two or several loci(RER+). Microsatellite instability was associated with location of the tumor in the proximal colon 66%(6 of 9 cases) and with poorly differentiated tumor phenotype 56%(5 of 9 cases). In order to better understand the role of somatic alterations within hMSH2 in the process of colorectal tumorigenesis, we examined the most conserved regions(codon 598~789) of this gene in nine patients with MIN spotadic colorectal cancer. 6 patient of RER(+) colorectal ca. patients had a polymorphism which was a T to C base change in the intron sequence at -6 position of the splice acceptor site at the 5'end of exon 13. This particular sequence variation is a polymorphism rather than a mutation which increase cancer susceptability. These data suggest that the genetic instability is detect ed in some colorectal cancers and play an important role in the pathogenesis of sporadic colorectal cancer.

The Expression and Correlation of Cyclin E, P21WAF1Protein and P53 Variant Protein in Colorectal Adenoma and Carcinoma.: Kim, Jong Woo , Ahn, Hee Jung , Choi, Sung Woo , Ahn, Dae Ho , Chung, Jae Sam , Lee, Kyung Po; J Korean Soc Coloproctol. 1998;14(1):51-58.

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Abstract PDF: Cyclins are proteins that activate different cyclin-dependent kinases(CDKs) and promote the cell cycles. Their correlations with several human cancers have been identified. Cyclin E, as one of G1 cylins, produces DNA replication through the progression of cell cycle G1 --> S phase. In contrast, cyclin-dependent kinase inhibitors(CDKI) bound with cyclin E-cdk2 complex control the cell cycle and inhibit the cell proliferation. P21(WAF1) proteins, which are CDKIs, are transcripted by a p53 gene and participate in the cell cycle inhibition. Variant p53 proteins produced by a mutated p53 gene lose the ability to control of the cell cycle resulting in cell proliferation. This study is aimed to reveal the expressions of cyclin E, p21(WAF1) protein, p53 variant protein in colorectal adenomas and carcinomas, and also reveal their correlations in the process of carcinogenesis. Twenty-one colorectal adenomas or adenomatous polyps, and thirty colorectal carcinoma tissues were obtained by operative resections or endoscopic polypectomies. Immuno histochemical stains of the above-mentioned three proteins and a statistical analysis of their correlations were made. The results were as follows: 1. P21 proteins were expressed in the upper-one third layer of all normal colonic mucosa, but cyclin E and variant p53 protein were not identified. 2. Cyclin E was expressed in 23.8% of adenomas and 76.7% of carcinomas. Variant p53 protein was expressed in 71.4% of adenomas and 83.3% in carcinomas. The degree of positivity of variant p53 expression was correlated with cancer staging. P21 protein was expressed in all adenomas, similar to normal mucosa, but was not expressed in 43.3% of carcinomas. 3. Expression of cyclin E was increased as to the positivity of variant p53 proteins but the correlations of p21 proteins and cyclin E, and p21 proteins and variant p53 proteins were not identified. Cancer staging was not correlated with the expressions of the three proteins. In conclusion, it can be thought that the overexpression of cyclin E and variant p53 proteins, and the loss of p21 proteins are related with the colorectal carcinogenesis. We can also identify the relationship of cyclin E and variant p53 proteins.

Clinical and Physiologic Evaluation of Anorectal Function Following Low Anterior Resection.: Lee, Sang Jeon , Park, Yoon Sang; J Korean Soc Coloproctol. 1998;14(1):61-72.

