Annals of Coloproctology

Volume 20(2); April 2004

Original Articles

Whitehead's Operation: Should We Abandon It?.: Kim, Hong , Jeong, Inho , Suh, Kwang Wook; J Korean Soc Coloproctol. 2004;20(2):75-79.

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Abstract PDF: PURPOSE
Total prolapse of internal hemorrhoids around the entire anal circumference still remains as a challenging problem. Whitehead's circumferential hemorrhoidectomy is one of the surgical options. To elucidate efficacy of Whiteheads operation, we analyzed the surgical outcomes of Whiteheads operation.
METHODS
The medical records of 165 consecutive patients who underwent Whiteheads operation for end-stage hemorrhoids were retrospectively reviewed. The mean operation time, the mean blood loss, and the mean hospital stay were examined. Also the types of complications were identified. All patients were followed for extended periods and in May 2003 they were asked to appraise their satisfaction (mean follow-up duration was 45.5 months, 12~93 month range).
RESULTS
The mean operation time was 21.5+/-5.3 minutes, the mean blood loss was 50.5+/-22.0 cc, and the average hospital stay was 5.5+/-1.5 days. Early postoperative complications were fecal incontinence (60.6%) and voiding difficulty (53.3%). These problems were spontaneously resolved within 2 weeks. Pain was the most difficult problem, and all patients required a parenteral opioid for relief of pain. The only late complication was anal stenosis. Objectively, anal stenosis was found in 66 patients; however, 22 patients (13.3%) complained of defecation difficulty. Among them, only 4 patients required surgical treatment. The average score of satisfaction according to the patients themselves was 4.0+/-2.2, 0 being no satisfaction and 5 being complete satisfaction.
CONCLUSIONS
The Whitehead operation, if performed properly for the selected patients, still remains as one of the best surgical options for end-stage hemorrhoids.

Anterior Extrasphincteric Anorectoplasty with an Illuminating Intrarectal Indicator for Repair of an Anorectal Malformation.: Sin, Jin Yong , Cho, Yong Hoon , Kim, Hae Young , Oh, Nahm Gun; J Korean Soc Coloproctol. 2004;20(2):80-85.

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Abstract PDF: PURPOSE
This study was conducted to evaluate the functional results of an anterior extrasphincteric anorectoplasty (AEA) guided by an illuminating intrarectal indicator, in which a transperineal positioning of the anal canal was performed without cutting the perineal sphincter muscle.
METHODS
Point A which would be a anal orifice in future was designated 0.3 mm anterior to the anal dimpling site. A semicircular incision was made in the front of the anus. The flap, which included from the anal skin to the upper margin of the external anal sphincter, was everted posteriorly. A quarter of the frontal upper rim of the external anal sphincter was exposed, and the center of the uppermost portion was designated as point B. From point A toward point B, a spinal needle was inserted through the anal sphincter, and needle's tract was dilated under direct identification of the sphincter muscle by electronic stimulation. An illuminating intrarectal indicator with a laparoscopic light source was pushed through the distal stoma of a sigmoid colostomy toward its distal lumen so that the blind rectal pouch was perineally exposured. On the blind pouch, a cruciate incision was made, and it was anastomosed to the anus.
RESULTS
From 1991 to 2000, 11 patients with imperforate anus of high and intermediate type were operated by our method. In one case, the urethral injury was found intraoperatively and was immediately repaired. One case of anal stenosis was improved after serial Hegar dilatation. The postoperative bowel function in the Kirwan's clinical assessment at 12 th month was grade I in 9 cases and grade II in 2 case.
Conclusion
This AEA with an illuminating intrarectal indicator shows acceptable clinical results and could be considered to be an effective surgical option for anorectal malformations.

Comparison of Rectoanal Physiologic Changes and Treatment Results between Transanal Repair and Transanal Repair with Posterior Colporrhaphy in Patients with Rectocele.: Kim, Joo Hyung , Kwon, Young Min , Lee, Yong Pyo; J Korean Soc Coloproctol. 2004;20(2):86-92.

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Abstract PDF: PURPOSE
Rectoceles are often associated with anorectal symptoms. Various surgical techniques have been described to repair rectoceles, but the surgical results vary. The aim of this study was to compare transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR+PC).
METHODS
The records of 58 patients operated on during a 56-month period were reviewed. Of those 26 patients had a TAR, and 32 patients had a TAR+PC. Interviews and anorectal physiologic studies were performed preoperatively and postoperatively.
RESULTS
The recurrence rate after a TAR+PC was lower than the recurrence rate after a TAR (TAR 19.2% vs. TAR+PC 3.1%). The rectal sensation (sensory threshold: TAR 64.8+/-18.9 ml vs. TAR+PC 56.1+/-23.67 ml; earliest defecation urge: TAR 116.4+/-29.5 ml vs. TAR+PC 104.8+/-31.2 ml) was more improved after a TAR+PC.
CONCLUSIONS
A TAR+PC for treatment of a rectocele is safe and effectively corrects obstructed defecation. The improvement probably relates, at least in part, to rectal sensational factors other than the dimensions of the rectocele.

