Annals of Coloproctology

Volume 15(5); December 1999

Randomized Controlled Trial

A Prospective Study on the Relationship between Postoperative Urinary Retention and Amount of Infused Fluid during Surgery of Benign Anal Diseases under Spinal Anesthesia.: Lee, Chai Young , Kim, Hee Cheol , Lee, Dong Hee; J Korean Soc Coloproctol. 1999;15(5):357-361.

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Abstract PDF: PURPOSE
Urinary retention is a frequent postoperative complication after benign anorectal surgery. Factors, known to affect postoperative urinary retention, are age, sex, anesthetics, operative method, operative time and perioperative fluid injection. This study was performed to know whether the incidence of urinary retention might be controlled by reducing the amount of perioperative fluid.
METHODS
Eighty patients underwent surgery for hemorrhoids and chronic anal fissures were allocated into two groups, fluid restriction group (n=37) and hydration group (n=43). All patients were consecutively randomized from May 1998 to January 1999 and they were under 50 years old without urologic abnormality. Fluid was infused at 100 ml/h from the midnight then it's rate was changed into 10 ml/h for 4 hours from the beginning of the anesthesia for the restriction group, whereas 1000 ml/h only during operation for the hydration group. Thereafter it was changed into the same rate with 100 ml/h on both groups.
RESULTS
There was no significant differences with regard to age, sex, operation time, degree of pain and use of analgesics between two groups. Although there was a significant difference in the total volume of the infused fluid (Restriction group: 53.4 119.5 ml versus Hydration group: 778.6 319.0 ml, mean SD, p<0.001). Catheterization was done in 29 patients of the restriction group (78.4%) and 37 patients of the hydration group (86.0%), respectively. The frequency of catheterization was 1.3 0.7 times in the former and 1.6 0.7 times in the latter group.
CONCLUSIONS
A strict restriction of fluid infusion appeared to be unnecessary for the purpose of preventing the urinary retention during surgery of benign anorectal diseases with spinal anesthesia.

Original Articles

Is Early Postoperative Oral Intake Safe after Elective Colorectal Surgery?.: Chung, Woo Shik , Jun, Si Youl; J Korean Soc Coloproctol. 1999;15(5):362-367.

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Abstract PDF: PURPOSE
The routine use of postoperative nasogastric decompression after abdominal surgery has been challenged. Furthermore, investigators have recently shown that early postoperative oral feeding is safe and generally well tolerated. This study was aimed to determine whether or not early postoperative feeding is safe after elective colorectal surgery.
METHODS
All patients who underwent elective colorectal surgeries between June 1998 and March 1999 were permitted to take oral intake one day after the operations. The patients were compared with other patients, who had underwent elective colorectal surgeries between September 1997 and June 1998 and permitted to have a meal after resolving postoperative ileus. The nasogastric tube was removed from all patients immediately after surgery. The patients were monitored for the time of ileus resolution, nausea/vomiting, abdominal distension, nasogastric tube reinsertion and complications.
RESULTS
Fifty-one patients were studied, 24 patients in early feeding group and 27 patients in traditional feeding group. Eighteen patients (75.0%) in the early feeding group tolerated the early oral intake. There were no significant differences between two groups in the time for resolution of ileus (3.46 1.38 days vs 3.56 1.80 days), nausea/vomiting (33.3% vs 29.6%), abdominal distension (16.6% vs 14.8%) and nasogastric tube reinsertion (12.5% vs 7.4%). No significant difference was noted in complications such as wound infection, pulmonary problems, intestinal obstruction and anastomotic leak.
CONCLUSIONS
Early oral intake after elective colorectal surgery was safe and most of the patients tolerated it. And it may become a kind of managements after elective colorectal surgery.

Clinical Analysis of Intestinal Volvulus.: Shin, Seung hyun , Baek, Moo Jun , Kim, Sung Yong; J Korean Soc Coloproctol. 1999;15(5):368-375.