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Abstract PDF: Twenty to twenty-five percent of patients are reported to experience problems with anorectal function after low anterior resection, complaining particularly urgency of defecation and minor fecal leakage, but the mechanisms underlying its cause and the recovery process are not well understood. We designed this study to elucidate the mechanism of anorectal functional problems and its recovery process after low anterior resection for rectal cancer by autonomic nerve preserving procedure. Standardized interviews and anorectal physiologic studies including balloon proctometry and manometry were performed in 32 patients preoperatively, and at 1 month, 3 months, 6 months and 1 year after the operation. Postoperatively stool frequency increased, the ability to defer defecation and discriminate stool characters were compromised, and anal incontinence scores increased, which recovered progressively by 6~12 months after the operation. Balloon proctometry showed that threshold volume, urgent volume and maximal tolerable volume decreased remarkably after the operation. The latter two parameters recovered considerably by 1 year after the operation. Rectal compliance also decreased significantly but it showed no evidence of recovery by 1 year after the operation. Anorectal manometry showed that maximum anal resting pressure decreased significantly after the operation which recovered significantly by 1 year after the operation. Maximum anal squeeze pressure showed no significant decrease after the operation. In most patients rectoanal inhibitory reflex was abolished after the operation, which recovered only in some cases by after 1 year. The group of short residual rectum(<4 cm, N=18) showed more impairment in continence and decrease in neorectal capacity and compliance than that of the long residual rectum(> or =4 cm, N=14). These results suggest impairment in fecal continence occurs due to decrease in rectal capacity, compliance, and anal canal pressure, and loss of rectoanal inhibitory reflex. Autonomic nerve preserving procedure could not prevent the decrease in resting anal pressure. Continence recovers clinically with increase in neorectal capacity, compliance and anal canal pressure but not with recovery of rectoanal inhibitory reflex. The length of the residual rectum seems to play an important role in the degree of impairment of continence and good continence can be expected when the residual rectum is more than 4 cm.

Gambee Anastomosis Using U-shaped Suturing Needle in Surgery of Lower Gastrointestinal Tract.: Jeon, Tae Yong , Oh, Nahm Gun; J Korean Soc Coloproctol. 1998;14(1):75-83.

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Abstract PDF: BACKGROUND
It is commonly accepted that the Gambee suture is a precise and reliable suturing method in the anastomosis of the intestine, especially in the aspect of the exact apposition of the submucosal layer. Generally, Gambee suturing technique requires much time and effort, as well as complicated actions and skills. For this reason, the Gambee suture is avoided by many surgeons. PURPOSE: Nahm-gun Oh has devised a U-shaped needle, which can prevent submucosal tearing of the posterior bowel wall, owing to the short distance between its both ends. As a result, an operator to perform a Gambee stitch more easily, safely. This study was undertaken to evaluate the usefulness, reliability of the U-shaped needle.
METHODS
The clinical analysis was made on 104 cases with Gambee anastomosed colo rectal disease who have been admitted and operated at the Department of Surgery, Pusan National University Hospital, from January, 1996 to December, 1997 and the disease and patients status, operative procedure, postoperative complication, needle holder grasping count according to anastomosis level of 104 cases were analyzed.
RESULTS
Gambee anastomosis was performed in 71 cases(68.3%) of colorectal cancers and 33 cases(31.7%) of nonmalignant colorectal diseases. Postoperative complication was 20 cases(19.2%) and 2 cases(1.9%) of anastomotic site leaks were observed. In aspect of needle holder grasping according to anastomosis level, U-shaped needles allow for an entire Gambee suture from one fixed grasp, while the common half-circled suturing needle requires at least 2 or 3 different grasping positions of the needle holder. In case of anterior bowel wall anastomosis, undesirable slipping-off of the submucosal tissue was founded. Authors also suggest a hook-style barb tip so that barb tip should prevent the slipping-off.
CONCLUSION
The half-ellipsed or half-track needle can prevent submucosal tearing of the posterior bowel, owing to the short distance between its both ends. Barb feature on the suturing needle tips will be able to prevent slipping-off of the submucosa contralateral from the needle holder during an entire Gambee stitch on the anterior bowel wall. We recommended, based on our results, with U-shaped suturing needle, as well as barb-tip needle feature, operators can save a lot of time and effort formerly required by other common needle in Gambee suture.

Effect of Lidocaine Injected on Lower Rectal Submucosa During Hemorrhoidectomy under Caudal Anesthesia.: Kim, Tae Soo , Kim, Do Sun , Kang, Yoon Sic , Jung, Seung Yong , Cho, Hang Jun , Lee, Doo Han; J Korean Soc Coloproctol. 1998;14(1):85-89.

