Annals of Coloproctology

Volume 20(5); October 2004

Original Articles

Management of Cecal Diverticulitis.: Sung, Jong Je , Song, Dan , Hong, Gaun Yue , Park, Nae Kyeong; J Korean Soc Coloproctol. 2004;20(5):251-256.

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Abstract PDF: PURPOSE
Diverticular disease of the cecum and ascending colon is a relatively uncommon disease, and is often difficult to diagnose. The purpose of this study was to investigate the clinical features of patients who underwent surgical treatment for cecal diverticulitis.
METHODS
A retrospective review was conducted between January 1998 and December 2002 of 44 patients treated at the Department of Surgery, Soonchunghyang Gumi Hospital.
RESULTS
All patients presented with right lower quadrant pain and tenderness. Preoperatively, 34 patients were diagnosed with acute appendicitis. The surgical procedures for cecal diverticulitis were an appendectomy only (5 cases), a diverticulectomy with appendectomy (31 cases), and a right hemicolectomy (8 cases). Postoperative complications were found in 17 cases: wound infection (13 cases), and partial intestinal obstruction (2 cases).
CONCLUSIONS
When cecal diverticulitis is found at the time of an operation, surgical management is a safe treatment with low morbidity and a low recurrence rate. A diverticulectomy with appendectomy is a safe and effective procedure for the treatment of cecal diverticulitis if there is no evidence of free perforation or abscess formation. If the diverticulitis is complicated, undistinguishable from a malignancy, a resection (ileocecal resection, right hemicolectomy) should be considered for the surgical treatment.

Laparoscopic Treatment of Colonic Injury Caused by Colonoscopy.: Lee, Sang Ho , Choi, Gyu Seog , Lee, Jong Ho; J Korean Soc Coloproctol. 2004;20(5):257-262.

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Abstract PDF: PURPOSE
Colonoscopy is a reliable and useful tool for diagnosis, surveillance and treatment of colorectal disease. In spite of its safety, in a large number of procedures, serious complications such as perforation or bleeding of the colon are rare, but inevitable. Laparoscopically, we treated patients with complications after diagnostic or therapeutic colonoscopy and evaluated the safety and the usefulness of laparoscopic treatment.
METHODS
From December 2002 to November 2003, thirteen patients were referred to us from regional colonoscopic clinics for laparoscopic surgery due to complications of colonoscopy. All patients presented radiologic intra- or retro-peritoneal free air and various degrees of clinical symptoms or signs comparable to colonic injury, such as abdominal pain and tenderness, distension, and/or fever. One patient with mild symptoms and an other colonoscopically treated were excluded for this study. Patients were followed up at least for two months after the operation.
RESULTS
Laparoscopic procedures ranged from exploration only or closure of a perforated colon to a standard operation for colorectal cancer according to the degree of injury or associated disease. The mean operative time was 102 min. Patients resumed meals at the 2nd to 4th post-operative day and were discharged 5 to 8 days after the operation. No operative complications occurred.
CONCLUSIONS
Laparoscopic surgery for complications of colonoscopy is feasible and safe and can allow an unnecessary laparotomy to be avoided. Even in patients with colonic injury due to the colonoscope and colorectal cancer together, laparoscopic surgery can be an alternative method for treatment of the disease.

Functional Outcome after Ileal J-pouch Anal Anastomosis in Patients with Ulcerative Colitis.: Yoon, Sang Nam , Hong, Chang Won , Lee, Min Ro , Park, Kyu Joo; J Korean Soc Coloproctol. 2004;20(5):263-270.

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Abstract PDF: PURPOSE
This study was performed to assess the complications and functional outcomes after a total proctocolectomy and ileal J-pouch anal anastomosis for patients with ulcerative colitis.
METHODS
We reviewed the medical records of 30 patients who had undergone a total proctocolectomy and ileal J-pouch anal anastomosis for ulcerative colitis from 1992 to 1999 in our hospital. We used questionnaires or telephone interviews to assess the functional outcomes of the patients. The median duration of follow-up was 23 months after the ileostomy take down.
RESULTS
The mean age of the patients at the definitive operation was 35.9 (+/-11.8). The indications for operation were medical intractability (76.7%), suspicious malignancy (13.3%), perforation (6.7%), and hemorrhage (3.3%). The double stapling method was used in 26 patients and the handsewn method in 4 patients. Of the 30 patients, 23 patients completed the functional analysis. Bowel frequency was 6.6 (+/- 2.6) per 24 hours, with 5.1 (+/- 2.1) in the daytime and 1.4 (+/-1.3) in the night. Fourteen patients (60.9%) had relatively mild incontinence, and four patients (17.4%) had to wear pads, especially at night. Eighteen patients (78.3%) were able to discriminate flatus from feces, and only one patient (4.3%) suffered from perianal irritation. Twelve patients (52.2%) had to restrict their diets, and five patients (21.7%) took antidiarrheal medications. Pouchitis occurred in three patients (13.0%). Sexual dysfunction was noted in four patients (17.4%), and urinary urgency in one patient (4.3%). There was no functional difference between the double stapling method and the handsewn method.
CONCLUSIONS
The functional outcomes after ileal J-pouch anal anastomosis for patients with ulcerative colitis were satisfactory, irrespective of the method of anastomosis.

