Annals of Coloproctology

Volume 19(1); February 2003

Original Articles

Benign Anal Diseases on Patients with HIV Disease.: Hwang, Do Yeon , Lee, Joo Shil , Yoon, Seo Gue , Rhyou, Jai Hyun , Song, Seok Gyu , Lee, Jong Kyun; J Korean Soc Coloproctol. 2003;19(1):1-5.

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Abstract PDF: PURPOSE
The number of patients with HIV disease has been increasing rapidly, with anorectal discomfort being the most common complaint of these patients. However, there are no data on HIV disease relating to the benign anorectal area in Koreans.
METHODS
A retrospective chart review was performed on patients diagnosed with benign anal diseases, combined with HIV disease, between 1996 and 2001. Their clinical aspects were compared with HIV patients registered with the National Institute of Health in Korea between 1985 and 2001.
RESULTS
A total of 1,613 patients were registered, with the National Institute of Health in Korea, as having HIV disease. The ratio of sex was 7.2:1, with a male predominance. The disease was most common in the 3rd & 4th decades, with 64.2%, of the patients in this age range. As for the routes of transmission, sexual contact was the most common (96.9%), followed by blood transfusion (including blood products) (2.8%), vertical transmission (0.1%) and drug injection (0.1%). With regard to the sexual contact routes, homosexuality accounted for 28.0%. Of the cases of HIV disease presenting with a benign anal disease, 32 patients, with a sex ratio of 31:1, with an overwhelming male predominance, were selected. Twenty-six cases had been newly diagnosed at our hospital. As for the routes of the transmission, the disease had been transmitted by sexual contact in all cases. In 43.8% of these cases, the disease had been transmitted by homosexual contact, which showed a marked difference to that of the National database (P<0.05). For those associated with an anal diseases, there were 10 cases of anal fistula, 9 of perianal abscess, 7 of condyloma acuminata, 7 of anal fissure, 5 of hemorrhoids and 2 of ulceration on the lower rectum, noted.
CONCLUSIONS
Nowadays, the numbers of anorectal-disease patients with HIV are increasing in Korea. Since HIV is common in the area of benign proctology, all proctologists must consider the possibility of HIV when managing patients.

The Clinical Results of a Total Proctocolectomy with an Ileal Pouch-Anal Anastomosis: 12 Cases.: Lee, Gyoung Chun , Lee, Seung Hyun , Ahn, Byung Kwon , Baek, Sung Uhn; J Korean Soc Coloproctol. 2003;19(1):6-12.

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Abstract PDF: PURPOSE
A restorative proctocolectomy has been accepted as the operation of choice for ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to assess the postoperative complications and functional outcomes following a total proctocolectomy with a J ileal pouch-anal anastomosis.
METHODS
The medical records of 12 patients who had undergone a total proctocolectomy, with a J ileal pouch-anal anastomosis, between January 1997 and June 2002, were retrospectively reviewed according to sex, age, underlying disease and postoperative complications. We evaluated the functional outcomes using medical record reviews and patients and telephone interviews.
RESULTS
Total proctocolectomy, with a J ileal pouch-anal anastomosis, were done for ulcerative colitis (n=2) and familial adenomatous polyposis (n=10). A diverting ileostomy was performed in 8 patients. Postoperative complications occurred in 7 patients (58%), intestinal obstructions in 4 and complications related with anastomosis in 3, i.e. J ileal pouch leakage (n=2) and ileal pouch-vaginal fistula (n=1). Re-operations, due to postoperative complications, were performed in 4 patients, i.e. small bowel segmental resection (n=1), adhesiolysis (n=1), diverting ileostomy (n=1) and ileal pouch resection & reconstruction (n=1). The daily median defecation frequencies were 7.7 (range 4~20) a month after the operation, 5.4 (3~12) at 2~3 months, 4.5 (3~7) at 6 months and 4.1 (3~5) at 12 months, following the operation. Two patients had gas incontinence, 1 had fluid incontinence, 4 had night soiling and 3 needed pads, but these incontinences, the need for anti-diarrhea medication and the use of pads, all improved within 6 months of the operation. Fluid incontinence and the use of pads improved within 3 months of the operation, gas incontinence and night soiling improved within 6 months of the operation. The mean length of follow-up was 30.6 months.
CONCLUSIONS
The postoperative complication rate was 58%. Thirty-three percent of patients had fecal incontinence, but all these improved within 6 months. The long- term functional outcomes, after a total proctocolectomy with J ileal pouch-anal anastomosis, were satisfactory, and the postoperative complications acceptable. The postoperative complication rates were no different between the protective diverting ileostomy and non-ileostomy .

