Annals of Coloproctology

Volume 18(3); June 2002

Original Articles

The Increased Expression of Chemokines in the Colonic Mucosa of Patients with Ulcerative Colitis.: Shim, Ki Nam , Yang, Suk Kyun , Myung, Seung Jae , Kim, Ok Hee , Oh, Hyun Ju , Lee, Jeong A , Cho, Yoon Kyung , Yu, Chang Sik , Jung, Hwoon Yong , Hong, Weon Seon , Kim, Jin Ho , Min, Young Il; J Korean Soc Coloproctol. 2002;18(3):147-151.

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Abstract PDF: PURPOSE
To better understand the extent to which chemokines participate in the mucosal inflammatory response in patients with ulcerative colitis (UC), we assessed the expression of an array of chemokines in the colonic mucosa of UC patients.
METHODS
Colonic mucosal biopsy specimens were obtained from 15 patients with UC and 12 normal controls. Messenger RNA (mRNA) levels for 10 chemokines were quantitated by reverse-transcription PCR using synthetic standard RNAs. The biopsy specimens were also cultured, and secreted chemokines in culture supernatants were assayed by ELISA.
RESULTS
The mRNA expression of C-X-C (IL-8, GROalpha, GRObeta, GROgamma, ENA-78, and IP-10) and C-C (MCP-1, MIP-1beta, and RANTES), but not C (lymphotactin) chemokines was significantly higher in the affected mucosa of UC patients than in the unaffected mucosa of UC patients or in the normal mucosa of normal controls. The degree of increased expression was more prominent in the C-X-C than in the C-C chemokines. Further, the secretion of IL-8, GROalpha, ENA-78, and MCP-1 was higher in UC patients than in normal controls. Secretions of MIP-1beta and RANTES also showed a trend toward an increase in UC, but it did not reach statistical significance.
CONCLUSION
The increased expression of a variety of chemokines in UC suggest that chemokines may play an important role in the immunopathogenesis of UC.

Current Trend of Inflammatory Bowel Disease.: Park, Won Kap , Kim, Hyun Shig , Park, Jong Beom , Song, Seok Kyu , Yoon, Seo Gue , Lee, Jung Kyun , Lee, Jung Dal , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(3):152-155.

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Abstract PDF: PURPOSE
Inflammatory bowel disease (IBD) has steadily increased, according to westernized life style, popular use of colonoscopy, and development of pathology and diagnostic radiology. However, there is no avaliable data about epidemiology of IBD in Korea. Even though our data is not a standard of IBD patients in Korea, it is possible to understand the trend of IBD.
METHODS
From Jan. 1995 to Dec. 2000, cases of ulcerative colitis (UC), Crohn's disease (CD), and indeterminate colitis (ID) were evaluated retrospectively. Annual incidence of IBD at our hospital was calculated with using new IBD patients/new out-patients. To compare the incidence of CD with that of intestinal tuberculosis (TB), intestinal TB cases from Jan. 1997 to Dec. 2000 were evaluated.
RESULTS
Total number of IBD patients was 651: UC (480, 73.7%), CD (149, 22.9%) and ID (22, 3.4%) in order of frequency. Male was more prevalent than female (1.2:1), especially in CD (2.5:1). However, there was no difference of sex in UC. Mean age was 37.9 ( 14.1) years old, ranging from 11 to 79. CD patients (25.1 9.4) were younger than UC (41.9 13.0). Incidence of IBD out of new out-patients increased annually:0.30% (53 cases) in 1995, 0.31% (67 cases) in 1996, 0.37% (99 cases) in 1997, 0.38% (100 cases) in 1998, 0.54% (158 cases) in 1999 and 0.58% (174 cases) in 2000. The most common types of UC and CD were proctitis (52.3%) and ileocolic type (59.7%), respectively. Incidence of CD was more prevalent than that of intestinal TB (2.5:1).
CONCLUSION
About 0.5% of new out-patients had IBD and the number of patients of IBD increased annually. CD patients were younger than those of UC and male was predominant. The number of patients with CD exceeded that of intestinal TB patients.