Randomized Controlled Trial

A Prospective Study Comparing Suprapubic with Transurethral Catheterization in Colorectal Surgery.: Joo, Young Tae; J Korean Soc Coloproctol. 2004;20(5):271-276.

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Abstract PDF: PURPOSE
Bladder drainage allows monitoring of urine output, intraoperative decompression of the bladder, and prevention of postoperative urinary retention. Commonly, bladder drainage is by transurethral cathterization, which is associated with a high incidence of bacteriuria, pain, discomfort, urethritis, abscess, and stricture. Suprapubic bladder drainage has been frequently reported to be superior to urethral drainage because of less urinary infections, less pain and discomfort, no urethritis, and easier care. We have prospectively compared the outcomes following suprapubic catheterization (SPC) with those following transurethral catheterization (TUC) in patients undergoing colorectal surgery.
METHODS
A prospective randomized trial of SPC versus TUC was undertaken in 40 patients (M:F=26:14) undergoing colorectal surgery from April 2003 to December 2003. Twenty patients were catheterized through the urethra using a 16F Foley catheter. In the other twenty patients, an identical catheter was placed in the bladder through the suprapubic abdominal wall. Significant bacteriuria was defined as > or =10(5) organisms/ml. The pain and discomfort of patients were obtained by using a questionnaire.
RESULTS
There were no difference in the incidence of complications between the SPC and the TUC. The number of patients with pain and discomfort was significantly greater and more severer for TUC, especially in males. According to operation type, abdominoperineal resection had the longest duration of catheterization.
CONCLUSIONS
This study suggests that the use of SPC rather than TUC significantly reduces pain and discomfort of patients undergoing colorectal surgery.

Original Articles

The Outcome of Preoperative Chemoradiation to Locally Advanced Rectal Cancer.: Park, Hyung Seok , Ahn, Byung Kwon , Lee, Seung Hyun , Baek, Sung Uhn; J Korean Soc Coloproctol. 2004;20(5):277-282.

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Abstract PDF: PURPOSE
Tumor downstaging after preoperative chemoradiation has been associated with an intent to improve anal sphincter preservation, resectability, local control, and possibly survival in locally advanced rectal cancer. We performed this study to evaluate the outcome of preoperative chemoradiation for locally advanced rectal cancer.
METHODS
We retrospectively reviewed the cases of 82 patients who had been treated by using preoperative chemoradiation combined with surgery for adenocarcinoma of the rectum between January, 1995, and December, 2002. All patients had fixed or locally advanced lesions, which had been detected by using digital rectal examination. No distant metastasis was proven before preoperative chemoradiation. All of the patients received the full scheduled dose of radiation (range, 3,000~5,400 cGy). Concurrent intravenous chemotherapy with 5-fluorouracil (450 mg/m2/day) and leucovorin (45 mg/day) was administered continuously on days 1~5 and 29~33. The mean interval between chemoradiation and surgery was 5.6 weeks (2.7~9.6 weeks). The survival rate was estimated by using the Kaplan-Meier method and the log-rank test. We compared the survival of locally advanced rectal cancers treated by using preoperative chemoradiation with surgery with that of 444 patients with resectable rectal cancers treated by using curative surgery alone during same period.
RESULTS
A curative resection could be performed on 64 of the 82 patients (78.2%). A sphincter-preserving surgery was performed on 42 patients (51.2%). A pathologic complete response (pCR) occurred in 6 patients (7.3%). The 5-year survival rates of patients with a pCR was 66.7%. In the comparison of the 5-year survival rates between patients with locally advanced rectal cancer treated by using preoperative chemoradiation with curative surgery and patients with rectal cancer treated by using curative surgery alone, those of stage I, stage II, and stage III cancers were 100% vs. 89.5%, 86.9% vs. 86.3%, and 52.9% vs. 63.3%, respectively (P>0.05).
CONCLUSIONS
The survival rates for patients with locally advanced rectal cancers, which are expected to be unresectable or non-curative, treated by using preoperative chemoradiation with surgery were similar to those for patients with resectable rectal cancers treated by using curative surgery alone. We think that preoperative chemoradiation with surgery improves the survival of patients with locally advanced rectal cancer. J Korean Soc Coloproctol 2004;20:277-282

Primary Cecal Lymphoma.: Park, Jung Hoon , Sin, Jin Yong , Hong, Kwan Hee; J Korean Soc Coloproctol. 2004;20(5):283-288.