Clinicopathological Characteristics of Sporadic Colorectal Cancer with DNA Microsatellite Instability.: Kim, Nam Kyu , Kim, Hoguen , Park, Jae Kun , Lee, Kang Yong , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2003;19(1):13-19.

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Abstract PDF: PURPOSE
Sporadic colorectal cancers, with DNA microsatellite instability (MSI), have been characterized by a predilection area of proximal colon, younger age onset, exophytic growth and larger tumor size. MSI colorectal cancers have recently been had a good survival rate. The aim of this study is to determine the MSI status in sporadic colorectal cancers, and compare their clinical and pathological characteristics with those of MSS (Microsatellite Stable) cancers.
METHODS
Between March 1995 and December 1997, deep frozen fresh tissue of 107 eligible colorectal cancer patients, who underwent surgical resections, were used for analysis. Hereditary nonpolyposis colorectal cancer, and familial adenomatous polyposis, patients were excluded. All the patients were registered on a colorectal cancer database, and followed up completely with regular visits for a potential recurrence. Genomic DNA was prepared by the SDS-proteinase K and phenol chloroform extraction methods. The DNA was amplified by PCR at five microsatellite loci (BAT26, BAT25, D2S123, D5S346, and D17S250) to evaluate the MSI. The PCR products were separated in 6% polyacrylamide gels, containing 5.6 M urea, followed by autoradiography. The MSI was defined as being over 2 marker positive, and the MSS as 1 marker positive, all marker negatives were classed as MSS. The survival rates were calculated by the Kaplan- Meier methods.
RESULTS
MSI was noted at 16/107 (15%), with mean ages for the patients of 51.8 vs. 58.6 years old for MSI and MSS, respectively. For the patients under 40 years old 5 (31.3%) vs. 6 (6.6%) had MSI and MSS, respectively (P<0.01). The cancer was located in the right colon in 12 of each of the MSI and MSS (P<0.01). There were no MSI rectal cancer tumors. The average tumor sizes were 7.6 3.6 cm vs. 5.3 2.2 cm (P<0.01) for MSI and MSS, respectively, but there were no correlations with the frequency of associated polyps, recurrence and distant metastasis between MSI and MSS. The cells were well differentiated (12.5% vs. 17.6%), moderately differentiated (68.8% vs. 76.9%), poorly differentiated (6.2% vs. 3.3%), and mucinous type (12.5% vs. 2.2%), with MSI and MSS, respectively. The overall survival rates were 93.8% vs. 73.8% for MSI and MSS (P=0.07), respectively.
CONCLUSIONS
Sporadic colorectal cancer, with DNA microsatellite instability (MSI), was located predominantly in the proximal colon, in the younger age onset, and larger size of tumor. The survival rate of the patients with MSI tumors were good, but with no statistical significance.

Loss of E-cadherin Function is Suggested to be Associated with Peritoneal Seeding in Colorectal Cancer.: Kim, Hee Cheol , Roh, Seon Ae , Kim, Jung Sun , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2003;19(1):20-25.