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Abstract PDF: PURPOSE
The intestinal volvulus is difficult to diagnose, and if the treatment and diagnosis are delayed, there is a risk of high mortality. This study was performed to ensure the more proper management method and diagnostic modality of volvulus.
METHODS
Between 1985 and 1998, 16 patients with a diagnosis of colonic and small intestinal volvulus were managed in Soonchunhyang University Chunan Hospital. Medical charts were reviewed, retrospectively and follow-up was done.
RESULTS
15 among the 16 patients with volvulus underwent the operation. The one case was diagnosed and expired before operation. The resection of the lesion and primary anastomosis had been generally selected as the procedure of choice. Segmental resection of the sigmoid colon with primary anastomosis was performed on 7 cases of the sigmoid volvulus. There were 6 cases of the small bowel volvulus, of which 5 cases got a segmental resection of the small bowel with primary repair and the one got a total resection of the small bowel with gastrocolostomy. The right hemicolectomy was performed in 2 cases which were the right colon volvulus. 9 cases of morbidity were developed; there were 5 cases of wound infection and others were enterocutaneous fistula, pulmonary infection, and septic shock respectively. There were three mortality.
CONCLUSION
If the small bowel volvulus is present or gangrenous signs are developed, and the management of the intestinal volvulus is delayed, there can be serious complications and the course can be life-threatening. Therefore, if gangrene or small bowel volvulus are suspected, operative management should be seriously considered.

Clinical Analysis of Patients with Acute Appendicitis Operated on during.: Lee, Dong Il , Choi, Sung In , Moon, Jae hwan; J Korean Soc Coloproctol. 1999;15(5):376-385.

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Abstract PDF: PURPOSE
During the night time decision making on patients suspicious of appendicitis is often difficult because diagnosis and timing for operation are frequently delayed. Therefore, we analyzed above cases and solution is suggested.
METHODS
This retrospective study included 360 patients who underwent laparotomies for suspected appendicitis at Hanil Hospital during one year, from March 1998 to Feb. 1999. They were divided into two groups according to presenting time to physician (Day time: 6 a.m. to 6 p.m., Night time: 6 p.m. to 6 a.m.). Sex & age distribution, time of presentation to physician, duration of symptoms, symptoms & physical findings, white blood cell counts, interval from presentation to operation, hospital stay, and pathologic diagnosis were compared.
RESULTS
There were no significant differences in sex & age distribution, duration of symptoms, symptoms & physical findings, white blood cell counts, pathologic diagnosis between the two groups. However, during the night time, the interval from presentation to operation was longer than that of the day time (9.15 hours versus 4.83 hours, p<0.001), the rate of delayed appendectomy during the night was 58.0%, the rate of negative laparotomy increased when appendectomy was delayed for more than 12 hours compared with less than 12 hours (28.1% vs 11.7%, p<0.01), and in the cases with perforated appendicitis, delayed appendectomy for more than 12 hours had longer hospital stay compared with less than 12 hours (12 days vs 9.44 days, p<0.01). Factors causing delayed appendectomy were related to the physician (42.5%), lack of anesthetic & nursing supports (19.5%), failure to structure the operation team (20.7%), and patient itself (17.3%). When white blood cell counts were rechecked in the next morning, levels above 10,000 cells/mm3 were highly associated with appendicitis in contrast to that below 10,000 cells/mm3 (91.7% vs 43.5%, p<0.002).

Prognostic Factors Influenced to the Recurred Colorectal Cancer and Treatments.: Kim, Sang Heon , Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 1999;15(5):386-396.

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Abstract PDF: PURPOSE
Recurrent disease after curative surgery for primary colorectal cancer is well-known problem. Recurred colorectal cancer, even hepatic metastasis, can be operable in case of non-systemic metastasis. In those cases, a favorable prognosis is expected. But, regrettably in most cases which showed recurrence after curative surgery poor prognosis was remained.
METHODS
In our hospital, we have experienced 98 patients with recurred colorectal cancer among 607 patients who had curative operation from Jan. 1980 to Feb. 1998. We analyzed retrospectively those patients and considered factors which influenced recurrence of disease and prognosis (type of recurrence, age, sex, location of tumor, histology of tumor, size of tumor, depth of tumor invasion, lymph node involvement, tumor stage, DNA ploidy pattern, serum CEA level, oncogene expression of tumor and reoperation).
RESULTS
1) The Mean of disease-free interval after curative operation was 15.9 months (range: 3.0~44.5 months). 2) Among total patients with recurrence, patients with local recurrence were 29 cases (29.6%), those with liver metastasis were 29 cases (29.6%), lung metastasis were 7 cases (7.1%), lung and liver metastasis were 7 cases (7.1%), peritoneal metastasis were 18 cases (18.4%), lymph node metastasis were 7 cases (7.1%), brain metastasis was 1 case (1.0%). 3) The curative reoperation was performed in 19 patients (19.4%). Those procedures were abdominoperineal resection (4), local perineal resection (6), hepatic resection (2), Hartmann's procedure (2), segmental resection of ileum (2), Whipple's operation (1), resection of ileal pouch in patient with FAP (1), oophorectomy (1). 4) Those factors which influenced recurrence were tumor stage, histologic type of tumor, depth of tumor invasion, lymph node status, preoperative serum CEA level. 5) The mean survival time of patients with recurred colorectal cancer was 25.1 months. The 36 months survival rate of patients with recurred colorectal cancer among various sites of recurrence was different significantly (p=0.04). Those patients with local recurrence showed most favorable prognosis (42.0% in 36 months survival rate) and those with liver metastasis showed worst prognosis (4.7%). 6) The 36 months survival rate of reoperative group was 54.3% and that of non-operative group was 20.5 months. The result of two groups was statistically different (p<0.001).
CONCLUSIONS
We concluded that those factors which influenced recurrence in colorectal cancer were tumor stage, histologic type, invasion depth, lymph node status, and preoperative serum CEA level. Also the survival rate of reoperative group was higher than that of non-operative group statistically.