Clinical Analysis for 30 Cases of Total or Subtotal Abdominal Colectomy and Total Proctocolectomy.: Lee, Jun Hyun , Lee, In Kyu , Oh, Seong Taek , Jin, Hyung Min , Chang, Suk Kyun; J Korean Soc Coloproctol. 2004;20(2):93-98.

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Abstract PDF: PURPOSE
A total or a subtotal abdominal colectomy and a total proctocolectomy are performed occasionally for the surgical treatment of familial adenomatous polyposis, multiple colorectal cancers, ulcerative colitis, acute lower GI bleeding, and malignancy other than colorectal cancer. We studied 30 cases of patients who received either a total or a subtotal abdominal colectomy and a total proctocolectomy in one of the three hospitals affiliated with the Catholic University between January 1990 and December 2001. Our goal was to determine whether the total or subtotal abdominal colectomy and the total proctocolectomy are difficult and complicated procedures by comparing the mortality, the morbidity, the survival rate, and the complications to previously considered and reported results.
METHODS
Thirty patients treated with either total or subtotal abdominal colectomy and with a total proctocolectomy from January 1990 to December 2001 were chosen for this study. Their gender, age, underlying diseases, family history, hospital days, symptoms, changes in defecation habits following the procedure, complications, mortality, survival rate, and relationship to malignancy were evaluated.
RESULTS
Of the patients who received either total or subtotal abdominal colectomy and a total proctocolectomy, the average age was 44.6 years, the gender ratio was 1:1, and the underlying diseases were familial adenomatous polyposis (FAP) (43%), ulcerative colitis (UC) (20%), multiple colorectal cancers (17%), stomach cancer (7%), and Crohn's disease (3%). Diarrhea and rectal bleeding were the most common clinical symptoms, and abdominal pain and intestinal obstruction were frequently observed. A total proctocolectomy (TPC) with permanent ileostomy was the most frequently performed procedure (47%), and a TPC with ileoanal anastomosis was done in 10% of the cases. A total abdominal colectomy (TAC) with ileorectal anastomosis was applied in 23% of the cases, and subtotal abdominal colectomy (sTAC) with ileosigmoidal anastomosis was done in 20% of the cases. The operative mortality rate was 3% as one patient among thirty died. Postoperative complications developed in 33% of the patients. FAP and UC patients without cancer (45%) survived for over 4 or 5 years, but FAP and UC patients with cancer, especially an adenocarcinoma, survived for only 2.5 years.
CONCLUSIONS
A total or subtotal abdominal colectomy (TAC or sTAC) and a total proctocolectomy (TPC) are appropriate procedures with low mortality, low morbidity, and a low complication rate for several kinds of diseases. A TPC with ileorectal anastomosis is the procedure of choice for sparing the rectum in FAP and UC patients without coexisting cancer and without mutation of the APC gene after codon 1250, but a TPC with ileoanal anastomosis is recommended if there is a mutation of the APC gene after codon 1250. A TPC with ileostomy is the preferred method for FAP and UC patients with coexisting cancer.

Clinical Usefulness of a PET Scan in the Diagnosis of a Recurrent Colorectal Carcinoma.: Park, In Ja , Yu, Chang Sik , Kim, Hee Cheol , Lee, Kang Hong , Ryu, Jin Suk , Ha, Hyun Kwon , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(2):99-104.

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Abstract PDF: PURPOSE
The aim of this study was to evaluate the potential efficacy of positron emission tomography using 2- [18F]-fluoro-2-deoxy-D-glucose in detecting recurrent colorectal carcinomas.
METHODS
Seventy patients suspected of having recurrent colon cancer were evaluated using PET from January 2001 to March 2003. The PET results were compared with those of computed tomography and clinical examination over 6 months.
RESULTS
Among the 70 patients, 17 patients had abnormal CEA levels and no abnormal findings with conventional radiologic methods (group 1), 29 had equivocal findings on computed tomography and other radiologic studies (group 2), and 24 were proven to have recurrent colorectal carcinoma (group 3) respectively. The sensitivity and the specificity of the PET scan, which were proved to be higher then those of CT (93% vs. 72.2%, 88% vs. 48.5%), were 85.7%, and 80%, respectively, in group 1, 86.7%, and 85.7% in group 2 and both 100% in group 3. The interval between diagnosis using PET and conventional studies was 1.9 months.
CONCLUSIONS
Positron emission tomography is more sensitive than computed tomography in detecting recurrent colorectal carcinomas. When conventional studies show no abnormal findings except for CEA levels, PET can be a valuable imaging tool in detecting recurrent colorectal cancer and can prevent other unnecessary exploratory procedures.

