Annals of Coloproctology

Volume 20(1); February 2004

Original Articles

Analysis of c-kit Gene Mutation and Prognostic Factors of GISTs in the Small and the Large Bowel.: Park, Jong Kyung , Yun, Sang Seob , Kang, Won Kyung , Cho, Hyeon Min , Kim, Ji Youn , Choi, Seung Hye , Oh, Seong Taek , Oh, Se Jeong , Oh, Seong Lee , Jeon, Hae Myung; J Korean Soc Coloproctol. 2004;20(1):1-7.

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Abstract PDF: PURPOSE
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors which arise anywhere in the tubular GI tract. The prognosis for GISTs that develop in the small and the large bowel is worse than it is for those that develop at other sites. We examined the significance of c-kit mutation as an independent prognostic factor for GISTs.
METHODS
The hospital records of 27 patients with GISTs in the small and the large bowel who were seen from January 1991 to December 2001 at the Department of Surgery, The Catholic University School of Medicine, were reviewed. c-kit mutation was measured by using the PCR and DNA sequencing.
RESULTS
Mutations in exon 11 were found in 5 cases (83.3%), exon 9 in 1 case (16.7%), and no mutations were noted in exon 13 and exon 17. All mutations in exon 11 were found in codon 560-570. c-kit mutation was observed more frequently in high-risk patients, and there was a significant difference between c-kit mutation and the survival rate (P=0.048).
CONCLUSIONS
We think that codon 550~560 in exon 11 of the c-kit gene is a hotspot of mutation, but c-kit mutation is uncertain as an independent prognostic factor for GISTs.

Early Result of Laparoscopic Colorectal Surgery.: Baek, Jeong Heum , Kim, Hye Kyoung , Lee, Jung Nam , Oh, Jae Hwan; J Korean Soc Coloproctol. 2004;20(1):8-14.

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Abstract PDF: PURPOSE
The aim of this study is to assess the safety and the efficacy of laparoscopic colorectal surgery compared to those of conventional open surgery and to determine the feasibility of laparoscopic colorectal surgery based on oncologic principles.
METHODS
From March 2001 to January 2002, 27 consecutive patients were assessed for the possible use of laparoscopic surgery. Thirty patients were included in the open group. Forty-seven patients were included in the laparoscopic group. The decision regarding the suitability of a patient for the procedure was made by the surgeon.
RESULTS
Laparoscopic surgery was attempted on 47 patients, and in 31 patients, it was completed successfully. Patients who underwent laparoscopic surgery required a smaller dose of analgesics and had an earlier bowel passage recovery and shorter hospital stay than patients who underwent open surgery. The mean operation times for the open group, the conversion group, and the laparoscopic group were 252 min, 269 min, and 272 min respectively (P>0.05). There was no difference in the number of lymph nodes dissected nor the length of the distal margin of the resected bowel in the case of anterior resection and low anterior resection of the laparoscopic group compared to the open and the conversion groups (P>0.05). Complications in the laparoscopic surgery group were anastomosis site leakage and bowel obstruction. In the open group, wound infection, urinary retention, anastomosis site leakage and bowel obstruction were found. The morbidities of the open group, the conversion group, and the laparoscopic group were 23.3%, 37.5%, and 12.9%, respectively. One mortality was observed in the conversion group.
CONCLUSIONS
In this study, there is no evidence that the laparoscopic technique is inadequate for following the cancer surgery principle, So laparoscopic colorectal surgery is a safe and feasible treatment. The overall morbidity and mortality in this study were acceptable. Sufficient lymph node dissection and distal margin of the resected bowel were accomplished with laparoscopic surgery. Further long-term follow up, however, will be necessary to confirm the value of this technique.

Effect of the Sitting Position after Spinal Anesthesia on the Incidence of Postdural Puncture Headaches: Saddle Block versus Low Spinal Anesthesia.: Lim, Seok Won , Yoo, Dong Won; J Korean Soc Coloproctol. 2004;20(1):15-19.

