Annals of Coloproctology

Volume 15(1); March 1999

Original Articles

Clinical Review of Crohn's Disease.: Choi, Sun Gyeung , jeon, Goan Hee , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 1999;15(1):1-7.

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Abstract PDF: PURPOSE
Crohn's disease is chronic, nonspecific inflammatory process and the incidence is becoming larger recently. The authors studied the clinical course of the Crohn's disease by reviewing the clinical characteristics, anatomical distribution, operative indications, operative procedures and postoperative results.
METHODS
We reviewed medical records of 30 patients who had treatment at the Chonbuk national university hospital from June 1988 to December 1997. We analyzed their age, sex distribution, clinical symptoms, anatomical distribution, operative indication, operative procedure, postoperative recurrence rate and postoperative results.
RESULTS
Sex ratio was 1.5:1 (male:female) and average age of onset was 33 year. Thirteen patients (43%) underwent operation but there was no remarkable difference between the groups that received operation and that had medical treatment. Abdominal pain and diarrhea were common but there were no extraintestinal symptoms. The most common site of involvement was ileocecum and the next was small intestine, followed by large intestine. Intestinal obstruction was the most common indication for surgery and fistula, abscess formation and palpable abdominal mass in order. Three cases out of 13 patients who had undergone primary resection needed second operation, and 2 cases of the 3 recurrent cases underwent the third operation. During the follow up period, there were two cases of re-operation due to anastomotic leak or ileus. The patient who received the third operation (right hemicolectomy, retroperitoneal abscess drainage and jejunal resection) died of anastomotic leak, enterocutaneus fistula, sepsis and respiratory failure.
CONCLUSIONS
The incidence of Crohn's disease in Korea is gradually increasing and the disease has been challenging problems to most surgeonsfor its frequent surgical indication, high recurrence rate, complication and poor surgical results. The above results suggest that Crohn's disease needs follow-up even after the operation.

Sphincter Repair for Fecal Incontinence after Obstetric Injury.: Ahn, Kwang Woo , Lee, Sang Jeon , Park, Jin Woo; J Korean Soc Coloproctol. 1999;15(1):9-19.

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Abstract PDF: PURPOSE
We designed this study to evaluate efficacy of sphincter repair and factors influencing in patients with postobstetric fecal incontinence.
METHODS
Twenty-one patients (mean age 42 years; range 23~67) undergoing sphincter repair for postobstetric fecal incontinence (mean duration 12 years; range 6 months~46 years) were evaluated prospectively. Preoperatively, standardized interviews, anorectal manometry and measurement of pudendal nerve terminal motor latency (PNTML) were performed. Incontinence was graded according to the Parks' classification: Grade 1 - continence to stool and flatus; Grade 2 - incontinent to flatus, some urgency to stool present but no incontinence; Grade 3 - incontinent to liquid stool; Grade 4 - incontinent to formed stool. Sphincter repair methods were overlap repair of external anal sphincter (EAS) in 4 patients, overlap repair of EAS with anterior levatorplasty in 15 patients, and overlap repair of EAS with anterior levatorplasty and postanal repair in 2 patients. Anorectal manometry at 3 months, and interviews at 3 months and 6 months after sphincter repair were performed again. Patients' satisfaction was classified as excellent, good, fair, and no improvement.
RESULTS
Difficulty in first delivery was noticed in 18 patients and history of previous sphincter repair was noticed in 5 patients. Preoperatively, most patients showed high grade incontinence (grade 3 in 13 and grade 4 in 8 patients). After sphincter repair, 18 patients (85.7%) became grade 1 or 2, and 16 patients (76.2%) replied their functional satisfaction excellent or good. There were no difference between the results at 3 months and 6 months. Poor functional outcome was in 2 of 3 patients with bilaterally prolonged preoperative PNTML. Short duration of incontinence and young age at the time of repair favored good results. Previous sphincter repair did not influence the outcome. Postoperatively both anal pressure and high pressure zone length were significantly increased in patients with improved continence Postoperative complications were wound infection in 2 patients and necrosis at the apex of the advancement skin flap in 1 case but these did not influence the outcome.
CONCLUSIONS
Most postobstetric fecal incontinence can be successfully treated with sphincter repair. Excellent results are expected when the duration of incontinence is short and the patients are young. Pudendal neuropathy seemed to be related to poor outcome.

