Annals of Coloproctology

Volume 18(1); February 2002

Original Articles

Expression of a Novel 90 kDa Heat Shock Protein in Colorectal Tumor.: Choi, Dae Hwa , Cho, Hong Rae , Ko, Byung Kyun , Nah, Yang Won , Nam, Chang Woo , Kim, Gyu Yeol , Im, Young Cheol , Park, Kun Choon , Kim, Do Ha , Park, Jae Hoo , Min, Young Joo , Suh, Fae Hee , Park, Jeong Woo; J Korean Soc Coloproctol. 2002;18(1):1-6.

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Abstract PDF: PURPOSE
When cells are subjected to a wide variety of stressful stimuli, they respond by increasing the synthesis of specific stress proteins. Stresses include heat shock, nutrient deprivation, oxygen radicals, toxic metal and viral infection. Major stress proteins are Hsp 27, Hsp 60, Hsp 70 (9), Hsp 90 (3) and Hsp 100 (1). Previously a novel 90 kDa stress protein has been reported to be induced in fish cells by virus infection. The novel 90 kDa stress protein is different from well-known major stress protein in size, antigenicity, cellular localization. The novel 90 kDa stress protein was found to be present in various kinds of cells including human cells and its expression was increased in human carcinomas. The purpose of this study is to evaluate the expression of the novel 90 kDa stress protein in human colonic mucosa of normal tissue, adenoma and adenocarcinoma using immunohistochemical method.
METHODS
85 colon tissues were screened for the expression of the novel 90 kDa stress protein; 85 normal colonic mucosa, 20 colonic adenoma and 65 colonic adenocarcinoma. The tissues were stained with monoclonal antibody against the novel 90 kDa stress protein. In scoring system, tissue sections with immunostained area above 10 % were decided to be positive and, among the positive, the tissue sections were divided into three score, 1, 2, and 3, based on the staining intensity and positive area proportion. The tissue sections with immunostained area below 10% were decided to be negative and grouped into 0 score. Correlation of immunohistochemical expression was analysed by using SPSS version 10.0 statistically.
RESULTS
The expression of the 90 kDa stress protein was significantly different among normal colonic mucosa, colonic adenoma, and colonic adenocarcinoma and the percentage of positive samples were 14.1%, 80.5%, and 95.4% respectively. This result suggests that the expression level of the novel 90 kDa stress protein was extremely low in normal tissue but increased significantly in adenocarcinomatous tissues.
CONCLUSIONS
The expression of the novel 90 kDa stress protein was increased significantly with transformation of the normal colon tissue to malignancy. This suggests the possibility that this novel 90 kDa stress protein play some role in cancerous transformation of colon tissue.

Prevalence of Anatomic Anal Stenosis in Patients with Chronic Anal Fissure and Results of Lateral Internal Sphincterotomy.: Cho, Dong Yoon , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 2002;18(1):7-9.

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Abstract PDF: PURPOSE
The aim of this study was to estimate the prevalence of anatomic anal stenosis in patients with chronic anal fissure (CAF) and ascertain the results of lateral internal sphincterotomy (LIS) using a new calibrator.
METHODS
Ninety-eight adults with CAF and a control group of 40 normal adults underwent anal calibration under spinal anesthesia. The calibrator was a conical design and the diameter was scaled in increments of 1 mm. The calibration was standardized and the reliability of it was assessed by two independent examiners for the same group (n=45). Confounding effects of age, sex, body weight, and height on the anal caliber were studied. The internal sphincter was divided to the level of the dentate line during LIS.
RESULTS
The anal caliber was 34.6 +/- 1.4 mm (mean +/- SD) in the control group and 28.7 +/- 3.0 mm (mean +/- SD) in patients with CAF. Excellent correlation was obtained between the two examiners (r=0.958). The confounding effects of age, sex, body weight, and height were not significant. Therefore, anal stenosis was defined as when the measurement was 31 mm or below (mean-2SD of control value). Stenosis was present in 82 of 98 patients (84%) with CAF. Patients with stenosis had an anal caliber of 27.9 +/- 2.5 mm, with a range of 21 to 31 mm. Following LIS, 91 of 98 patients (93%) with CAF attained the normal range, two patients still had stenosis, and five patients had an anal caliber exceeding the normal value.
CONCLUSIONS
Anatomic anal stenosis was found in 84% of the patients with CAF. Ninety three percent of these patients attained a normal anal caliber, 2 percent of the patients still had stenosis and 5 percent of the patients had an anal caliber exceeding the normal value after LIS.