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Abstract PDF: BACKGROUND
/AIMS: The caudal anesthesia for anal surgery is simple and effective. Also, it is relatively safe because there is no headache or other neurologic complications. But, during the operation under caudal anesthesia, the unwanted symptoms such as lower abdominal pain or hypotensive symptoms were experienced in some patients. These unwanted symptoms may occur due to anal and lower rectal dilatation. The precise mechanism is unknown. But we speculated that some sensory nerve endings in rectal submucosa may be involved in this mechanism. So, we think that it is possible to prevent or reduce these symptoms if we block these sensory nerve endings effectively with local anesthetics. Therefore, the aim of this study is to see whether the locally injected lidocaine can reduce or prevent the unwanted symptoms during anal surgery under caudal anesthesia.
METHODS
There were 100 consecutive patients in this study who had hemorrhoidectomy with Jack-knife position under caudal anesthesia at our clinic. We divided evenly these 100 patients into two groups, injection and control groups(in each group, 50 patients were included.). In injection-group, We injected 10 cc(100 mg) of 1% lidocaine solution cir cumferentially into the lower rectal submucosa at the beginning of the operation. In control-group, we did not inject lidocaine solution initially, but the lidocaine injection was done during the operation in the same manner in the injection-group if the severe unwanted symptoms occurred. We used Parks-type retractor to dilate the anus and recorded the patient,s complaints.
RESULTS
In injection-group, male to female ratio was 33:17, mean age was 42.1 years(20~69) and mean operation time was 38.3 minutes(15~80). In control-group, male to female ratio was 25:25, mean age was 43.7 years(17~65) and mean oeration time was 38.5 minutes(15~80). Lower abdominal pain was present in 11 patients(22%) among injection-group and in 37 patients(74%) among control-group(p=0.000). Hypotensive symptoms such as nausea, vomiting, sweating and dizziness were present in 1 patient(2%) among injection-group and in 8 patients(16%) among control-group(p=0.014). We injected lidocaine solution into lower rectal submucosa during the operation in 18 patients with severe symptoms among control-group. The effect of the injected lidocaine solution in 18 control patients was good in 13(72%) and fair in 5(28%). With regard to factors influencing the occurrence of symptoms, there was a tendency of higher occurrence in male, the younger-aged and the longer-operation groups.
CONCLUSION
The lower rectal submucosal lidocaine injection reduced the unwanted symptoms such as lower abdominal pain and hypotensive symptoms during the anal surgery under the caudal anesthesia.

A Clinical Study of Bipolar Diathermy (BICAP) in Hemorrhoids.: Choi, Dong Ha; J Korean Soc Coloproctol. 1998;14(1):91-100.