Effects of Preoperative Chemoradiotherapy on the Healing of Colonic Anastomosis with the Lapse of Operation Time in the Rat.: Yun, Sung Su , Kim, Dong Sik , Kim, Chun Jik , Kim, Sang Woon , Kim, Jae Whang , Suh, Bo Yang , shim, Min Chul , Kwun, Kaing Bo , Sung, Un Ki; J Korean Soc Coloproctol. 1999;15(1):21-30.

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Abstract PDF: PURPOSE
Preoperative chemoradiotherapy has become an important adjunct in the management of rectal cancer. But both systemic toxicity of chemotherapy and local effect of radiation interfere wound healing of intestinal anastomosis and ultimately may lead to anastomotic leak and septic complications. The purpose of this study is to determine the optimal time interval between preoperative chemoradiotherapy and anastmotic construction, and it was evaluated by security of anastomotic construction.
METHODS
One hundred and twenty male Sprague Dawley rats weighing approximately 250 g were randomly divided into 4 groups (Control group; n=40, Group 1; n=20, Group 2; n=20, Group 3; n=40). The control group (n=20) underwent anastomotic construction at 1 week after general anesthesia without preoperative chemoradiotherapy. The experimental animals (group 1, 2, 3) received preoperative chemoradiotherapy with 5 daily dose (20 mg/kg) of 5-fluorouracil and single dose of 1500 cGy radiation at the rectosigmoid junction under general anesthesia on the day after last dose of chemotherapy. And group 1~3 subsequently underwent a laparotomy to make anastomotic construction at 1 week (Group 1), 2 weeks (Group 2), and 3 weeks (Group 3; n=20) after completion of chemoradiotherapy. The security of anastomotic construction was determined by bursting pressure, tissue hydroxyproline content, gross and microscopic findings of anastomotic area at the 5th and 10th postoperative day after anastomotic construction. To evaluate systemic toxicity after che-moradiotherapy, serial body weight and alteration of CBC were measured in the control group (n=20) and Group 3 (n=20) without anastomotic construction.
RESULTS
At the 5th postoperative day, Mean bursting pressures of the all treated groups were lower than that of the control group (Control group; 88 23 mmHg, Group 1; 49 22 mmHg, Group 2; 56 17 mmHg, Group 3; 78 23 mmHg). The difference was not significant in the group 3 compared with the control group. Body weight decreased in the all treated animals. The mean body weight was lowest on the day 8 after completion of chemoradiotherapy and then it gradually increased. WBC and platelet counts also decreased in the all treated animals. WBC count was lowest on the day 1 and platelet count was lowest on the day 3 after completion of chemoradiotherapy. Mean hydroxyproline contents at the anastomotic sites in the all treated groups were higher than that of the control group, especially in the group 2 and 3. Similar histologic changes were observed in both group 3 and control group.
CONCLUSION
The results suggest that the optimal time interval for safe intestinal anastomosis after preoperative chemoradiotherapy is 3 weeks or later.

A Survey II for Satisfaction for Stoma on Ostomates.: Kim, Joon Ho , Lee, Seok Hwan , Ko, Young Gwan , Oh, Soo Myung , Yoon, Choong , Joo, Hoong Zae , Lee, Kee Hyung; J Korean Soc Coloproctol. 1999;15(1):31-35.