CEA Study on the Effect of the No-touch Isolation Technique for Preventing Tumor Metastasis in Patients with Colorectal Cancer.: Bae, Ok Suk , Lee, Tae Soon , Park, Sung Dae , Park, Jong Wook , Chun, Dong Suk; J Korean Soc Coloproctol. 2004;20(2):105-111.

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Abstract PDF: PURPOSE
Although the 'No-touch' isolation technique was introduced by Turnbull et al. in 1967, the controversy over whether or not it reduces the risk of metastasis during surgery exists even today. The aim of this study was to evaluate the effect of the 'No-touch' isolation technique in primary colorectal cancer surgery.
METHODS
The evaluation was done by comparing the levels of CEA and CEA m-RNA expression from the same draining vein before and after tumor mobilization. Blood samples from 25 patients with primary colorectal cancer were collected for analysis. At the time of surgery, the main draining vein from the tumor was isolated and ligated at the proximal end. The 1st blood samples were collected just prior to tumor mobilization, and the 2nd samples right after. Both samples were analyzed for serum CEA level and CEA mRNA expression by using reverse transcriptase polymerase chain reaction (RT-PCR).
RESULTS
The mean CEA value from draining veins after tumor mobilization (8.08+/-8.98 ng/ml) was significantly higher than it was before mobilization (4.17+/-4.98 ng/ml). CEA mRNA was detected in 16% (4/25) of the blood specimens post-mobilization, whereas it was detected in only 4% (1/25) of the pre-mobilization samples.
CONCLUSIONS
The results suggest the validity of using the 'No-touch' isolation technique to reduce the risk of metastasis into the draining vein during mobilization.

Cyclooxygenase-2 Expression in Colorectal Cancer.: Kang, Won Kyung , Cheon, Joon Sung , Chang, Seh Jin , Cho, Hyun Min , Chun, Sung Won , An, Chang Hyeok , Oh, Seong Taek; J Korean Soc Coloproctol. 2004;20(2):112-117.

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Abstract PDF: PURPOSE
Cyclooxygenase (COX) is an important enzyme that transforms arachidonic acid into prostaglandins and exists as two types of isoenzyme, COX-1 and COX-2. Recently, the expression of COX-2 was presented as an important factor in determining the prognosis in colorectal cancer, and the expressed COX-2 was related with recurrence and liver metastasis after an operation for colorectal cancer. Thus this study was to investigate the relationship between COX-2 expression and the prognosis for colorectal cancer.
METHODS
We studied colorectal cancer patients who received operations at the Catholic University of Korea from Jan. 1993 through Dec. 2000, by reviewing their medical records and pathological reports. We used immunohistochemistry to determine the expression rate of COX-2 and to study its relationship with other clinical variables, the disease-free survival rat, and the recurrence rate.
RESULTS
Among the 217 cases, 171 cases (78.8%) showed positive COX-2 expression. The COX-2 expression increased with the differentiation and was lower in cases with lymph-node metastasis. However, no statistically significant difference in age, sex, location of lesion, invasiveness, stage, organ of metastasis, disease-free survival rate, and recurrence existed between patients with positive COX-2 expression and those with negative COX-2 expression.
CONCLUSIONS
There is no evidence that COX-2 expression is associated with a poor prognosis for colorectal cancer.

Review

New Trend in Chemotherapy for Colorectal Cancer.: Kim, Young Jin , Kim, Hung Dai; J Korean Soc Coloproctol. 2004;20(2):118-123.

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Abstract PDF: 5-Fluorouracil (5-FU) has been the main chemotherapeutic agent for the treatment of colorectal cancer for four decades with modest efficacy. Modulation of 5-FU by leucovorin or continuous infusion improves the response rate, but overall survival duration remains approximately 12 months. Many oral fluoropyrimidines have been studied, including capecitabine, UFT, S-1, and Eniluracil. Capecitabine has demonstrated equivalent efficacy with 5-FU and has been approved as first line treatment. CPT-11 demonstrated non-crossover resistance with 5-FU and was proven to be effective treatment for patients who received prior 5-FU. CPT-11 in combination with 5-FU has demonstrated improved response rate and overall survival duration over 5-FU or CPT-11. Oxaliplatin plus 5-FU has offered another effective treatment option for colorectal cancer. Both 5-FU plus leucovorin in combination with CPT-11 or oxaliplatin are widely used first-line chemotherapies for advanced colorectal cancer. The combinations of capecitabine with CPT-11 or oxaliplatin are being developed. Several molecular targeting agents such as EGFR inhibitors and antiangiogenic agents have developed. Cetuximab induces a broad range of cellular responses in tumors expressing EGFR, enhancing sensitivity to radiotherapy and chemotherapeutic agents. A key angiogenic pathway in the stimulation of tumour growth is the vascular endothelial growth factor (VEGF) pathway, inhibited by the monoclonal antibody bevacizumab. Phase II first line and phase III second line studies of oxaliplatin in combination with bevacizumab are now in progress. Optimal combinations and sequences of treatment are being studied, since several effective regimens have become available.

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