The Usefulness of a Harmonic Scalpel(R) for Hemorrhoidectomy.: Choe, Kyu Hyung , Kim, Yu Yong , Chang, Eu Myung; J Korean Soc Coloproctol. 2002;18(1):10-14.

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Abstract PDF: PURPOSE
The aim of this study was to compare conventional scissors and Harmonic Scalpel(R) hemorrhoidectomy.
METHODS
Two hundred and five patients were prospectively assigned to two groups in the consecutive order. The group was divided into Group A (Harmonic Scalpel(R) excision; n=101) and Group B (conventional scissor excision; n=104). All other aspects of surgery and anesthesia were standardized. Intramuscular opiate was available on demand during the postoperative period, and analgesic requirements were also recorded. All patients noted their pain on a daily basis using a visual analogue scale (0=no pain; 10=worst pain). The length of hospitalization, operative time and postoperative complications were also analyzed.
RESULTS
The operative time was 16.6 +/- 0.9 minutes 25.3 +/- 0.8 minutes in Group A and B, respectively (p<0.01). Length of hospital stay was 4.1 +/- 0.1 and 4.5 +/- 0.1 days (p<0.05). Pain scores in the group A were significantly lower than in the group B (p<0.01). Analgesic requirements were also significantly less in group A (p<0.05). Postoperative complications, such as urinary retention, fecal impaction and skin tags were rarer in group A. One patient in group A and two patients in group B developed secondary hemorrhage, but no patient had anal stricture.
CONCLUSIONS
The Harmonic Scalpel(R) excision significantly shortens the operative time for hemorrhoidectomy with less blood loss and postoperative pain without remarkable early or late postoperative complications.

Laparoscopic Anterior Resection for Rectal Cancer: an Analysis of Early Experiences.: Yoon, Jin Seok , Kim, Seon Han , Lee, Dong Keun , Moon, Hong Young; J Korean Soc Coloproctol. 2002;18(1):15-21.

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Abstract PDF: PURPOSE
Regarding laparoscopic colon cancer resection, the surgical society is currently waiting for the long-term oncologic result of multi-center randomized trials with over thousands patients. For rectal cancer surgery, however, laparoscopic approach is in much debate. The aim of this study was to evaluate the feasibility and safety of laparoscopic anterior resection for rectal cancer, based on the early results of our initial experiences.
METHODS
Nineteen patients (M:F=10:9, median age 55 years) underwent laparoscopic anterior resection for rectal cancer among the 71 malignant neoplasms of the colon and rectum resected laparoscopically between October 1997 and February 2001. All clinical data were prospectively collected. During the initial period, rectosigmoid lesion was the only indication. With the development of a new roticulating stapler for distal rectal transection, the indication was extended to the lesions of the upper and middle third of the rectum. The operation parameters (operation time, blood loss), tumor parameters (stage, resection margins, and number of resected lymph nodes), and postoperative clinical course (bowel function recovery, hospital stay, and complication) were evaluated.
RESULTS
The tumors located in the rectosigmoid (n=13), upper third of the rectum (n=4), and the middle third of the rectum (n=2). Four cases were converted to an open procedure. The reasons for conversion were bladder invasion (1), tumor located too low (1), inappropriate distal resection margin (1), and tumor fixation to the sacrum (1). Median operation time was 210 minutes. Median blood loss was 400 ml. Median times to passage of flatus and oral feeding were 2 days and 3 days after surgery, respectively. Median length of the distal resection margin was 3 cm. Median number of harvested lymph nodes were 22. TNM stages were as follows; 0:I:II:III:IV=1:2:6:9:1. Two anastomotic leaks occurred in the converted patients. There were no major postoperative complications in other patients. There was no operative mortality. Median time to hospital discharge was 13 days. During a median follow-up period of 15 months, one patient developed distant metastases. There were no local/port sites recurrences.
CONCLUSIONS
Laparoscopic anterior resection is a safe alternative to conventional surgery for rectal cancer. Long- term follow-up is mandatory to evaluate the oncologic safety.