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Abstract PDF: PURPOSE
Primary colonic lymphomas are very rare disorders and the most common location of a colonic lymphoma is the cecum. However, the prognosis for patients with a primary cecal lymphoma is not well understood clear. This study was undertaken to assess the prognosis for patients with a primary cecal lymphoma.
METHODS
A retrospective analysis of our patients, who were categorized into two groups, cecal lymphoma (10 cases) and non-cecal lymphoma (10 cases), was performed from January 1985 to December 2001. The prognostic factors were analyzed. RESULTS: The most common presenting symptoms and signs of cecal lymphomas were abdominal pain (80.0%), nausea/ vomiting (80.0%), and abdominal mass (40.0%). The preoperative biopsy- proven diagnostic rate of cecal lymphoma was 10.0%. The mean size of cecal lymphomas was significantly smaller than that of non-cecal lymphomas (6.2 cm vs. 10.0 cm). Histologically, 9 (90.0%) of the primary cecal lymphomas were classified as intermediate-grade lymphoas, and 1 (10.0%) as a high-grade lymphoma. three (30.0%) of the cecal lymphomas were Stage IE, 5 (50.0%) were Stage IIE1, and 2 (20.0%) were Stage IVE. Tumor resection and chemotherapy was used for 8 (80.0%) of the cecal lymphomas. Two regimens of chemotherapy were used: CHEP-Bleo (cyclophosphamide, doxorubicin, and epirubicin, prednisone, and bleomycin) and COP-BLAM (cyclophosphamide, vincristine, prednisone, bleomycin, doxorubicin, procarbazine). The median survival time for patients with a cecal lymphoma was 56 months, but that survival time was not significantly different from the survival time for patients with non-cecal lymphoma.
CONCLUSIONS
The prognosis for patients with a primary cecal lymphoma appears to be similar to that for patients with a non-cecal lymphoma. However, the number cases in our study was very small, the more cases are needed to establish a general prognosis for patients with a primary cecal lymphoma.

Laparoscopic Resection of Colon Cancer: Early Oncologic Outcomes.: Joh, Yong Geul , Kim, Seon Hahn , Hahn, Koo Yong , Lee, Dong Keun; J Korean Soc Coloproctol. 2004;20(5):289-295.

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Abstract PDF: PURPOSE
The aim of this study was to evaluate the interim oncologic outcome following a laparoscopic resection of colon cancer.
METHODS
Prospectively collected data was obtained on 119 patients (M:F=60:59, mean age=56 years) undergoing a laparoscopic colon-cancer resection between January 2001 and May 2004. Fifty-nine tumors were in the sigmoid, 17 in the right colon, 15 in the transverse colon, 12 in the hepatic flexure, 12 in the left colon, 10 in the cecum, and 4 in the splenic flexure.
RESULTS
The operative procedures included 51 sigmoidectomies, 48 right colectomies, 15 left colectomies, 3 transverse colectomies, and 2 total abdominal colectomies. The mean operative time was 186 minutes. The mean blood loss was 91 ml. Conversion to an open procedure was not required. TNM stages were 0 in 11 patients, I in 19, II in 55, III in 30, and IV in 4. The portion of T3 plus T4 was 73%. The mean number of resected lymph nodes was 27. The mean proximal and distal margins were 14 cm and 12 cm. The overall morbidity rate was 26% (15 wound seromas/ abscesses, 5 chylous leaks, 3 perianastomotic inflammations, 2 ileus, 2 intraabdominal bleedings, 1 anastomotic leak, 1 anastomotic obstruction, 1 intractable hiccup, 1 fungal peritonitis). There were no operative mortalities. The mean hospital stay was 10 days. Ninety eight patients were followed-up longer than 6 months (median 19 months, range 6~0 months) after the curative resection. Distant metastases occurred in 3 stage-IIIB and 3 stage-IIIC patients (6%): liver (2), liver & peritoneum (1), lung (1), paraaortic and iliac lymph nodes (1), and peritoneum (1). The mean time to recurrence was 10.3 months after the operation There were no local or port-site recurrences.
CONCLUSIONS
In this study, Laparoscopic resections of colon cancer provided an acceptable morbidity rate and satisfactory early oncologic outcomes. Long-term follow-up is mandatory and ongoing.