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Abstract PDF: PURPOSE
This survey was designed to acknowledge that it is necessary to rehabilitate ostomates.
METHODS
This medical survey attempted to make an analysis of the types and causes of stoma, the problems stemming from the stoma, the degree to which ostomates are satisfied with their life quality, and the extent to which they are affected in doing their jobs, on the basis of the examinations conducted for eighty eight ostomates, who responded to the questionnaire at the 3rd Workshop for Stoma Rehabilitation for Ostomates on August 29, 1998 by the Department of Surgery, Kyung-Hee University Hospital, or who replied back to the questionnaire that was sent by mail.
RESULTS
On examination, it was found that the ratio of male to female was nearly 1.5:1 (53:35); by age distribution, the ostomates in their 50 and 60's constituted 65.9%; by stoma pattern, colostomy was made up of 81 cases (92%), ileostomy 4 cases (4.5%), urostomy 2 cases (2.3%); by duration, permanent stoma was 81 cases (92%), temporary stoma 6 cases (6.8%); by the cause of stoma operation, malignancy consisted of 78 cases (88.6%), IBD 4 cases (4.5%), congenital anomaly 1 case, car accident 1 case, benign bladder disease 1 case, intestinal obstruction after radiation therapy 1 case, but 2 cases were not identified. Besides, it was also examined that, regarding the degree of post-operation satisfaction for stoma, dissatisfaction amounted to 58 cases (65.9%); as for the problems stemming from the stoma, skin irritation or injury reached 30 cases (34.1%), discomfort for stoma location 17 cases (19.35%), parastomal hernia 8 cases (9.1%), stoma retraction 4 cases (4.5%) and disease recurrence 3 cases (3.4%); as for the degree of the satisfaction of ostomates for their life quality, dissatisfaction revealed 70 cases (79.5%); regarding the extent to which the ostomates are affected in doing their jobs, fifty four out of eighty eight ostomates (62.0%) had a disturbance.
CONCLUSIONS
This medical survey clearly shows that most of ostomates suffered from stoma in their daily lives and doing their occupations, thus they need helps from the experts such as colorectal surgeons and enterostomal therapists, or the ostomy association. In addition, it is also necessary to pay a more deliberate attention to determining the location of stoma.

Solitary Juvenile Polyp Manifesting as Spontaneous Resection with Rectal Bleeding in a Child.: Um, Jun Won , Kim, Kwang Hee , Kim, Han Kyum; J Korean Soc Coloproctol. 1999;15(1):37-40.

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Abstract PDF: Juvenile polyp of the large intestine is the most common polyp among children and has no malignant potential. We experienced a case of 3-year old male who presented with rectal bleeding and polyp. The polyp was spontaneously resected and the size was 35 50 10 mm. Pathologically, the polyp was consistent with juvenile polyp of the rectum.

Case Report

Three Cases of Amebic Colitis Misdiagnosed as T.B. Colitis.: Lim, Seok Won , Kim, Hyun Shig , Hwang, Do Yean; J Korean Soc Coloproctol. 1999;15(1):41-49.

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Abstract PDF: Nowadays, inflammatory bowel disease, such as ulcerative colitis and Crohn's disease, is increasing; however, infectious colitis, such as amebic colitis, is decreasing, so many doctors are not apt to be interested in infectious colitis. In addition, recently amebic colitis has been relatively rare in Korea, and the colonoscopic and the pathologic findings of amebic colitis are very similar to those of other inflammatory bowel diseases. As a consequence, the diagnosis is very difficult if the cyst or the trophozoite of the ameba is not found in the stool examination or in the tissue pathology. The authors experienced three cases in which initial diagnoses of tuberculous colitis, ulcerative colitis, and a simple ulcer were made based on colonoscopic and X-ray findings. However a colonoscopic biopsy revealed a trophozoite form of ameba in the tissue. Hence, a diagnosis of amebic colitis could be made with confidence. Based on these results, we insist that infectious colitis should be included in the differential diagnosis when making a diagnosis of inflammatory bowel disease. In addition, it is extremely important to consider all kinds of infectious colitis, such as amebic colitis.