Immunohistochemical Study of KAI1, a Tumor Metastasis Suppressor Gene, Expression in Rectal Cancer.: Kim, Ik Yong , Kim, Sang Hee , Kim, Jong Seok , Cho, Mee Won , Kim, Dae Sung , Rhoe, Byoung Seon; J Korean Soc Coloproctol. 2002;18(1):22-29.

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Abstract PDF: PURPOSE
KAI1/CD82 gene is a recently identified metastasis suppressor gene on human chromosome 11p11.2. Alteration to or reduction of this molecule may allow tumor cells to invade the surrounding tissue and blood vessels. Decreased KAI1 expression seems to be involved in the progression of human prostate, lung and possibly breast cancer, and recently has been demonstrated in several colorectal cell lines. The aim of this study is to determine whether the gene is altered to investigate it in the progression and metastatic process of rectal carcinoma. In addition, its prognostic significance is also evaluated.
METHODS
Total 108 tumor samples from primary, metastatic rectal carcinoma were prepared for immunohistochemical study with an anti-KAI1 polyclonal antibody. To analysis the correlation between KAI1 expression and clinicopathological parameter and to evaluate for relation expression and survival.
RESULTS
Decrease of KAI1 protein expression was associated with the depth of invasion of tumor (P < 0.0001) and node metastasis (P < 0.05). Liver metastasis showed reduced KAI1 expression when compared with their corresponding primary tumor. Although there was a trend for deteriorating survival from patients with KAI1-positive tumors to those with KAI1-decreased and -negative tumors, it was not significant statistically (P CONCLUSIONS
KAI1 may play a role in the malignant progression of rectal carcinoma through the down-regulation of expression. KAI1 might influence the metastatic ability of human rectal cancer. And its prognostic significance needs further investigation with a larger number of cases.

Complete Single Stage Management of Left Colon Cancer Obstruction with a New Devices.: Kim, Jae Hwang , Shon, Dae Ho , Cahng, Byung Ik , Chung, Mun Kwan , Shim, Min Chul; J Korean Soc Coloproctol. 2002;18(1):30-36.

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Abstract PDF: Intraoperative antegrade colonic irrigation for single stage procedure in left colon cancer obstruction is a preferred technique recently however, synchronous pathology cannot be detected. A new device that enables easy intraoperative irrigation and colonoscopy before resection of tumor was devised. PURPOSE: To evaluate the efficacy of the new device for single stage procedure in left colon cancer obstruction.
METHODS
The new device (NICI; MITech co., Ltd, Seoul, Korea) consists of a Y-shaped teflon tube of maximum diameter 2.9, 3.5 and 4.1 cm, one proximal end is designed to connect with the dilated colon just proximal to the lesion. Two distal branches are for drainage of fecal matter and for retrograde insertion of irrigation catheter and subsequent colonoscope respectively.
RESULTS
There were 53 patients (27 male, median age 64, range; 28~82) who underwent this procedure. No extraintestinal leaks were encountered. The volume of saline used was 12 (range; 6 to 27) Liters over 14 (range; 9 to 22) minutes. Subsequent colonoscopic examination added 10 (range, 8 to 15) minutes to the entire operation in 28 patients. There were one anastomotic leakage and 2 wound infections, however, there was no operative mortality. On-table colonoscopy resulted in extended resection in 3 cases because of synchronous malignancy in frozen biopsy and found synchronous polyps in 13 of 28 cases.
CONCLUSIONS
The new device enabled safe, simple and time saving single stage surgical management of left colon cancer obstruction. The ability to perform on-table colonoscopy enabled treatment of synchronous bowel pathology.