The Clinical Effect of Sphincter-Preserving Modified Loose Seton Technique in Complex Anal Fistula.: Lee, Yun Young , Choi, Sun Keun , Kim, Sei Joong , Lee, Keon Young , Hur, Yoon Seok , Ahn, Seung Ik , Hong, Kee Chun , Shin, Seok Hwan , Woo, Ze Hong; J Korean Soc Coloproctol. 2002;18(3):156-162.

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Abstract PDF: PURPOSE
The cutting seton technique is a world-wide operative method in management of a complex anal fistula. However it has still some risks of anal deformity and fecal incontinence because of sphincter injury, and also required two-stage operation under the anesthesia. We have modified this conventional method into sphincter-preserving technique using the seton and evaluated the clinical effect of patients with complex anal fistula.
METHODS
The operative steps consisted of excision of the fistular tract without cutting the sphincter, and insertion of a non-absorbable suture material as a seton around the sphincter. When enough fibro-granulated tissues grew and pus discharge decreased markedly, the seton was just cut out from the wound without anesthesia at the outpatient basis. The clinical effect following treatment by using this method was assessed retrospectively in 81 patients, including 33 recurrent cases, who were treated during the four and a half-year period.
RESULTS
The average follow-up period to remove the seton and to eradicate the fistula was 68.9+/-39.5 and 82.1+/-45.6 days, respectively. No patients experienced fecal incontinence after surgery. The fistula was healed without recurrence in 78 patients (96.3%), preserving integrity of the sphincter. Recurrence developed in 3 patients who had two suprasphincteric fistulas and one transsphincteric fistula with supralevator abscess.
CONCLUSION
We suggest that this method is good for treating complex anal fistulas without two-stage operation because it has some advantages such as a lower recurrence, a lower functional impairment, and less anal deformity.

Polymorphisms of the 5'-Flanking Region of the Human Tumor Necrosis Factor-alpha Gene in Korean Patients with Crohn's Disease.: Lee, Kil Yeon , Kim, Hyo Jong , Chi, Sung Gil , Oh, Soo Myung , Yoon, Choong , Lee, Kee Hyung; J Korean Soc Coloproctol. 2002;18(3):163-172.

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Abstract PDF: PURPOSE
Recently, a key role of tumor necrosis factor (TNF) in the development of inflammatory bowel disease (IBD), especially Crohn's disease (CD), has emerged. In Japan, 3 single base pair polymorphisms in the 5'-flanking region of the TNF-alpha gene at position 1031, 863, and 857, which are related to high transcriptional promoter activity, have been identified in the Japanese CD patients. And the polymorphisms of the TNF-alpha gene at position 308, 238 have been reported in western CD patients. So, in order to find the same polymorphisms in Korean population and CD patients, the author evaluate the patients diagnosed with CD, ulcerative colitis (UC) and healthy controls (HCs).
METHODS
Blood samples were obtained from 70 patients with CD, 72 patients with UC and 52 healthy controls. Polymorphisms in the TNF-alpha gene at their respective positions were analyzed by single strand conformational polymorphism (SSCP), and allele frequencies in CD and UC patients were compared with those in healthy controls.
RESULTS
Allele frequencies of 1031C, 863A, and 857T in health controls were 18.3%, 8.7%, and 19.2%, respectively. Polymorphic allele frequencies of 1031C, 863A, 857T were 22.9%, 27.1%, and 24.3% in CD patients respectively. The frequencies at all 3 positions were higher in CD patients than in HCs. However, the frequency at 863A was statistically significant (P=0.000). The allele frequencies of 308A and 238A alleles were 0.7% and 3.6% in CD, 0.7% and 2.1% in UC, and 1.9% and 4.8% in HCs, respectively. The allele frequency of 1031C was significantly higher in B3 than in B2 (P=0.033).
CONCLUSION
Polymorphisms of 5'-flanking region of the TNF-alpha at positions 1031 (T/C), 863 (C/A) and 857 (C/T) may be associated with susceptibility of CD.