Pelvic Exenteration for Locally Advanced Carcinoma Located in Sigmoid Colon and Rectum.: Jung, Byung Ok , Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 1999;15(5):397-404.

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Abstract PDF: PURPOSE
Extensive local growth of rectal carcinoma and sigmoid colon carcinoma without evidence of extrapelvic dissemination occurs infrequently but does represent a small number of potentially curable neoplasms. Such lesions may present with bulk-related problems such as pelvic pain and lower colonic obstruction or with rectum, the vagina, or the bladder. Even in the absence of distant spread, many of these patients will have unresectable disease and will undergo an incomplete resection or proximal colostomy for pallliation. In selected patients, some of the locally advanced rectal cancer may be curable if total pelvic exenteration is performed.
METHODS
This report describe a group of patients with locally advanced sigmoid or rectal carcinoma confined to the pelvis who underwent total pelvic exenteration at the Chonnam University Hospital.
RESULTS
Seven patients had received total pelvic exenteration within five years and they were all men. One patient among them had recurred rectal cancer after previous abdominoperineal resection. Four rectal cancer and three sigmoid colon cancer were included and the range of age was third to eighth decade. According to modified Dukes' stage, stage B3 were five, and C2 were two. Postoperative complications were presented in three patients. They were wound infection, mechanical ileus, and anastomotic leakage.
CONCLUSIONS
Postoperative death was presented in one patient due to sepsis with mechanical ileus. Long term follow up of these patients which was arranged from two to fourty-seven months showed five patients alive and one patient died.

Endoscopic Characteristics and Management of.: Kim, Hyun Shig , Cho, Kyung A , Kim, Kuhu Uk; J Korean Soc Coloproctol. 1999;15(5):405-416.

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Abstract PDF: PURPOSE
A laterally spreading tumor (LST) has its own characteristic features and growth pattern. Information about LST is scanty in Korea, therefore this study was designed in order to contribute to the literature.
METHODS
In this study, 43 patients with LSTs were included. The diagnoses were made by colonoscopy in all cases. Treatment options included endoscopic resection, transanal excision, and surgical resection. In reviewing and analyzing the cases, we made a special emphasis on size, classification, histology, and treatment.
RESULTS
The most frequent location was the rectum, followed by the sigmoid colon and the ascending colon in that order. Lesions smaller than 20 mm accounted for 69.8%. Granular homogeneous LSTs, 41.9%. Lesions larger than 20 mm, except granular homogeneous LSTs, showed an abrupt increase in malignancy rate. Tubular adenomas accounted for 65.1%. The overall malignancy rate was 20.9%, and the submucosal cancer rate, 9.3%. There were no malignancies in the granular homogeneous LSTs. The malignancy rate for the mixed-nodule type lesions was 33.3% (4/12), and the nongranular LSTs, 38.5% (5/13). Polypectomy was done in 37.2% of the lesions, endoscopic mucosal resection (EMR) in 16.3%, and endoscopic piecemeal mucosal resection (EPMR) in 16.3%. The overall endoscopic resection rate was 83.7% (36/43). EMR was applicable to lesions smaller than 20 mm, and EPMR to those larger than 20 mm. Transanal resection was done in 2 cases with lesions. Five cases were resected surgically. Four of them were submucosal invasive lesions, and one, a mucosal lesion which was wide and had initially been thought to be a submucosal cancer. There were two recurrences during the average 15-month follow-up period. The follow-up rate was 81.4% (35/43). Of these 2 recurring cases, one patient was treated endoscopically and the other, transanally.
CONCLUSIONS
LSTs show different behavior depending on the endoscopic classification. Granular homogeneous LSTs are seldom larger than 30 mm and are good candidates for endoscopic treatment. The mixed-nodule type and the nongranular type show a marked predisposition to malignancy when they are over 20 mm, and nongranular-type LSTs have a higher rate of submucosal invasive cancers. Thus, in the cases of the mixed-nodule and nongranular types, careful consideration should be given for deciding between endoscopic treatment and surgical resection. Complete resection should be assured to prevent recurrence, and follow-up surveillance is required in all lesions for more than 3 to 5 years.

