Annals of Coloproctology

Volume 16(5); October 2000

Original Articles

Expression of MMP-2 (Matrix Metalloproteinase Type 2) and TIMP-2 (Tissue Inhibitor of Metalloproteinase Type 2) in Color.: Baek, Moo Jun , Chu, Chong Woo , Chae, Man Kyu , Kim, Sung Yong , Lee, Moon Soo , Kim, Chang Ho , Kim, Dae Jung , Hwang, Kyu Yoon , Song, Ok Pyung; J Korean Soc Coloproctol. 2000;16(5):285-292.

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Abstract PDF: PURPOSE
The matrix metalloproteinases (MMPs) have been implicated in proteolysis of basement membrane for initiation of metastatic cascade. Tissue inhibitors of metalloproteinases (TIMPs) are specific inhibitors of MMPs. The purpose of this study was to evaluate the expression of MMP-2 and TIMP-2 in human colorectal carcinomas.
METHODS
The paraffin blocks of 140 colorectal carcinomas were recalled and immunostained with monoclonal antibodies specific for MMP-2 and TIMP-2. These antibodies were effective on formalin fixed, paraffin embedded sections. The rate of stain was estimated, and the relationships between the expression and the stage, the differentiation, lymph node metastasis, distant metastasis and the survival rate were assessed.
RESULTS
MMP-2 was present in 31.4% of colorectal cancers. TIMP-2 was identified in 63.6% of tumors. The expression of MMP-2 was significantly associated with the presence of lymph-node metastasis, the stage, and the presence of distant metastasis. However the expression of TIMP-2 was not correlated with any risk factors.
CONCLUSIONS
These results suggest that MMP-2 could predict the ability of cancer invasion and be used as a prognostic factor for the colorectal adenocarcinoma.

Modified Anal Cushion Preserving Hemorrhoidectomy.: Bae, Ok Suk , Park, Seong Dai; J Korean Soc Coloproctol. 2000;16(5):293-295.

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Abstract PDF: PURPOSE
The ligation and excision method of hemorrhoids is a simple and rapid procedure, but it has a drawback of possible damage to the anal cushion. To solve this problem, we tried to preserve the anal cushion with superficial ligation and excision method of anorectal mucosa including removal of the hemorrhoidal tissues from the anal cushion after submucosal dissection. However, it was difficult to remove hemorrhoidal vessels with this procedure and it was time consuming. To minimize these problems, we originally tried a new cushion preserving procedure in 15 patients during 1 year.
METHODS
R> After mobilization of the anorectal mucosa, hemorrhoidal tissues and anal cushion from the anal sphincter muscles, the anorectal mucosa was first dissected from the anal cushion, then the hemorrhoidal vessels were removed and the remaining anal cushion was reattached to the anal sphincter muscles.
RESULTS
The results of this surgery have been satisfactory with only one postoperative bleeding and two anal skin tags.
CONCLUSIONS
This method is simple and convenient for preservation of anal cushion with minimal complications when compared with the conventional method of anal cushion preservation.

The Effect of Intraoperative Anal Sphincter Injection of Ketorolac Tromethamine for Pain Control after Hemorrhoidectomy.: Park, Jea Kun , Kim, Nam Kyu , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(5):296-301.

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Abstract PDF: PURPOSE
An adequate pain control is one of important factors for obtaining good outcomes in the ambulatory basis of hemorrhoidectomy. There have been many methods for pain control after hemorrhoidectomy such as narcotics, various kinds of analgesics, etc. The aim of this study is to compare intraoperative internal anal sphincter injection of Ketorolac tromethamine and other two conventional methods for pain control.
METHODS
A total of 56 patients with hemorrhoid grade III or IV underwent surgery between May and October 1999, and prospectively assigned to three groups in the consecutive order. The group was divided in Group 1: [Ketorolac tromethamine (Tarasyn) 60 mg intrasphincteric injection intraoperatively and 30 mg IM/prn?10 mg po/6hrs], Group 2: [No intraoperative injection and maintain pain control with Tarasyn 30 mg IM/prn/10 mg po/6hrs], and Group 3: [No intraoperative injection and maintain pain control with Pethidine (Demerol) 50 mg IM/prn and Ibuprofen 400 mg/Paracetamol 500 mg/Codeine 20 mg (Myprodol) po/8hrs]. The post operative data and pain scoring was performed on the questionnaire with Point box scale (BS-11) and Behavioral rating scale (BRS-6) each 24 hours during 5 days after surgery.
RESULTS
There are 22 patients in the Group 1, 16 in the Group 2 and 18 patients in the Group 3. The median age of the Group 1 is 42.5, Group 2, 44.5 and Group 3, 45 years. The pain score on the first day after surgery in group 1 was significantly lower than group 2 (p<0.05) in the both pain scoring scale but was no differences between group 1 and 3. On the fifth day after surgery group 3 was significantly lower than both group 1 and 2 in the point box scale (p<0.05). The urinary retention rate and the day of first bowel movement after surgery show no differences among three groups (p>0.05).
CONCLUSIONS
Intraoperative internal anal sphincter injection of Ketorolac tromethamine shows a better pain control than conventional methods in early postoperative period. Therefore it might be helpful for patients to go home on the day after surgery, and strong pain killer to control pain after discharge will be needed.