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Abstract PDF: Many nonsurgical techniques are currently employed for outpatient treatment of hemor rhoids. Sclerotherapy, rubber band ligation, cryotherapy, laser therapy, infrared photocoagula tion and direct current therapy have been utilized in the management of hemorrhoids in the outpatient setting, but bipolar diathermy(BICAP) has not been introduced in korea yet. This study is a clinical analysis of 472 patients of hemorrhoids treated with BICAP bipolar diathermy at outpatient department from July 1996 to June 1997. Among them, 396 patients had been followed up for 3 to 15 months. Male to female ratio was 2.2:1 and mean age of male and female was 42.8 and 39.7 years, respectively. Duration of symptoms in 216 patients(57.6%) was below 5 years. The most frequent degree of internal hemorrhoids was second degree(62.7%), followed by third degree(23.9%), first degree (7.8%) and fourth degree(5.5%). Major presenting symptoms were prolapse combined with bleeding(45.8%), prolapse(21.2%) and bleeding(19.7%). In 62.9% of patients 3 piles were treated. Associated anorectal diseases with hemorrhoids, such as skin tags, thrombi and anal polyps were present in 179 patients. Among them, 126 patients were operated as outpatient operation procedure with BICAP therapy. Previous medical managements of hemorrhoids, such as use of rectal suppositories(32%), injection of sclerosing agents(8.6%) and hemorrhoidectomy(7.8%) were done in 240 patients(51%). Number of treatments was one session(88.7%), two sessions(10%), three sessions(1.1%) and four sessions(0.2%) in order of frequency. Mild to moderate anal discomfort was experienced during BICAP therapy by 215 patients(46%), mild sensation of local heat by 95 patients(20%) and mild bleeding by 10 patients(2%). No postdiathermy discomfort was observed in 337 patients(85.1%). However, postdiathermy bleeding and pain were present in 41 patients (10.4%) and 18 patients(4.5%), respectively. Results of followed up patients for 3 to 15 months were asymptomatic in 270 patients(68.2%), improved in 88 patients (22.2%), and no changed in 38 patients(9.6%). Among 18 patients with fourth degree hemorrhoids, only 2 patients(11%) became asymptomatic, 5 patients(28%) improved and 11 patients(61.9%) were not changed in their symptoms. Six patients experienced recurrent hemorrhoids requiring hemorrhoidectomy. In conclusion, bipolar diathermy(BICAP) for hemorrhoids is safe, easy to apply, painless, needs no anesthesia and bowel preparation with short time and repeated treatments and can be applied to first, second, third and some patients of fourth degree hemorrhoids. The effect of treatment was satisfactory in about 90%. Side effects were minimal compared to other nonoperative treatments. Therefore, the auther believes that bipolar diathermy(BICAP) is a desirable nonoperative treatment for internal hemorrhoids.

Revisit the Original Whitehead Hemorrhoidectomy The postoperative results of W-shaped circular incision & preservation of perianal skin.: Kim, Ji Hun , Kang, Dong Wan , Sun, Byung Ho; J Korean Soc Coloproctol. 1998;14(1):101-107.

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Abstract PDF: Since Whitehead had described a circular hemorrhoidectomy in 1882, many surgeons adopted it for decades for patients with protruding anal deformity. After a few decades of performing Whitehead operation, devastating complications such as anal stricture, fecal incontinence, and wet anus with mucosal eversion had been reported on the literatures and then it was buried as an abandoned procedure by surgeons for a long period. Recently, a few prominent anal surgeons reported that they could avoid such devastating complications by introducing diverse modifications of the original Whitehead's operation. The authors analyzed 22 patients who had undergone original Whitehead circular hemorrhoidectomy with the technique of preserving most of the perianal skin and W-shaped circular incision during the period from 1991 to 1996, with special regard to the com plications such as anal stricture and anal mucosal eversion which have been debated on so far and reviewed the articles about these issues. In immediate postoperative period, suture failure and resultant non-surgery requiring, mild anal stricture were documented in 3 of the 22 cases(13.6%). On long-term follow-up with the mean period of 44 months (18~79 months) in 14 cases, except those 8 cases that were lost, with phone-call questionaire, 13 patients(93%) had quite normal anal functions. The authors would like to suggest that the original Whitehead's circular hemorrhoidec tomy is a valuable surgical technique to manage the protruding anal deformity if surgeons can avoid well known complications such as anal stricture and anal mucosal eversion by choosing a correct location of initial W-shaped incision to preserve as much perianal skin as possible.

Clinical Analysis of 62 patients with Rectovaginal Fistula.: kang, Seung Hyun , Kim, Nam Kyu , Lim, Dae Jin , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 1998;14(1):109-114.