Clinicopathological Analysis of Suspicious Attenuated Adenomatous Polyposis Coli.: Lee, Dong Hee , Ahn, Byeong Yul , Jeong, Choon Sik , Kim, Hee Cheol , Yu, Chang Sik , Yang, Suk Kyun , Min, Young Il , Kang, Kyung Hoon , Kim, Jin cheon; J Korean Soc Coloproctol. 1999;15(5):417-426.

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Abstract PDF: Familial adenomatous polyposis (FAP) is an inherited autosomal dominant syndrome caused by germ-line mutations of the adenomatous polyposis coli (APC) gene. Clinical diagnosis of familial adenomatous polyposis is usually based on the presence of >100 colonic adenomas, which, if left untreated, progress to colorectal cancer, typically at age under 40 years. Attenuated adenomatous polyposis coli is a variant of familial adenomatous polyposis and also has been described as "hereditary flat adenoma syndrome". Attenuated adenomatous polyposis coli is recognized by the occurrence of <100 (> or =5 or > or =10) colonic adenomas. It is tend to be located proximal to splenic flexure and a later onset of colorectal carcinoma than familial adenomatous polyposis. PURPOSE: This study was performed to analyze the clinicopathologic features of suspicious attenuated adenomatous polyposis coli, to document the occurrence of colorectal carcinoma, and to assess the definition of attenuated adenomatous polyposis coli.
METHODS
From June 1989 to June 1998, we reviewed 773 cases of colonic adenomas and compared with three groups (Group I, II, III) at Asan Medical Center. Median follow-up period was 16.4 months (range, 1 to 102 months).
RESULTS
The incidence of suspicious attenuated adenomatous polyposis coli (Group II) was 4.9%. The most common symptom was anal bleeding (36.9%). Median size and number of adenomas were 1.0 cm (0.2 to 7.5 cm), 2 (1 to 43), respectively.Location of adenoma was prevalent at right colon in Group II (P<0.05). In respect to the occurrence of carcinoma in situ (CIS), it was more frequently presented in Group II (13.5%) and Group III (13.6%) whereas 4.1% in Group I (P<0.05). Recurrence rates within 12 months after polypectomy or surgery in Group II was 13.5% whereas 5.6% in Group I (P<0.05).
CONCLUSIONS
Histopathology revealed suspicious attenuated adenomatous polyposis coli with villous component to be relatively correlated with occurrence of colorectal carcinoma. In suspicious attenuated adenomatous polyposis coli (Group II), the interval of the recurrence of the polyps was shorter than the control group with right colonic predominancy. These findings might be associated with genetic codominance of APC gene or other mutator genes.

Is Postoperative Radiotherapy Still Useful for the Rectal Cancer Patients in the Era of Total Mesorectal Excision?.: Kim, Bong Wan , Suh, Kwang Wook , Cho, Yong Kwan , Lim, Ho Young , Chun, Mi Son , Kim, Myung Wook; J Korean Soc Coloproctol. 1999;15(5):427-433.

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Abstract PDF: PURPOSE
The exact role of postoperative radiotherapy following curative surgery of rectal carcinoma has been debated. In this retrospective study, we examined the effect of radiotherapy on the survival and recurrence rate of rectal cancer patients who underwent total mesorectal excision (TME).
METHODS
Since June of 1994, we have recommended postoperative chemoradiation (6 cycles of 5-FU with folinic acid plus 5040 cGy external irradiation) for stage II and III rectal cancer patients. Among 134 stage II and III rectal cancer patients who underwent TME, 100 patients received postoperative chemoradiation (group A) and 34 patients decided not to receive radiation therapy (group B). For these two groups, survival and recurrence rates were compared. Follow-up times were 6 to 60 months (mean 24.7). There was no difference between two groups with regard to sex, stage of the disease, mean tumor location from dentate line, status of lateral margins, type of operation and mean follow-up duration. However, mean age was higher in group B (65.6 vs 53.9, P<0.05).
RESULTS
The overall recurrence rate showed no difference between two groups (28.0% in group A vs 21.0% in group B, P>0.05). Local recurrence rate was also similar (11.0% vs 3.0%). There was no significant difference in duration between surgery and initial recurrence (14.0 months vs 11.0 months, P=0.18). The 5-year-disease-free survival rate was 57.0% in group A and 63.0% in group B (P=0.33).
CONCLUSION
In this study, we found no beneficial effect of postoperative radiation therapy following TME for the rectal cancer.