Surgical Treatment of Right Colon Diverticulitis.: Lee, Do Sang , Lee, Chul Soo , Sung, Gi Young , Song, Moo Hyung , Kim, Wook , Park, Il Young , Won, Jong Man; J Korean Soc Coloproctol. 2000;16(5):302-308.

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Abstract PDF: PURPOSE
Diverticular disease of the cecum and ascending colon is a relatively uncommon disease and there are some difficulties in the accurate preoperative diagnosis and the proper surgical treatment. This study is aimed to determine what is the proper procedure during the emergency operation of right colon diverticulitis.
METHODS
This study is a retrospective clinical analysis of 86 cases of the right colon diverticulitis from January 1992 to December 1999.
RESULTS
1) The incidence of right colon diverticulitis (RCD) was 2.1% of that of appendicitis and the RCD to sigmoid colon diverticulitis ratio was 9.6:1.2) The highest incidence was noted at the fourth decades and average age was 37 years. Male to female ratio was 1.9:1. 3) Most patients (73 cases, 85%) had right lower quadrant abdominal pain. 4) The duration of symptom was less than 3 days in 54 cases (63%). 5) The preoperative confirmation by radiologic work-up was not decisive, but barium enema might be more accurate than other studies and CT was more accurate method than ultrasound. 6) The correct preoperative diagnosis was made only in 13 cases (15%) and the remaining misdiagnoses were appendicitis with or without complications in 72 cases (83%). 7) Operative procedures varied markedly according to multiplicity, extent of inflammation and complications; diverticulectomy and appendectomy in 48 cases (56%), ileocecectomy in 15 cases (17%) and right hemicolectomy in 11 cases (13%). 8) The most commom postoperative complication was wound infection. 9) Among the 30 cases who took diverticulectomy or diverticulectomy and appendectomy, remained diverticulums were found in 14 cases (47%), especially 11 cases (37%) on the right colon. And so multiplicity of right colon reached about 37%.
CONCLUSIONS
The authors suggest that one should suspect RCD in fourth decade patients with right lower quadrant pain for more than 3 days with unusual clinical findings. Barium enema can be used because of the high accuracy rate but CT is a safe tool in complicated or urgent situation. The operative modalities should be selected on the extent of the disease and it is sufficient to treat a single diverticulitis with diverticulectomy or diverticulectomy and appendectomy but right hemicolectomy should be recommanded in the suspicious multiplicity or malignancy.

Clinical Analysis of Fournier's Gangrene.: Park, Jung Hyun , Park, Seung Chul , Jeon, Hae Myung , Jung, Jae Hee , Kim, Won Woo , Oh, Seug Taek , Kim, Jung Soo , Kim, Wook , Kim, Eung Kook , Jang, Suk Kyun; J Korean Soc Coloproctol. 2000;16(5):309-315.

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Abstract PDF: PURPOSE
Fournier's gangrene is a rapidly progressive (and aggressive), necrotizing fasciitis of the genitalia and perineum. Despite the use of broad spectrum antibiotics and surgical debridement, morbidity and mortality remain significant. The purpose of this study is to investigate and evaluate the clinical and laboratory characteristics of this disease.
METHODS
We reviewed 17 cases of Fournier's gangrene during 10 years from January, 1990 to December, 1999. We retrospectively analyzed these patients and considered several factors, which were age, sex, combined and etiologic factors, symptom and location of infection, duration of admission, operation and its complication, result of bacterial culture and sensitivity of antibiotics, morbidity and mortality.
RESULTS
the mean age was 47.4 years with an age range of 3 to 77. The etiologies included unknown (65.7%), anorectal infection (23.5%) and hemorrhoidectomy (11.8%). The combined diseases (predisposing factors) included diabetes mellitus (52.9%), alcohol abuse, steroids or chemotherapy, liver cirrhosis and malignancy. Aggressive surgical debridement with broad spectrum antibiotics therapy was done on 16 patients, 1 patient refused operation. There were 3 colostomy cases, one orchiectomy, one suprapubic cystostomy case. The most common cultured organism was E.coli, 8 cases (53.3%). The mean hospital stay was 32.9 days. 3 patients (17.6%) were died due to sepsis and multiorgan failure.
CONCLUSIONS
Our results showed that the early recognition, aggressive debridement of devitalized tissue, antibiotic therapy, search for primary source are considered as the treatment of choice for Fournier's gangrene.