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Abstract PDF: PURPOSE
We investigated whether the loss of E-cadherin function was related to the peritoneal seeding in colorectal carcinomas.
METHODS
Eleven patients who had undergone a palliative resection for a colorectal carcinoma, with peritoneal seeding, were enrolled onto the study. The primary tumors and seeding nodules were analyzed with regarded to mutations in the expressions of the CDH1 and protein of E-cadherin using SSCP, direct sequencing and immunohistochemical staining.
RESULTS
In the primary tumors, the E-cadherin was normally expressed in 9 of the 11 cases, with 2 cases showing a reduced expression. In the seeding nodules, the E-cadherin was normally expressed in 6 of the 11 cases, with 5 cases showing a reduced expression. The degree of E-cadherin expression in the seeding nodules was significantly decreased comparing to that in the primary tumors (P<0.001). In the mutational analysis, there were no pathogenic mutations in either the primary tumors or the seeding nodules, with the exception of two silent changes in the ctgggt>ctaggt (intron 2) and GTG>GTA (codon 782).
CONCLUSION
The loss of E-cadherin expression might be related to peritoneal seeding. The functional derangement of E-cadherin in peritoneal seeding could possibly be caused by a mechanism, such as promoter methylation, rather than the mutation of the CDH1.

DCC Gene and Protein Expression in Colorectal Cancer.: Kim, Jong Ik , Jeong, Hae Jin , Yang, Young Il , Paik, Kye Hyung , Yoon, Hye Kyoung , Hong, Kwan Hee , Choi, Kyung Hyun; J Korean Soc Coloproctol. 2003;19(1):26-37.

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Abstract PDF: PURPOSE
The germline, or somatic, inactivation of tumor suppressor genes, through point mutation, or deletion, plays an important role in carcinogenesis. Several gene alterations, such as adenomatous polyposis coli (APC), deleted in colorectal cancer (DCC) and p53, have been detected in the development of colorectal cancer. Within these genes, a loss of heterozygosity (LOH) at the DCC gene locus was frequently associated with colorectal tumors, and the LOH of the DCC gene, and the expression of the DCC protein, might be related to malignant formation and metastasis. The aim of this study was to determine the DCC LOH and the expression of DCC protein in colorectal cancers, and evaluate their prognostic value and relationship with the clinicopathological data. MTHODE: Fifty colorectal cancer tissues were obtained from resected specimens. Using formalin-fixed paraffin- embedded sections as a source of DNA, we examined the DCC protein in the tissue through immunohistochemical stainings and immunoblotting analysis, the DCC LOH through a polymerase chain reaction (PCR) and single strand conformation polymorphism (SSCP).
RESULTS
DCC LOH was observed in 24 of the 50 patients (48.0%). The expression of the DCC protein was decreased in the cancer tissue (62.3 23.6%) compared with the adjacent normal mucosa inform the immunoblotting analysis. A decreased DCC protein expression was also observed from the immunohistochemistry, which coincided with the immunoblotting analysis. However, both the DCC LOH and the decreased DCC protein were not related to the clinical and pathological parameters, such as location of tumor, tumor size, histological type and the venous, and lymphatic invasions. There were significant correlations between the DCC protein expression and tumor progression, and hematogenous metastasis (P<.05).
CONCLUSIONS
A decreased expression of the DCC protein was noted in human colorectal cancers, and there was a significant relationship between the expression of the DCC protein and distant metastasis, but there was no correlation between the DCC LOH and distant metastasis. These results suggest that the expression of the DCC protein might be related to tumor progression and metastatic potential, and the DCC protein immunoreactivity may be a useful prognostic factor in patients with colorectal cancers.

Gender Differences in Patients with Colorectal Cancer.: Kang, Won Kyung , Shin, Seung Yong , Cho, Hyun Min , Park, Jong Kyung , Kim, Ji Yeon , Jeon, Hae Myung , Oh, Seong Taek , Kim, Se Kyung; J Korean Soc Coloproctol. 2003;19(1):39-44.