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Abstract PDF: Rectovagianl fistula(RVF) is a congenital or acquired communication between the two epithelial-lined surface of the rectum and the vagina. We present our experience with 62 patients with RVF. There were various etiologies and repair methods of rectovaginal fistula. The purpose of this study was to retospectively review the clinical course of the patients we treated and to evaluate the efficacy of various treatment options. The mean age was 40.5 yr, The type of RVF was classified to one of two(simple and complex), according to their location, size and etiology. RVF was developed most commonly after radiotherapy due to cervical cancer(n=17), then after pelvic surgery due to malignancy(n=16), obstetric trauma after episiotomy at delivery(n=7), congenital malformation(n=4), inflammatory bowel disease(n=1), Bechet's disease(n=1), infections such as perianal fistula or abscess(n=2), direct invasion of carcinoma(n=3), after chemotherapy(n=1), and idiopathic(n=6). Three cases of them associated with rectovesicovaginal fistula. Surgical therapeutic option was divided to local repair, abdominal approach and tissue transposition by the type of RVF. Most simple RVFs were repaired with local approach through the vagina or rectum. Most complex RVFs were repaired through abdominal approach or tissue transposition. With an average follow up of 20 months, the treatment results were as follows: completely healed(n=36, 58.1%), persistent symptom(n=6, 9.7%), recurrence after repair(n=5, 8.1%), loss of search or death(n=15, 24.1%). Therefore we assist that the management of RVF depends on size, location, and cause. anal sphincter function and overall health status of the patient. Careful preoperative assessment of the fistula, surrounding tissues, and anal sphincter and exclusion of associated disease are essential. With through evaluation, thoughtful consideration of treatment options, and meticulous operative technique, patient can be assured of an optimal outcome.

Ischemic Colitis.: Lim, Seok Won , Park, Weon Kap , Lee, Kwang Real , Yoo, Jung Jun , Kim, Hyun Shig , Lee, Jong Kyun; J Korean Soc Coloproctol. 1998;14(1):115-123.

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Abstract PDF: Ischemic colitis is an uncommon disease in Korea, but nowadays, the incidence of this disease is increasing in Korea. The reason is that the number of old patients is increasing and colonoscopic diagnosis is performed more frequently. It is especially important to differentiate it from other inflammatory bowel disease, such as infectious colitis, ulcerative colitis, Crohn's disease, and drug-induced colitis, because ischemic colitis is similar to other inflammatory bowel disease in symptoms and colonoscopic findings. However, the authors were able to differentiate ischemic colitis from other inflammatory bowel disease by close examination of a patient's history, microscopic examination and culture studies of the bacteria in the stool, and close observation of the changes in the colonoscopic findings with time. We experienced six cases of ischemic colitis and report them along with a brief review of the literature.

Sigmoidoscopy, is it Enough as a Screening Tool? -Undetectable colorectal adenomas by sigmoidoscopy-.: Jeong, Seung Yong , Kang, Yoon Sic , Kim, Do Sun , Lee, Doo Han , Cho, Hang Jun , Kim, Tae Soo; J Korean Soc Coloproctol. 1998;14(1):123-128.

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Abstract PDF: BACKGROUND
It is generally accepted that most colorectal cancers develop from adenomas, so the detection and removal of them can reduce the incidence of colorectal cancers. Sigmoidoscopy is the effective tool for detecting and removing adenomatous polyps in the rectosigmoid region, but its major limitation is that sigmoidoscopy alone can not detect considerable portion of colorectal adenomas.
METHODS
From October, 1996 to August, 1997, we performed 2017 sigmoidoscopies and 1683 colonoscopies. We analysed the anatomical distribution of adenomas and compared the detection rate of adenomas between two groups. In 32 cases, adenomas detected by sigmoidoscopy were followed by colonoscopy in less than 2 months.
RESULTS
We found 125 cases of adenomas in 2017 sigmoidoscopies and 281 cases of adenomas in 1683 colonoscopies. In 281 cases of adenomas found by colonoscopy, 151 cases had rectosigmoid adenomas only and 25 cases had rectosigmoid and proximal adenomas, 105 cases had proximal adenomas only. The detection rate of adenomas by sigmoidoscopy was significantly lower than that by colonoscopy in the rectosigmoid region(6.1% vs. 10.5%, p=0.002). In 32 cases of adenomas found by sigmoidoscopy that were followed by colonoscopy, 7 cases of proximal adenomas and 6 cases of additional rectosigmoid adenomas were detected.
CONCLUSION
Sigmoidoscopy cannot detect adenomas in the proximal colon beyond the sigmoid, it also can miss a significant portion of adenomas in the rectosigmoid.

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