Analysis of Criteria for Tumor Response after Preoperative Chemoradiation Therapy for Locally Advanced Rectal Cancer: Correlation between Tumor Volume Reduction and Histopathologic Downstaging.: Kim, Nam Kyu , Pyo, Hong Ryull , Baik, Seung Hyuk , Lee, Kang Young , Sohn, Seung Kook , Cho, Chang Hwan , Rha, Sun Young , Chung, Hyun Chul; J Korean Soc Coloproctol. 2004;20(5):296-302.

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Abstract PDF: PURPOSE
Preoperative chemoradiation treatment (CCRT) for locally advanced rectal cancer has been known to be safe and effective. The aim of study is to find any correlation between tumor volume reduction and histopathologic downstaging in locally advanced rectal cancer by preoperative CCRT.
METHODS
A total of 16 patients of rectal cancer were selected. They had been T3,4 N (+) preoperatively staged by using a transrectal ultrasonography and pelvic MRI. Radiation was given, a total of 5,040 cGy over 5 weeks, and systemic chemotherapy was also given 5 FU 450 mg/m2 and leucovorin 20 mg/m2 concurrently intravenously during the first and the fifth week of CCRT. Surgery was done 4~6 weeks after completion of CCRT. A 3D CT image was obtained with AcQsim PQ 5000 3D (Philips, USA). Tumor volume was measured before and after CCRT.
RESULTS
The type of operative procedures were abdominoperineal resection 7, low anterior resection 5, coloanal anastomosis 3 and Hartmann operation 1. Volume reduction was ranged from 14.6% to 84.4%. Over a 50% tumor volume reductions were in 9 patients (56.2%). Pathologic complete remission was observed in 2 patients (12.5%), who showed 72% and 58.5% tumor volume reductions. Patients showing pT and/or pN downstaging patients (N=9) had a 55.9% tumor reductions (14.6~84.4%), and patients showing no pT and/or pN downstaging (N=7) had 51.8% volume reduction (24.7~79%).
CONCLUSIONS
Preoeperative CCRT has been thought to be able to decrease tumor size and volume and to increase respectability. However, among our 9 patients who showed over 50% tumor volume reductions, 3 patients did not show any T and N downstaging, which is really important for long-term oncologic outcomes.

The Characteristics and Prognosis of Patients with Obstructing Carcinoma of the Left Colon and Rectum: A Case-Control Study.: Lee, In Taek , Choi, Gyu Seog , Lee, Jong Ho; J Korean Soc Coloproctol. 2004;20(5):303-310.

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Abstract PDF: PURPOSE
Many reports have described significantly lower survival rates for patients with obstructing colorectal cancer than for patients with non-obstructing colorectal cancer. The aim of this retrospective study was to assess the long-term prognosis of patients with obstructing carcinomas of the left colon and rectum and to identify the clinical and pathologic characteristics that affect the prognosis.
METHODS
From June 1996 to October 2003, 46 patients with obstructing left colon and rectal cancer underwent curative surgery (case group), and from the patients with non- obstructing left colon and rectal cancer who had curative surgery, 48 patients with clinicopathologic characteristics similar to those of the case group were selected and matched as a control group. A comparative analysis of demographic, clinical, and pathologic characteristics, the recurrence rate, and the long-term survival rate between these two groups was done.
RESULTS
Emergency operations were done more frequently for obstructing cancer than for non-obstructing cancer (P=0.0001), and more patients with obstructing cancer presented to non-specialists (P=0.0001). The overall recurrence rate was significantly higher in obstructing cancer patients than in non-obstructing cancer patients. Further, the 5-year overall and the disease-free survival rates were significantly lower in obstructing cancer patients when examining either overall patient outcome or stage-III patients outcome.
CONCLUSIONS
The long-term prognosis of patients with obstructing carcinomas of the left colon and rectum is poor. We suggest that the poor general condition of patients with obstructing cancer, the increased number of emergency operations involving those patients, and more patients with obstructing cancer presenting to non-specialists may contribute to poor long-term prognosis for obstructing cancer patients.

Multicenter Study

Factors Influenceing the Oncologic Results after Abdominoperineal Resection: Does the Introduction of Laparoscopic Procedures Influence the Oncologic Results?.: Heo, Youn Jung , Cho, Hyeon Min , Kim, Jun Gi , Won, Yong Sung , Jun, Kyong Hwa , Chin, Hyung Min , Park, Woo Bae , Chun, Chung Soo; J Korean Soc Coloproctol. 2004;20(5):311-318.