Original Articles

In the View of the Private Practitioner.: Choi, Kyung Dal; J Korean Soc Coloproctol. 1999;15(1):49-54.

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Abstract PDF: No abstract available.

Modified Hanley's Operation in the Treatment.: Rhyou, Jai Hyun , Shim, Kang Sup , Kim, Kwang Ho; J Korean Soc Coloproctol. 1999;15(1):55-63.

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Abstract PDF: PURPOSE
Horseshoe type-ischiorectal fistula is originating initially from infected anal gland that connect with an anal crypt usually situated in the posterior midline of the anal canal. In the modified Hanley's operation, a prove inserted into the primary opening in directed into the posterior anal space. A straight incision from the primary opening toward the tip of the coccyx is made to unroof the posterior anal spcae and the anal portion of the fistulous tract. The secondary external fistula openings are incisied to permit better external drainage. The tracts are curratted but their entire lengths are not unroofed. This study presents the clinical features and the results obtained with modified Hanley's operation in the surgical management of horseshoe fistula.
METHODS
This report is based on the clinical analysis of 22 cases of horseshoe type among 329 cases of fistula in ano, which were treated at the Department of General Surgery of Ewha Womans University Hospital from October 1993 to May 1998.
RESULTS
The male to female ratio was 3.7:1 and the age was range from 19 years-old to 61 years-old. The symptom were anal discharge and pain. The previous or combined anal disease were anal abscess and hemorrhoids. The internal openings were located at the dentate line in 18 cases and anterior portion in 5 cases. Horseshoe ischorectal fistula included 17 cases of semi-horseshoe fistula and 1 case of horseshoe fistulous sinus. The spinal anesthesia and lithotomy position was used for operations. The cutting seton was applied in the 4 cases for preservation of sphincter function. The average hospital stay was 7.6 days and average wound healing time was 5.4 weeks. The postoperative complication of urinary retensio was found in the 2 cases. Recurrence, fecal incontinence, anal deformity and anal anterior diaplacement was not developed during following periods.
CONCLUSIONS
We confirm that the modified Hanley's operation is a effective and conservative surgical procedure that minimizes the disadvantages of complete unroofing method & useful method for preservation of sphincter function.

Repair of Rectovaginal Fistulas.: Park, Weon Kap , Hwang, Do Yeon , Kim, Khun Uk; J Korean Soc Coloproctol. 1999;15(1):65-71.

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Abstract PDF: Thirteen women with rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy were operated on during Jan. 1993 - Jul. 1997 at Song-Do Colorectal Hospital. The mean age was 36.9 (range, 25~56) years. The mean follow-up after operation was 33 (range, 8~62) months. The etiology of the fistula in the majority of patients was obstetric injury and operative trauma (10/13). Seven patients were referred after attempts at repair elsewhere. Eleven patients were managed with a mucosal flap advancement and a 3-layered repair of the rectovaginal septum: 4 without and 7 with a perineal body reconstruction or sphincter repair. Two patients were managed with a mucosal flap advancement only without a repair of rectovaginal septum. In all cases, a concomitant colostomy was not performed. Postoperative complications were noticed in 3 of the patients managed by a mucosal flap advancement and 3-layered repair of the rectovaginal septum with perineal body reconstruction or sphincter repair and all were perineal wound infections. All of these infections were cured, without recurrence, by simple rubber seton drainage. Recurrence occurred in one case managed by a mucosal flap advancement only. Three patients with liquid incontinence became continent after a sphincter reconstruction. We conclude that most rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy can be managed with a mucosal flap advancement and 3-layered reconstruction of the rectovaginal septum. If any signs or symptoms of sphincter injury are noticed preoperatively while taking the patient's history or during manometry and endorectal ultrasonography, a perineal body reconstruction or sphincter repair should be performed.