Benefits of Stapled Hemorrhoidectomy Compared with Ultrasonic Dissector and Milligan's Hemorrhoidectomy.: Seo, Hyung Min , Park, Chul Woon , Lee, Gil Yeon , Yoon, Choong , Lee, Kee Hyung; J Korean Soc Coloproctol. 2002;18(3):172-177.

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Abstract PDF: PURPOSE
Surgical hemorrhoidectomy has a reputation for being a painful procedure. Many surgical methods have been devised for reducing posthemorrhoidectomy pain. Nevertheless, the result are unsatisfactory. Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared among three hemorrhoidectomy methods.
METHODS
A total of 150 consecutive patients with 3rd and 4th degree of prolapsed hemorrhoids underwent hemorrhoidectomy with stapler group (n=50) or hemorrhoidectomy with ultrasonic dissector group (n=50) or Milligan's hemorrhoidectomy using by diathermy (n=50) (by same surgeon between January and September 2001). We evaluated the difference among three techniques in operative time, postoperative pain, and patient satisfaction (using visual analogue scale).
RESULTS
Mean operative time for hemorrhoidectomy with ultrasonic dissector was 19 minute; for stapler group, it was 18 minute; for Milligan's group, it was 23.6 minute (P<0.05). There was significant difference in operative time between stapler and Milligan's group. There were significant difference in pain measurement reported on immediate (5.8 for stapler, 7.2 for ultrasonic dissector, and 9.2 for Milligan's group, P<0.01), day 1 (4.3, 5.5, and 6.8, P<0.01), day 2 (3.7, 4.7, and 6, P<0.01), day 3 (3.0, 3.6, and 4.6, P<0.01), day 4 (3.1, 3.5, and 4.6, P<0.01), day 5 (2.5, 3.4, and 4.6, P<0.01), day 6 (2.0, 3.2, and 4.3, P<0.01), day 7 (1.8, 3, and 4.2, P<0.01), and defecation (4.0, 7.0, and 8.9, P<0.01). The mean analgesic (piroxicam 20 mg) requirement was 0.3 times for stapler, 1.9 for Ultrasonic dissector, and 3.1 for Milligan's group (P<0.01). Mean hospital stay was 1.6 days for stapler, 1.7 for ultrasonic dissector, 2.8 for Milligan's group (P<0.01). Patient satisfaction on day 7 was 8.2 for stapler, 6.2 for ultrasonic dissector, and 5.2 for Milligan's group (P<0.01). There was no difference in catheterization for urinary retention. It is probably due to spinal anesthesia.
CONCLUSION
The study demonstrates significantly reduced postoperative pain and shorter hospital day after stapled hemorrhoidectomy compared among three groups. This resulted in an earlier return to working activities for stapled technique.

The Role of Computed Tomography in the Diagnosis of Acute Appendicitis.: Choi, In Seok , Yea, Byung Kook , Han, Gun Taek , Sim, Mun Sup; J Korean Soc Coloproctol. 2002;18(3):178-183.