Surgery for Lung Metastases from Colorectal Cancer.: Paik, Hyo Chae , Maeng, Dae Hyeon , Song, Suk Suk , Kim, Kil Dong , Chung, Kyung Young; J Korean Soc Coloproctol. 2002;18(1):37-41.

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Abstract PDF: PURPOSE
The liver and lung are the most common site of metastases after curative resection of colorectal carcinoma, and only 10 months of median survival is achieved once metastases has occurred in the lung. About 10% of patients have a solitary pulmonary metastasis and surgical resection leads to a 5 year survival rate of 21~43%. We have tried to define ideal candidates for pulmonary resection in a patient with pulmonary metastases from colorectal carcinoma.
METHODS
Between March 1990 to Feb. 2001, 25 patients underwent pulmonary resection for metastatic colorectal carcinoma. 15 patients were male, and 10 were female with mean age of 60.0 (range, 36~73) years. The primary sites were colon in 7 patients and rectum in 18 patients.
RESULTS
The mean disease free interval was 30.04 19.79 (range, 1~84) months and 19 patients had single metastasis and 6 patients had multiple metastatic lesions. Twenty- one patients had unilateral lesion. Wedge resection was done in 10 patients, lobectomy in 7, pneumonectomy in 2, wedge resection with bilobectomy in 2, segmentectomy and wedge resection in 1, and segmentectomy and lobectomy in 1 patient. Six patients recurred mean 13.7 months after the first operation (range, 1~33 months) and they underwent wedge resection in 4 and one case each of lobectomy and segmentectomy. Seven patients died during follow up with 3 year survival rate of 70.8% and 5 year survival rate of 43.4%.
CONCLUSIONS
The disease free interval, number of metastases, type and location of pulmonary resection, level of carcinoembryonic antigen had no correlation with the survival rate. We conclude that surgical resection of colorectal lung metastases is safe and effective, and every patients should be evaluated as a surgical candidate.

Epidermoid Carcinoma of the Anal Canal: Treatment Outcome and Prognostic Factor.: Kang, Sung Bum , Youk, Oui Gon , Heo, Seung Chul , Jung, Seung Yong , Choi, Hyo Sung , Park, Kyu Joo , Choe, Kuk Jin , Park, Jae Gahb; J Korean Soc Coloproctol. 2002;18(1):42-52.

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Abstract PDF: PURPOSE
During recent two decades, therapeutic strategy for epidermoid carcinoma of anal canal has been changed on basis of the knowledge of the natural course and biologic features. The current study evaluated the treatment outcome and prognostic factors in epidermoid carcinoma of the anal canal.
METHODS
Fifty-seven cases with epidermoid carcinoma of anal canal were treated curatively in Seoul National University College of Medicine from 1976 to 1997. The sex ratio was 1.5 to 1 with male predominance, with a median age of 57.0 years. The histology consisted of 59.6% (34 cases) in squamous cell carcinoma and 40.4% (23 cases) in cloacogenic carcinoma. According to UICC/AJCC staging system, there were 24.6% in stage I, 28.1% in stage II, 31.6% in stage IIIa and 15.8% in stage IIIb. Operation- based treatment was performed in 96.6% of 29 cases during period I (1976~1988) and in 60.7% of 28 cases during period II (1989~1997). Forty-five cases were treated on the basis of operation: 13 cases, operation only; 20, operation plus radiation; 12, operation plus chemoradiotherapy. And 12 cases were managed by combined radiation and chemotherapy.
RESULTS
On median follow-up of 52.0 months (range, 1~160 months), there were 19.3% in local recurrence and 8.8% in systemic recurrence. Recurrence rates were not significantly related to therapeutic strategy (P=0.37). The overall 5-year survival rate was 74.9%. The 5-year survival rates according to therapeutic strategy were 73.3% in the operation-based treatment and 80.0% in the combined radiation and chemotherapy. Survival rates were not significantly related to therapeutic strategy (P=0.48). Three cases, whose sizes were 1 cm, 2 cm and 2.5 cm without lymph node metastasis, were excised locally and are still alive without recurrence. In the multivariate analysis, the metastatic status of lymph nodes had the only independent significant influence on survival.
CONCLUSIONS
Combined radiation and chemotherapy in epidermoid carcinoma of anal canal is the preferred treatment for sphincter-preservation, and local excision in early lesion have good outcome without morbidity associated with chemotherapy or radiation therapy. In this study, lymph node status was the only prognostic variable.