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Abstract PDF: PURPOSE
Postdural puncture headache is one well-known complications of spinal anesthesia. The development of postdurals puncture headaches is related to needle size, the direction of the needle bevel, the number of dural punctures and the age of the patient. However, the effect of the sitting position after spinal anesthesia (saddle block) on the incidence of postdural puncture headaches is not yet known. This study was performed to compare the incidence rates of headaches between a saddle block group (sitting position group) and a low spinal anesthesia group (supine position group). In addition, this study was performed to identify the predisposing factors influencing postdural puncture headaches (age, sex, seasonal variation, onset of headache, location of headache).
METHODS
The authors analyzed 960 anal-surgery patients who were operated on using a saddle block or low spinal anesthesia at Hang Cinic from Jan. 2000 through Dec. 2000. The authors compared the incidence rates of headaches between the saddle block group (480 cases) and the low spinal anesthesia group (480 cases).
RESULTS
1) The incidence of postdural puncture headaches was not significantly different between the two groups (2.5% in the saddle block group, and 2.3% in the low spinal anesthesia group) (P>0.05). 2) The postdural puncture headache incidence rate was higher for younger patients (20~30 years) and for females. (M:F=7:16) (P<0.05). 3) The onest of postdural puncture headaches was at the postoperative 2nd day in 16 cases (70%) and at the postoperative 3rd day in 6 cases (26%). 4) The incidence rate of postdural puncture headache was higher in the summer (5 cases in June, and 3 cases in July, 4 cases in August). 5) The headache were located in the frontal region in 16 cases (70%) and in the occipital region in 3 cases (13%).
CONCLUSIONS
There is no significant difference in the incidence rates of postdural puncture headaches between the saddle block group and the low spinal anesthesia group. Postdural puncture headaches had a tendency to occur more frequently in young female patients and during the summer season. In addition, a more intensive study of the use of saddle block anesthesia for ambulatory anal surgery is required.

Usefulness of Laparoscopic-assisted Surgery for the Treatment of Colonic Diverticulitis.: Ha, Seok Hyo , Kim, Gyu Sung , Jo, Hae Chang , Rhee, Jung Ahn , Bae, Byung Jo; J Korean Soc Coloproctol. 2004;20(1):20-26.

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Abstract PDF: PURPOSE
Colonic diverticulitis was rare in Korea in the past. However, it is progressively increasing probably because of a prolonged life span and a westernized diet pattern. Especially, right-sided colonic diverticulitis is difficult to differentiated from acute appendicitis. The purpose of this study was to verify the usefulness of laparoscopic-assisted surgery for the diagnosis and treatment of colonic diverticulitis.
METHODS
We retrospectively reviewed 65 patients with colonic diverticulitis who underwent surgery from January 1998 to December 2002.
RESULTS
The mean age of the patients was 36.3 years. Males were more prevalent than females (1.6:1). Abdominal ultrasonography (USG) was used as a diagnostic tool in 40 cases (61.5%), abdominal USG with colon enema in 8 cases (12.3%), and abdominal USG with abdominal CT in 4 cases (6.2%). The preoperative diagnosis was acute appendicitis in 52 patients (80.0%), perforated diverticulitis in 10 patients (15.4%), peritonitis in 2 patients (3.5%), and peptic ulcer perforation in 1 patient (1.5%). The postoperative diagnosis was simple diverticulitis in 47 cases (72.3%). The cecum was the most commonly involved area (55 cases, 84.6%). The types of open surgery were an appendectomy in 17 cases (26.1%), a right hemicolectomy in 17 cases (26.1%), a cecectomy in 6 cases (9.2%). The types of laparoscopic- assisted surgery were an appendectomy in 17 cases (26.1%), a laparoscopic-assisted right hemicolectomy in 4 cases (6.2%), and an anterior resection in 1 case (1.5%). The postoperative complication rate was 11.9% (5 cases). All of these occurred with the open technique, but no statistically significant difference existed between the complication rates for the two operative procedures (P=0.158). The mortality rate was zero for both operative procedures. The length of hospital stay (4.72+/-4.3 vs 10.1+/-6.2)(P=0.001) was significantly shorter in the laparoscopic-assisted group than in the open group.
CONCLUSIONS
Preoperative diagnosis is sometimes difficult in patients with colonic diverticulitis. We consider laparoscopic-assisted surgery to be a useful diagnostic and therapeutic modality in such cases. The laparoscopic technique offers particular advantages to diverticulitis patients because of the short hospital stay and the low morbidity and mortality rates.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Polyethylene Glycol and Sodium Phosphate Oral Lavage Solutions.: Yun, Seong Hyeon , Kang, Jung Gu; J Korean Soc Coloproctol. 2004;20(1):27-31.