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Abstract PDF: PURPOSE
Appendicitis represents one of the most common surgical disorders. Typically, the diagnosis can be made from well established clinical criteria, with an acceptable negative appendectomy rate from 7~25%. However, when surgical intervention is performed in the patients suspected of having appendicitis but with equivocal clinical findings, the negative appendectomy rate approaches 50%. Routine contrast-enhanced computed tomography (CECT) has described as an accurate diagnostic imaging modality in patients with suspected appendicitis. We evaluated the role of intravenous CECT (iCECT) in patients suspected of having appendicitis but with equivocal clinical exams.
METHODS
Eighty seven consecutive patients who were thought to have appendicitis but with equivocal clinical findings and/or physical exams were imaged by iCECT over 18 months period. Intravenous contrast-enhanced, spiral abdominal and pelvic images were obtained using 7.5 mm cuts. iCECT images were interpreted by a board-certified radiologist. Main outcome measures included iCECT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accurary and negative appendectomy rate in the diagnosis of acute appendicitis, and determining the impact iCECT on the clinical management of the patient population.
RESULTS
A group of 87 patients consisting of 36 males (41.4 %) and 51 females (58.6%) with median age of 32 years (range 12 to 75 years) were imaged with iCECT to evaluate suspected appendicitis. Of the 87 iCECTs performed, 8 false-positive and 2 false-negative readings were identified, resulting in a sensitivity of 93.5%, specificity of 85.7%, PPV of 78.4%, NPV of 96%, and an overall accuracy of 88.5%. With regard to clinical management, 100% (31/31) of patients with appendicitis, and 4% (2/50) of patients without appendicitis underwent appendectomy. Therefore, the overall negative appendectomy rate was 6.1% (2/33).
CONCLUSION
iCECT is a useful diagnostic imaging modality for patients suspected of having acute appendicitis but with equivocal clinical findings and/or physical exams. iCECT is particularly useful in excluding the diagnosis of appendicitis in those without disease.

Measurement of External Anal Sphincter Function by Fatigue Rate Index.: Seong, Moo Kyung , Yoo, Young Bum; J Korean Soc Coloproctol. 2002;18(3):184-189.

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Abstract PDF: PURPOSE
Fatigue rate index (FRI) is one of relatively unknown parameters of anal manometry. It was devised to assess sustained voluntary contractibility of external anal sphincter muscle. We designed this study to determine the predictability of FRI in evaluating patients with symptoms of fecal incontinence.
METHODS
Consecutive male patients with fecal incontinence, those with prolapsed hemorrhoids but without any kind of incontinence symptom, and male healthy volunteers who have no anal symptom were grouped as A, B, C. Anal manometric parameters including FRI were measured and compared statistically among them.
RESULTS
All subjects were 84. Group A 27, Group B 33, and Group C 24. Their ages were 33.33+/-2.91 (mean SE), 39.27+/-2.80, and 50.81+/-4.33, respectively. Mean resting pressures (mmHg) were 78.11 6.56 for group A, 81.18+/-7.19 for group B, and 57.81+/-7.80 for group C. Maximum resting pressures (mmHg) were 98.67+/-9.69, 100.82+/-8.49, 78.13+/-10.26. Mean squeeze pressures (mmHg) were 229.11+/-18.72, 248.18+/-23.03, 156.94+/-17.89. Maximum squeeze pressures (mmHg) were 286.50+/-33.76, 298.59+/-27.83, 187.38+/-21.08. Resting radial asymmetries (%) were 18.85+/-2.81, 19.85+/-2.31, 28.70+/-4.79. Squeeze radial asymmetries were 15.73+/-2.90, 16.29+/-1.96, 16.47+/-2.95. Fatigue rates were 0.90+/-0.21, 1.17+/-0.15, 1.38+/-0.40. Fatigue rate indices (min.) were 3.76+/-0.41, 2.63+/-0.20, 1.94+/-0.26, respectively. Differences between group A and group C were statistically significant in mean squeeze pressure (P=0.0093), maximum squeeze pressure (P= 0.0190) and FRI (P=0.0008). Those between group B and group C were significant also in mean squeeze pressure (P=0.005), maximum squeeze pressure (P=0.0051), and FRI (P=0.0396). Multiple logistic regression analysis revealed that independently significant parameters were age (P= 0.002) and FRI (P=0.007). Cut-off point of FRI for incontinence with maximum sensitivity and specificity was 2.4min. by ROC (receiver operating characteristics) analysis.
CONCLUSION
FRI is a meaningful parameter in predicting fecal incontinence, which can be used in assessment of sphincter function and future treatment protocols.

The Significance of Perioperative Serum Carcinoembryonic Antigen Measurement in Patients with Curative Colorectal Cancer.: Cho, Young Kyu , Kung, Hwan Nam , Hong, Hyun Kee , Yoo, Jang Hak , Kim, Jeong Rang , Kim, Hee Chul , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2002;18(3):190-195.