Short-term Results of Radiofrequency Ablation for Liver Metastasis of Colorectal Cancer.: Choi, Sung Il , Chang, Weon Young , Paik, Kwnag Yeool , Lee, Doo Seok , Oh, So Hyang , Kim, Jeong Han , Heo, Jin Seok , Lee, Woo Yong , Kim, Seung Hoon , Lee, Won Jae , Lim, Hyo Keun , Lim, Jae Hoon , Joh, Jae Won , Chun, Ho Kyung; J Korean Soc Coloproctol. 2002;18(1):53-58.

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Abstract PDF: PURPOSE
Radiofrequency ablation (RFA) is emerging as a new therapeutic method for the management of hepatic malignancy. We report our experience on the use of his technique for the management of liver metastasis of colorectal cancer.
METHODS
All 32 colorectal cancer patients with synchronous or metachronous liver metastasis treated with RFA from May 1999 to May 2001 were reviewed using retrospective method including chart review and telephone interview. All patients were followed up postoperatively to assess complications, complete necrosis, local recurrence, and survival rate.
RESULTS
Forty-one RFA sessions were performed on 70 metastatic tumors in 32 patients. There were no treatment- related death. Two complications related with RFA treatment, one intrahepatic bleeding and one intrahepatic abscess, occurred in 41 sessions of RFA (6.2%). With a median follow-up of 13.5 months, tumors recurred in 7 of 70 lesions (10.0%) from 5 patients due to incomplete necrosis and intrahepatic new lesion or distant metastasis in 13 patients of 27 patients (51.9%) after complete necrosis. There were 5 deaths and the 2 year survival rate was 80.9%. Disease free survival was 90.1%, 75%, 26.4% in 6 months, 12 months and 24 months, respectively. Seven patients underwent liver resections successfully with the application of RFA for the residual lesions in the remaining contralateral lobe. In these patients, with 9.0 months median follow up, the disease recurred in 2 patients due to incomplete necrosis, while recurring in 2 patients after complete necrosis and 3 patients were survived without recurrence or distant metastasis.
CONCLUSIONS
Radiofrequency ablation is a safe, well-tolerated, and effective treatment for liver metastasis in colorectal cancer patients. The procedure can be used to treat the residual tumor load in the contralateral lobe following liver resection in those considered unresectable at first presentation. This new therapeutic strategy seems to increase surgical resectability in patients whose mass is determined unresectable. To approve the efficacy of RFA, more long- term follow up should be attempted.

Case Report

Duplication of the Transverse Colon: A Case Report.: Kang, Yong Won , Park, Won Kap , Lee, Jong kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(1):59-63.

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Abstract PDF: Duplications of the alimentary tract are rare congenital malformations and accurate diagnosis is difficult. Duplications can occur at any level in the gastrointestinal tract. Ileal duplications are the most common while colonic duplications are rare. Duplications are usually single, vary widely in size, are more often spherical than tubular and are lined by alimentary tract mucosa. They usually share a common smooth muscle wall and blood supply with the adjacent bowel, with which they may be communicated. Some duplications are asymptomatic but more than 80% of cases present before age of 2 years. Recently, we have experienced a case of duplication of the transverse colon in 9-year old female patient without any other combined anomaly. The chief complaint were palpable abdominal mass, defecational difficulty and intermittent cramping pain of abdomen. The duplication of the transverse colon was diagnosed at operation. A left hemicolectomy was performed with complete resection of duplicated bowel. We report a case of colonic duplication and review the literature.

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