Is Laparoscopic Procedure Adequate for Colorectal Cancer Surgery?.: Kim, Jae Hwang , Huh, Jin Myeung , Yoon, Sung Su , Kim, Sang Woon , Shim, Min chul , Kwun, Koing Bo; J Korean Soc Coloproctol. 1999;15(5):434-442.

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Abstract PDF: PURPOSE
To evaluate the possibility that laparoscopic procedure could perform surgeries keeping the principle of oncologic surgery.
METHODS
From July 1993 to June 1996, thrity patients undergone laparoscopic assisted colon and rectal resections (LR) for malignant disease at Yeungman university hospital. Margins of resection and lymph nodes (LNs) recovered were compared with those of thirty stage matched open resection cases (OR, n=30) retrospectively. There was no operative mortality in both group. Operative techniques used in LR vs OR were colectomy, 5:6; anterior resection, 6:5; low anterior resection, 11:12 and abdominoperineal resection, 8:7. Parameters were analgesic use, duration of postoperative ileus, operative time, hospital stay, margins of rescetion, lymph node yield (LNs), and recurrence.
RESULTS
Patients who underwent LR had less pain, a shorter period of postoperative ileus and hospital stay than patients who underwent OR. But, the length of operative time was greater for patients undergoing LR. Mean lymph node yield in the laparoscopic group was 16 compared with 18.1 in the open group (P=0.560). Average margins of resection in LR vs OR were 13.9 cm vs 14.1 cm proximally (P=0.823), 3.6 cm vs 5.2 cm distally (P=0.498). In no case did the margins contain tumor. There was no statistical significance in dissected LNs and the length of both resection margins in both groups. Recurrence was similar in both groups.
CONCLUSIONS
In this study, there is no evidence that laparoscopic technique is inadequate in following the cancer surgery principle.

Case Reports

A Case of Colonic Pseudo-obstruction Two case reports.: Hong, Seung Kon , Park, Jung hyun , Kim, Kee Hwan , Jeon, Hae Myung , Kim, Jeong Soo , Oh, Seung Taek , Chae, Hiun Suk , Yoo, Seung Jin , Kim, Jae Sung; J Korean Soc Coloproctol. 1999;15(5):443-449.

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Abstract PDF: Pseudo-obstruction of the colon, first described by Ogilvie1 in 1948 and usually referred to as Ogilvie's syndrome, is a specific variety of adynamic ileus. It is characterized by massive colonic dilatation with a clinical and radiologic findings very similar to mechanical large intestinal obstruction, except that there is no organic obstruction. The cecum is usually the site of greatest dilatation, though the whole large bowel may be involved, from the terminal ileum up to the rectosigmoid junction. The dilatation is rapidly progressive and, if untreated, may even cause cecal necrosis and perforation, with highly increased mortality rate. The syndrome has been associated with various metabolic and organic dysfunctions, and has been observed following gynecologic as well as simple surgical procedures; yet its occurrence has been rather uncommon. The followings are two case reports with this syndrome.

Two Cases of Unusual Abscesses in Right Colon Cancer.: Lee, Chae Young , Jeon, Hae Myung , Kim, Jeong Soo , Oh, Seung Taek , Kim, Won Woo , Kim, Kee Hwan , Chae, Hiun Suk , Ahn, Bo Young; J Korean Soc Coloproctol. 1999;15(5):450-456.

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Abstract PDF: Two unusual presentations of carcinoma of the right colon are described. One of the two patients presented with huge abdominal abscess with adhesed to surrounding small bowels and the other presented with anterior abdominal wall abscess. Colonic carcinoma very rarely presents as abdominal wall abscess, retropertoneal abscess, groin inflammatory mass, subcutaneous thigh abscess, and obstruction with diastatic rupture of cecum. The appearance of the abscess may antecede any gastrointestinal symptoms, thus lessening the surgeon's suspicion of carcinoma. The literature has been reviewed and the pathology that characterizes such lesions and this management is discussed. The bulky colonic tumors with extensive local invasion and negative mesenteric lymph nodes have a relatively good prognosis if adequate resection is performed.

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