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Abstract PDF: PURPOSE
Regular monitoring of serum carcinoembryonic antigen (CEA) has been used as a tool to detect recurrence of colorectal cancer postoperatively. This study aimed to evaluate the significance of perioperative serum CEA level in patients with curative colorectal cancer.
METHODS
We analyzed the data obtained from the 420 patients with colorectal cancer who underwent curative resection. Preoperative serum CEA level (ng/ml) was divided into 3 groups, i.e. groups I: or=20. Each group of preoperative serum CEA level was analyzed in accordance with location, histologic differentiation, stage of tumor, recurrence and survival. Postoperative serum CEA level was analyzed in accordance with preoperative serum CEA level and recurrence.
RESULTS
Preoperative serum CEA level correlated with tumor stage (P=0.009). Ninety six patients among 420 patients showed recurred and recurrences were more common in patients with high preoperative serum CEA level (P =0.002). Systemic recurrences were more common in patients with high preoperative serum CEA levels than normal levels (P=0.029). In recurrence cases, 75 patients (78.1%) had elevated serum CEA levels and 55 patients had high preoperative serum CEA levels (P=0.008). The disease free 5-year survival rate in preoperative serum CEA group I, II, and III were 91.4%, 70.5%, and 58.3% respectively (P= 0.000) CONCLUSION: Preoperative serum CEA levels seemed to be closely correlated with distant metastasis and survival. Meticulous follow-up evaluation and generous use of adjuvant therapy are recommanded in patients with high preoperative CEA level.

Case Reports

CMV Colitis in a Patient with Colon Adenocarcinoma.: Kung, Hwan Nam , Cho, Young Kyu , Yu, Chang Sik , Kim, Hee Cheol , Kim, Jung Sun , Jang, Jae Jung , Kim, Jin Cheon; J Korean Soc Coloproctol. 2002;18(3):196-199.

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Abstract PDF: Cytomegalovirus (CMV) colitis occurs almost exclusively in immune-compromised patients namely, HIV infection, immunosuppressant therapy after organ transplantation, anti-cancer chemotherapy, and long- term steroid user. Some patients with solid tumor have gastrointestinal CMV disease without anti-cancer chemotherapy. A 64-year-old male patient underwent surgery due to sigmoid colon cancer. On histopathologic examination of surgical specimen, CMV colitis was found in the colon. The AJCC tumor stage was II. Although CMV colitis is rarely associated with colon cancer, it maybe considered in patients with combined colitis with colorectal cancer.

A Case of Turcot's Syndrome Combined with Colon Cancer in a 15-year-old Girl.: Lee, Seok Ryeol , Lee, Kil Yeon , Lee, Kee Hyung , Leem, Won , Kim, Hyo Jong , Lee, Ju Hie; J Korean Soc Coloproctol. 2002;18(3):200-204.

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Abstract PDF: Turcot's syndrome is a rare hereditary disease marked by the association of central nervous system neuroepithelial tumor with colonic polyposis. Authors report herein a case of a 15-year-old girl diagnosed as having Turcot's syndrome, otherwise known as brain tumor-polyposis syndrome, combined with sigmoid colon cancer. The patient was carried out craniostomy and brain tumor removal. The tumor was confirmed histologically to be oligodendroglioma. The patient visited the department of internal medicine for bloody diarrhea during 6 months. Colonoscopy and biopsy was done. The patient was diagnosed as having Turcot's syndrome combined with sigmoid colon cancer, and was then transferred to the department of surgery for treatment of sigmoid colon cancer. Total proctocolectomy and IPAA (ileal pouch-anal anastomosis) was carried out. Multiple polyps were found in the colon, two large masses were confirmed histologically to be adenocarcinoma. The remaining polyps were adenomas. This case report describes the characteristic features of Turcot's syndrome presented by this patient.

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