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Abstract PDF: PURPOSE
This study was undertaken to determine whether a mechanical bowel preparation with 90 ml of sodium phosphate (NaP) solution (Group II) increased the acceptability of bowel preparation and reduced discomfort compared with 2 liters of polyethylene glycol (PEG) combined with a bisacodyl 20 mg (Group I).
METHODS
We conducted a prospective, randomized, single-blinded study. Forty-four patients undergoing elective colorectal surgery in the National Health Insurance Corporation Ilsan Hospital from March 2002 to November 2002 were included in this study. We assessed the patients' tolerance and cleansing ability, as well as the surgeon's satisfaction, by using a structured questionnaire. Postoperative complications were also evaluated.
RESULTS
Patient tolerance to NaP was higher than it was to PEG (P=0.034). The cleansing ability and the surgeon's satisfaction were not different between the two groups (P=0.217, P=0.349). There is no significant postoperative complication except for 1 case of wound infection in both group.
CONCLUSIONS
Both oral solutions proved to be equally effective and safe. However, patient tolerance to the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Clinical Effectiveness of a Circular Stapled Hemorrhoidectomy.: Yun, Seong Hyeon , Min, Byung Soh , Kang, Jung Gu; J Korean Soc Coloproctol. 2004;20(1):32-38.

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Abstract PDF: PURPOSE
The circular stapled hemorrhoidectomy established by A. Longo involves reducing the mucous membrane prolapse and blocking the end branches of the upper hemorrhoidal artery through transverse incision of a suitable section of the mucosa between the rectum and the anal canal. This study was undertaken to determine the efficacy and the safety of a circular stapled hemorrhoidectomy by comparing it with a conventional Milligan-Morgan hemorrhoidectomy.
METHODS
One hundred thirty (130) patients with prolapsed hemorrhoids underwent surgical treatment with either a conventional (n=66)(conventional group) or a circular stapled (n=64) (stapled group) hemorrhoidectomy. The operation time was recorded, and the resected specimen was examined. The patients assessed their postoperative pain. Time to first bowel movement, hospital stay, and postoperative complications were analyzed. All patients received follow-up examinations at the out-patient clinic, and the time to return to work and the degree of their satisfaction were checked.
RESULTS
The stapled group had a shorter average operation time (19.2 min. vs 26.1 min., P=0.016). The postoperative pain score in the stapled group was significantly lower than it was in the conventional group (P<0.05). Time to first bowel movement and hospital stay were not significantly different between the groups. Return to work was significantly faster in the stapled group (6.5 days vs 15.8 days, P<0.05). The degrees of satisfaction for the two groups were similar, and postoperative complications in the two groups were both similar and acceptable (6.1% vs 11.0%, P>0.05).
CONCLUSIONS
A circular stapled hemorrhoidectomy offers a significantly less painful alternative to the conventional technique and is associated with an earlier return to normal activity. However, the long-term outcome needs to be evaluated further.

CEA Expressions in Colorectal Tumor.: Bae, Ok Suk , Lee, Tae Soon , Park, Sung Dae; J Korean Soc Coloproctol. 2004;20(1):39-45.