Clinical Significance of Subtotal or Total Colectomy in Obstructing Left Side Colon Cancer.: Jung, Jae Ho , Lee, Yun Sik , Park, Jin Hyun , Lee, Byung Chul; J Korean Soc Coloproctol. 2000;16(5):316-322.

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Abstract PDF: PURPOSE
Although the cancer of the right side colon is usually managed by primary anastomosis following resection, but the optimal management of obstructing left side colon cancer is controversial. So, we performed this study to evaluate the feasibility and safety of subtotal or total colectomy as a method of one-stage operation in malignant obstruction of left side colon.
METHODS
We analyzed retrospectively 35 patients with obstructing left side colon cancer among 74 cases of obstructing colorectal carcinoma who were treated surgically at the Wallace Memorial Baptist Hospital from January 1989 to December 1998.
RESULTS
One-stage operation was performed in 16 patients (subtotal colectomy in 13, total colectomy in 3). Staged operation was performed in 15 patients (two-stage operation in 10, three-stage operation in 5). Palliative colostomy was performed in 4 patients. Postoperative complications had been developed in 6 patients (37.5%) with subtotal or total colectomy group and in 7 patients (46.7%) with staged operation group. The postoperative frequent bowel movement was shown in 13 patients (81.2%) with subtotal or total colectomy group and in 7 patients (70.0%) with staged operation group. Frequent bowel movement was improved with antidiarrheal medications within 3 months. Operative mortality was 6.3% (1 patient) in subtotal or total colectomy group and 13.3% (2 patients) in staged operation group. There was no significant difference in morbidity and mortality statistically between two groups.
CONCLUSIONS
We believe that subtotal or total colectomy as a method of one-stage operation can be performed with acceptable morbidity and mortality in selected patients with obstructing left side colon cancer.

Low Anterior Resection for Rectal Cancer Using Double Stapling Technique.: Cho, Cheon Chun , Baek, Moo Jun , Kim, Sung Yong , Lee, Moon Soo , Kim, Hyung Chul , Kim, Chang Ho , Song, Ok Pyung , Park, Hee Ju; J Korean Soc Coloproctol. 2000;16(5):323-327.

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Since its introduction by Knight and Griffen in 1980, the double stapling technique has gained widespread popularity in performing the low anterior resection for the rectal cancer. But their effectiveness is not clear. The purpose of this study is to evaluate the usefulness of the low anterior resection using the double stapling technique for rectal cancer in an oncological, technical standpoints.
METHODS
Perioperative and follow up data were retrospectively reviewed in all patients undergoing the low anterior resection using the double stapling technique by same surgeons for rectal cancer over a 2.5 year period.
RESULTS
Thirty two rectal cancer patients had double stapling technique anastomoses. There was no postoperative mortality. Intraoperative complications including rectal wall tearing, incomplete doughnuts, misfiring and extraction related problems occurred in 9 of 32 patients (28.2%). Early and late postoperative complications occurred in 9 (28.8%) and 8 (24.9%) of 32 patients. Early anastomotic leak developed in 1 patient (3.1%) and anastomotic site bleeding developed in 2 patient (6.3%). Lately, the local recurrence occurred in 3 patients (9.3%) and anastomotic site stricture occurred in 3 patients (9.3%).
CONCLUSIONS
The low anterior resection using the double stapling technique has relatively low rate of leakage, stricture, local recurrence. The double stapling technique can be performed for mid or low rectal cancer with greater safety and facility.

A Study of Anal Manometric Finding after Low Anterior Resection of Rectal Cancer.: Min, Byung Wook , Ryu, Keun Won , Kim, Seon Han , Choi, Sang Yong , Goo, Bum Hwan , Park, Young Tae , Moon, Hong Young; J Korean Soc Coloproctol. 2000;16(5):328-333.