Local Excision of Rectal Carcinoma.: Shin, Dong Gyeu , Shim, Kang Sup , Kim, Kwang Ho; J Korean Soc Coloproctol. 1999;15(1):73-81.

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Abstract PDF: PURPOSE
Curative local excision of the rectal cancer had been advocated by many surgeons over the standard abdominoperineal resection (APR) for lower rectal cancer due to its low complication rate and improved quality of life. The aim of this study was to evaluate the result of the local excision for rectal cancer.
METHOD
We prospectively analyzed 31 rectal cancer patients (including 2 patients of carcinoid tumor) who were suitable indication for local excision between Oct. 1993 and Dec. 1998 at Mokdong Hospital.
RESULTS
The age of the patients ranged from 39 to 81 years (>60 years: 77.8%) while sex ratio was 1:5 (M:F). Of 31 patients, 29 patients were located below 4 cm from anal verge. Other two were in between 7 cm and 10 cm from the anal verge. The tumor size ranged from 0.7 cm to 5 cm, most commonly within 3 cm. Invasion depth by tumor were as follows: 12 patients in mucosa; 7 patients in submucosa; 4 patients in inner muscle layer; 6 patients in outer muscle layer; and 2 patients in whole layer. Ten patients had well-differentiated tumors and 17 patients had moderately differentiated tumors, while one patient had mucinous histologic type. Seventy percent of patients with muscular layer invasion received adjuvant radiation therapy. Six patients received oral chemotherapeutic agent and 4 received immunopotentiator. During the follow-up period (mean: 18.4 months, range: 1~54 months), no local recurrence was found in the patients who were operated under curative intent.
CONCLUSION
We concluded that this method can be favorabe choice for the treatment of early rectal cancer without lymph node involvement if strict indication of the local excision for rectal cancer could be applied.

Endoscopic Mucosal Resection and Its Clinical.: Kim, Hyun Shig , Park, Weon Kap , Hwang, Do Yeon; J Korean Soc Coloproctol. 1999;15(1):83-90.

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Abstract PDF: PURPOSE
Endoscopic mucosal resection (EMR) or endoscopic piecemeal mucosal resection (EPMR) is a useful method for treating benign neoplastic lesions and selected cases of early colorectal cancers, especially those cancers with flat or depressed shapes. However, clinical data concerning EMR or EPMR are still lacking. Accordingly, we designed this study to review and analyze our cases for more information and in order to achieve more adequate and prudential application.
METHODS
We performed 2609 colonoscopic polypectomies from January 1997 to December 1998. Among those, 77 lesions (3.0%) were treated by using the EMR or the EPMR technique. We analyzed those 77 lesions with special reference to size, configuration, and histologic diagnosis.
RESULTS
The most common age group was the 5th decade. The male-to-female ratio was 1.75:1. The most common sites of the lesions were the rectum and the sigmoid colon. Most of the lesions were equal to or smaller than 15 mm in size (97.4%). Flat, elevated lesions were the most common type (39%), followed by sessile (31.2%) and depressed (18.2%) lesions in order. Adenomas and adenocarcinomas accounted for 51.9% (40/77) of the lesions and the malignancy rate was 9.1% (7/77). Three were submucosal cancers. Seventy-one percent of the carcinomas were less than 10 mm in size, and the only submucosal cancer was below 5 mm in size and was a depressed lesion. Carcinoid tumors accounted for 15.6% of the lesions, and chronic nonspecific inflammation for 9.1%. An EPMR was performed on 4 lesions which were larger than 10 mm. There were no complications such as bleeding, perforation, or recurrence.
CONCLUSIONS
EMR and EPMR are useful endoscopic resection techniques, especially for sessile, flat, and depressed neoplastic lesions. Lesions up to 15~20 mm in size are good candidates for EMR and those up to 40 mm for EPMR. At the same time, a carefully performed procedure is mandatory to prevent recurrence or complications such as bleeding or perforation.

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