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Abstract PDF: PURPOSE
The purpose of this research is to investigate the clinical usefulness of carcinoembryonic antigen (CEA) expression in colorectal cancer tissue.
METHODS
We performed immunohistochemical staining of CEA on 64 surgically resected colorectal cancer tissues obtained during the period from May 2000 to May 2001. CEA expression was detected by immunohistochemistry using a CEA monoclonal antibody. The degrees of CEA expression in the tumor cell cytoplasm and the luminal secretion of the tumor gland were grouped into positive (strongly positive) and negative groups (weakly positive) by using the Sinicrobe method and were compared with clinicopathological variables.
RESULTS
The expression rates were positive in 38 cases (59.4%) and negative in 26 cases (40.6%). The preoperative CEA level showed a higher trend in the positive group (8.23+/-13.7) than it did in the negative group (17.89+/-38.7 ng/ml), but the difference was not statistically significant. The relationships between the CEA expressions of the two groups and the clinicopathologic factors were not statistically significant. We observed CEA expression in the luminal secretion of the tumor gland in 41 cases. The expression rates in the luminal secretion were positive in 21 cases (51.2%) and negative in 20 cases (48.8%). No significant clinical difference were noted between the two groups.
CONCLUSIONS
The results suggest that CEA expression may not play a role as a prognostic factor for colorectal cancer.

Efficacy of Preoperative Radio-chemotherapy in Patients with Advanced Low Rectal Cancr.: Yu, Chang Sik , Kim, Jong Hoon , Lee, Je Hwan , Kim, Tae Won , Chang, Heung Moon , Namgung, Hwan , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(1):46-51.

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Abstract PDF: PURPOSE
This study was performed to evaluate the surgical and the oncological outcomes of preoperative radio-chemotherapy (PRCT) in patients with low rectal cancer.
METHODS
We reviewed 26 (M:F=17:9) patients who underwent PRCT between September 1999 and December 2001. Inclusion criteria were lower rectal cancer (4~5 cm from AV), more than T3 or N1 in preoperative staging using CT scan and transrectal ultrasound, and no distant metastasis. Patients received a mean of 47.3 (45.0 ~56.0) Gy of radiation therapy for 5 weeks and concomitant intravenous or oral chemotherapy using 5 FU and leucovorin. Surgery was performed in about 5~6 weeks after completion of radiotherapy. Total mesorectal excision and autonomic nerve preservation was the routine procedure. Adverse events during PRCT were assessed according to the NCI Common Toxicity Criteria (version 2.0, 1997).
RESULTS
The mean age was 49 (28~65) years old. The median follow-up period was 31 (20~44) months. The most frequent adverse event was diarrhea (8, 30.8%), followed by nausea and vomiting (5, 19.2%), dermatitis (5, 19.2%), anemia (4, 15.4%), leucopenia (2, 7.7%), and mucositis (1, 3.8%). The mean location of the tumor was elevated from 4.5 cm to 5.5 cm after PRCT. Downstaging of the tumor was identified in 69.2% of the T-level and 63.2% of the N-level. The serum CEA level was decreased from 14.5+/-5.0 ng/ml to 3.5+/-0.5 ng/ml after PRCT (P=0.034). A sphincter-saving resection (SSR) was possible in 16 cases (61.5%). The mean distal resection margin was 2.2+/-0.7 cm in SSRs. Small bowel obstruction was the most frequent complication (6 cases, 23.1%), followed by hydronephrosis 2 (7.7%), a recto-vaginal fistula (1, 3.8%), and a recto-vesical fistula (1, 3.8%). There were no mortalities. Five (19.2%) recurrences developed in distant area, one (3.8%) in a local area, and one in both a local and a distant area. The patients with N-level downstaging revealed a significantly low recurrence rate (8.3% vs. 57.1%; P=0.03).
CONCLUSIONS
PRCT can be performed with an acceptable toxicity and complication rate. It is effective in downstaging of the tumor and in increasing the sphincter-saving rate. However, a prospective, randomized, controlled trial should be performed to prove the oncological benefit.

Efficacy of Stump Irrigation in Removing Tumor Cells During Low Anterior Resection Using the Double Stapling Technique.: Park, Sang Jun , Kim, Hee Cheol , Yu, Yuen Sik , Yu, Jang Hak , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(1):52-56.