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Abstract PDF: PURPOSE
Low anterior resection, irrespective of anastomotic technique, may be associated with frequent bowel movement and other bowel management difficulties. The aim of this study was to access the anorectal function after low anterior resection of the rectal cancer.
METHODS
We studied 28 patients who had mid and low rectal cancer (average 8.3 cm above the anal verge) had undergone low anterior resection using stapling suture devices (average level of anastomosis was 3.8 cm above anal verge) and anal manometry was undertaken 95 times preoperatively (N=28) and 3 month (N=26), 6 months (N=22) and 12 months (N=19) postoperatively from 1992 to 1995 in Korea University Guro Hospital.
RESULTS
Maximum resting pressure was reduced after resection (from 64.7 mmHg to 42.7 mmHg, change ?22 mmHg) but gradually increased and returned to preoperative level at 12 months postoperatively. Minimum perceived volume was decreased after operation (from 40.3 ml to 25 ml change of ?15.3 ml) and this change persist at 12 months postoperatively. Rectoanal inhibitory reflex was present in all patient before surgery but disappeared in most of the patient after operation. Reflex returned to normal in 4 of 22 patients at 6 months later and in 7 of 19 patients at 12 months after operation. Maximum squeezing pressure and maximum tolerable volume were not decreased after operation.
CONCLUSIONS
Anorectal function (maximum resting pressure, minimum perceived volume and rectoanal inhibitory reflex) was reduced immediately after low anterior resection of rectal cancer. But this functional changes returning to normal at 6 months and most of the patients had good function at 12 months after operation.

Ultralow Anterior Resection and Coloanal Anastomosis for Distal Rectal Cancer Functional and Oncologic Results.: Kim, Nam Kyu , Lim, Dae Jin , Yun, Seong Hyeon , Lee, Kang Young , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(5):334-338.

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Abstract PDF: PURPOSE
Coloanal anastomosis (CAA) following ultralow anterior resection became more popular techniques for preservation of anal sphincter in distal rectal cancer. The purpose of this study is to evaluate a functional and oncologic safety of patients who underwent ultralow anterior resection and coloanal anastomosis for distal rectal cancer.
METHODS
Forty-eight patients underwent coloanal anastomosis following ultralow anterior resection between January 1988 and January 1998. Main operative techniques were total mesorectal excision with autonomic nerve preservation. Colonic J pouch was made 8 cm in length with GIA 95. All patients were followed up for fecal or gas incontinence, frequency of bowel movement and local or systemic recurrences.
RESULTS
Mean tumor distance from anal verge was 4.0 cm. Postoperative complications were transient urinary retention (N=7), anastomotic stenosis (N=3), anastomotic leakage (N=3), rectovaginal fistula (N=2), cancer positive margin (N=1; patient refuses reoperation). Overall recurrences occurred in 7/48 (14.5%). Local recurrence (N=1) and systemic recurrence (N=1) in Astler-Coller stage B2, local recurrence (N=1), systemic recurrence (N=2) and combined local and systemic recurrence (N=2) in Astler-Coller stage C2. Mean frequency of bowel movement were 6.1 per day at 3 month, 4.4 at 1 year and 3.1 at 2 years. Kirwan grade for fecal incontinence were 2.7 at 3 months, 1.8 at 1 year and 1.5 at 2 years.
CONCLUSIONS
With careful selection of patients and good operative techniques, CAA can be performed safely in distal rectal cancer. Normal continence and acceptable frequency of bowel movements can be obtained at 1 year after operation without compromising the rate of local recurrence.

Case Reports

Four Cases of HNPCC Including Two Cases with Synchronous Stomach Cancer.: Park, Seon Ja , Jung, Yeon Soon , Chang, Seong Hoon , Son, Ho Sung , Lee, Byoung Kun , Park, Moo In , Ahn, Byung Kwon , Baek, Sung Uhn , Koo, Ja Young; J Korean Soc Coloproctol. 2000;16(5):339-345.

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Abstract PDF: Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominant disease characterized by early manifestation of colorectal cancer (CRC), occurrence of multiple colorectal tumors and high frequencies of extracolonic malignancies. Evaluation of clinical findings in concert with a well-documented and extended pedigree and genetic studies of colorectal cancer can identify person who are at high risk and who thereby might benefit from targeted early detection and primary prevention programs. Here we report 4 cases of HNPCC including 2 cases with synchronous gastric cancers.

A Case of Appendiceal Mucocele with Concominant Colon Cancer.: Yang, Sang Seok , Lim, Seon Hee , Song, Chan Ho , Sheen, Dong Hyuk , Lee, Jee Youn , Han, Yoon Ju , Lim, Byeong Cheol , Kim, Nayoung , Lee, Kyeheui , Yang, Dae Hyeon , Choi, Shin Eun; J Korean Soc Coloproctol. 2000;16(5):346-350.

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Abstract PDF: The appendiceal mucocele is a rare disorder, usually found incidentally during ultrasonography or radiologic studies. Mucoceles of the appendix include benign or malignant disease. Both of benign cystadenoma and malignant cystadenocarcinoma are characterized by an obstructed, mucin-filled appendix displacing the cecum. We experienced a case of partial obstruction of large bowel who had a cystadenoma at appendix and a colon cancer at other site on operation field. Here in, we report a case of appendiceal mucocele and concominant colon cancer with the review of literatures.

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