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Abstract PDF: PURPOSE
Gender differences as prognostic factors in colorectal cancer surgery are still controversial. The prognostic factors for patients undergoing colorectal cancer surgery, include the clinicopathological staging and the possibility for curative surgery. The gender difference was suggested due to the difference in the average life span, anatomy, sex-hormones and tumor immunology. Therefore, we investigated the significance of gender factors in the patients with colorectal cancer.
METHODS
The study was performed though retrospective chart review, and included 778 patients who had undergone surgery for the colorectal cancer, between January 1, 1990 and March 31, 1999, at St. Mary's Hospital, Kangnam, Seoul, Korea. The average follow-up period was 24.8 24.4 months. The patients were divided according to their gender, and the prognosis of each group evaluated according to age, stage, characteristics of tumor, recurrence and survival rates, the possibility of curative surgery and the pathological findings.
RESULTS
The males group consisted of 444 cases (57.1%), with a median age of 58.9 12.8 years, and the females group consisted of 334 cases (42.9%), with a median age of 58.2 13.8 years. Thes analyses revealed no significant gender differences in tumor locations, stage and pathological findings. The recurrence rate in the men (120 patients, 27.0%) was higher than (68 patients, 20.4%) in the women (P<0.05). The incidences and ratios of abdominoperineal resections were significantly higher in the men compared to the women, but the five-year survival rates (56.1% in male and 60.1% in female) and the five-year disease free survival rates (44.3% in male and 50.1% in female) showed no significant differences between the sexes (P>0.05).
CONCLUSIONS
Although the overall survival rates were equal for each genders, different recurrence rates and anatomical differences exist.

Case Reports

A Case Report of Rectal Herniation through Rectovaginal Fistula Associated with Uterine Prolapse.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2003;19(1):45-47.

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Abstract PDF: A rectovaginal fistula, associated with a uterine prolapse, is a very rare entity. The case presented here is that of an elderly woman with a uterine prolapse, associated with an anterior rectal wall herniation through a rectovaginal fistula just above the anorectal ring. It was thought the uterine prolapse had caused the weakness, and long diastasis, of the posterior vaginal wall and the rectovaginal fistula, and then the anterior rectal wall became herniated, with eversion through the rectovaginal fistula. A total abdominal hysterectomy, with bilateral salpingo-oophorectomy, was performed. The rectum was mobilized just beyond the level of the rectovaginal fistula, and resected at that point. Then, from a perineal approach, a coloanal anastomosis was performed using the Parks' sleeve anastomosis technique. After the repair of the long diastasis of the posterior vaginal wall, with inclusion of the fistula opening, a portion of the omentum was interposed between the posterior vaginal wall and the coloanal anastomosis site.

A Case of Cecal Volvulus Diagnosed with Abdominal Computed Tomography.: Hwang, Dae Jhun , Kim, Tae Hwa , Cho, Ji Woong , Lee, Hae Wan , Ryu, Byoung Yoon , Kim, Hong Ki , Kim, Bong Soo; J Korean Soc Coloproctol. 2003;19(1):48-51.

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Abstract PDF: Cecal volvulus is a rare disease of the colon, which occurs in less than 2% of adult intestinal obstruction cases. Precipitating factors can be identified in some patients, including adhesions, a recent abdominal operation, congenital bands, pregnancy, violent exercise, malrotation, obstructing lesions of the left colon and colonoscopy, etc. A right colectomy is a definitive treatment for the best long term control of symptoms, and is the treatment of choice when gangrenous changes are present in the bowel. However, in the presence of viable bowel, the preferred treatment is a controversial matter, with options including; detorsion, cecopexy and cecostomy, etc. We experienced a case of cecal vovulus, which had been treated for COPD at ICU. A diagnosis was made with abdominal computed tomography, and a right hemicolectomy was performed.

Review

Colorectal Cancer and Prostaglandin.: Chang, Woong Ki; J Korean Soc Coloproctol. 2003;19(1):52-59.

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Abstract PDF: The possibility for cyclooxygenase (COX) inhibitors in colorectal cancer prevention and theraphy is evident from epidemiologic data (reduction of colorectal cancer in nonsteroidal anti-inflammatory drugs (NSAIDs) users), animal experiments (nude mouse xenograft tumor reduced by NSAIDs or reduction of colorectal cancer in APCmin mouse and azoxymethane treated rat by using NSAIDs), and molecular genetics. Among two variant COX, inducible COX-2 enzyme is more involved in tumorigenesis than constitutive COX-1 enzyme and molecular method have given us insight into the mechanism of colorectal cancer development by COX-2 such as, apoptosis, angiogenesis, invasiveness, and immune modulation. Based on that COX-2 is involved in tumor promotion during colorectal cancer progress, a large number of prevention and treatment trials of colorectal cancer have been started. And many trials to elucidate the function of prostaglandin produced by COX-2 are now in progress.

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