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Abstract PDF: BACKGROUND
In low rectal cancer, creating a permanent stoma can be avoided by applying a low anterior resection using the double stapling technique. However, the problem of local recurrence is still a major pattern of tumor recurrence in rectal cancer. We aimed to verify the clinicopathologic variables related to exfoliation of tumor cells and searched for an efficient method to remove the tumor cells from the rectal stump during a low anterior resection.
METHODS
Forty-four patients who underwent a low anterior resection using the double stapling technique were enrolled prospectively. For patient, we irrigated each rectal stump twice with 500 cc of normal saline through the anus. Two specimens from each irrigation were obtained and examined for any malignant tumor cells. Cases in which no tumor cells were found from the two specimens were defined as Group I, cases in which tumor cells were found in only the first specimen were defined as Group II, and cases in which tumor cells were found in both the first and the second specimens were defined as Group III. Clinicopathologic variables were analyzed with regard to the presence of exfoliated tumor cells in irrigated saline.
RESULTS
There were sixteen (36%), fourteen (32%), and fourteen cases (32%) in Groups I, II, and III, respectively, according to the examination results. Age classification (P=0.05) and metastatic lymph nodes (P=0.013) were associated with the presence of tumor cells in irrigated saline (I vs. II, II).
CONCLUSIONS
Stump irrigation during a low anterior resection using the double stapling technique is recommended as an easy and simple method to remove exfoliated tumor cells from anastomosis sites, although further study is necessary to elucidate the association between exfoliated tumor cells and local recurrence.

Clinical Significance of Lymph Node Micrometastasis in Patients with Dukes' B Colorectal Cancer.: Lee, Hyo Won , Jang, Yong Seog; J Korean Soc Coloproctol. 2004;20(1):57-63.

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Abstract PDF: PURPOSE
This study aimed to provide immunohistochemical evidence of micrometastasis in patients with node-negative Dukes' B colorectal cancer and to evaluate the clinical implications, including prognostic significance, of lymphatic metastasis.
METHODS
A retrospective study of 90 patients who underwent a curative operation due to colorectal neoplasms from 1996 to 2001 was performed. Two consecutive sections of lymph nodes were prepared: one for ordinary hematoxylin-eosin staining, and the other for immunohistochemistry with pancytokeratine antibody. All clinical factors, including survival rate, were compared between patients with and without lymph-node metastasis. The mean follow- up period was 36.1 months.
RESULTS
Micrometastasis was confirmed in 115 nodes (7.9%) from 32 patients (35.6%). No correlations were observed between micrometastases and prognostic factors, including survival rate, except for lymphatic invasion and postoperative TNM staging. Twenty-six of the 32 (81.3%) patients with micrometastases belonged to stage T3N0M0 (P<0.003).
CONCLUSIONS
The immunohistochemical assay may be a useful way to identify micrometastasis in patients with Dukes' B colorectal neoplasms, but we were not able to demonstrate the prognostic significance of micrometastasis.

Review

Mechanism of Genomic Instability and Its Clinical Applications.: Lee, Suk Hwan; J Korean Soc Coloproctol. 2004;20(1):64-73.

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Abstract PDF: Multiple genetic alterations are common prerequisite for carcinogenesis including colorectal cancers (CRCs). Recently, mutations within microsatellites have been described as a result of defective DNA mismatch repair (MMR) mechanisms, resulting in the phenomenon of microsatellite instability (MSI). This has been implicated in the etiology of hereditary non-polyposis colorectal cancer (HNPCC) and significant portions of sporadic colorectal cancers. However, the mechanisms underlying the MSI are different from hereditary CRCs and sporadic CRCs. While the germline mutation of MMR genes is responsible for HNPCC, the hypermethylation of MLH1 gene promoter regions, an epigenetic, not inherited alteration is responsible for most sporadic CRCs showing MSI. MSI tumors exhibit characteristic clinco- pathologic features, i.e, tumors are preferentially located to proximal to splenic flexure, poorly differentiated, mucinous cell type, frequently showing peritumoral lymphocytic infiltration, and, of importance, showing better survival in stage- matched cases. In this article, the results of recent investigations about MSI and its clinical applications are comprehensively reviewed. Knowledge of these biochemical mechanisms are likely to lead to more effective diagnosis and therapy of CRCs in the future

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