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Abstract PDF: PURPOSE
Although indications for abdominoperineal resection (APR) are decreasing due to the widespread of sphincter-saving procedures, APR is still the mainstay in the treatment of rectal cancer. The purpose of this study is to demonstrate the appropriateness of laparoscopic APR in terms of oncologic parameters.
METHODS
From January 1984 to December 2003, 110 patients with a rectal adenocarcinoma who underwent APR were involved in this study. The data were grouped according to five main items: 1) patient demographic data, 2) operative procedure, 3) gross tumor findings, 4) pathologic tumor findings, and 5) perioperative treatment. Each item was subdivided by factors that could influence the oncologic results, and univariate analyses were performed. Thereafter, a multivariate analysis was performed with those factors considered statistically significant.
RESULTS
The mean follow-up period was 106.01+/-9.98 months, the local recurrence rate was 23.6%, and distant metastasis rate was 31.8%. The five-year survival rate was 58.1%, and the ten-year survival rate was 51.1%. Multivariate analysis after univariate analyses showed that independent prognostic factors influencing local recurrence were preoperative CEA level, T-stage, and preoperative radiation therapy. Factors influencing distant metastasis were preoperative CEA level, N-stage, and preoperative radiation therapy. Univariate analysis showed that the laparoscopic approach was beneficial in terms of local recurrence; however, with the multivariate analysis, this was not statistically evident. Prognostic factors influencing long-term survival in the multivariate analysis were preoperative CEA level, stage, and perineural invasion.
CONCLUSIONS
Laparoscopic APR was not significantly different from an open procedure in terms of oncologic outcomes. In the near future, a randomized prospective multicenter trial should tell us which approach is more beneficial.

Original Article

Characteristics of Bone Metastasis of Colorectal Carcinoma.: Tak, Sang Do , Moon, Sun Mi , Hwang, Dae Yong , Chang, Ung Kyu , Lee, Soo Yong; J Korean Soc Coloproctol. 2004;20(5):319-325.

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Abstract PDF: PURPOSE
Since the first case of bone metastasis of a rectal carcinoma was reported by Curling in 1870, bone metastasis in primary colorectal cancer has remained uncommon event. The aim of our study was to gain insight into the clinical characteristics of bone metastasis of colorectal cancer.
METHODS
This is a 10-year retrospective study that covers patients with bone metastasis of colorectal cancer in the Department of Surgery, Korea Cancer Center Hospital, from Jan. 1993.
RESULTS
In a total of 1461 cases of primary colorectal cancer treated in the same period, the clinical analysis was possible in 1356 cases. Of these, 53 cases showed bone metastasis. The incidence of bone metastasis was 3.9 Thirteen cases (25%) had bone metastasis only whereas 40 cases (75%) had bone metastasis combined with metastases of other organs. The most frequent site of bone metastasis was the vertebral bone (38, 71.7%), especially the thoracic spine (21, 39.6%). The median survival after onset of bone metastasis was 4.4 months, including 9.8 months in the bone-metastasis-only group and 3.5 months in bone metastasis with other-site- metastasis group. However, there was no significant difference in survival rate from the onset of bone metastasis between the two groups (P=0.3876).
CONCLUSIONS
If the colorectal cancer patient has complaint of bony pain, bone metastasis should be considered even though it is a rare event. However, most cases of bone metastasis occur with metastases of other organs. Management is often limited to simple procedures intended to relieve pain in the terminal phase of the disease.

Case Reports

A Case of Crohn's Disease Which is Diagnosed through Acute Sigmoid Colon Obstruction.: Moon, Jong Ha , Sung, Chi Won , Kim, Kab Tae; J Korean Soc Coloproctol. 2004;20(5):326-332.

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Abstract PDF: Crohn's disease is an inflammatory bowel disease like ulcerative colitis. Distinct from ulcerative colitis, Crohn's disease may involve any portion of the alimentary tract from the mouth to the anus. Recently, the incidence of Crohn's disease has been increasing in Korea. The proportion of the colon type is smaller than that of the ileocecal type or the small-bowel type. In the colon, Crohn's disease affects mainly the right side. Relatively, the sigmoid colon is rarely involved. Small-bowel obstruction is the most common complication requiring surgery in Crohn's disease. On the contrary, an obstruction limited to the colon requiring surgery is less common in Crohn's disease. We experienced a case of a severe acute sigmoid colon obstruction with peritonitis. At first, we suspected colon cancer, but after an emergency laparotomy, we diagnosed it as Crohn's disease. Such a situation is rare in Korea, so we hope this case report may provide a good opportunity to reconsider Crohn's disease.

Necrotizing Fasciitis of Perineum after Surgery and Radiation Therapy for Rectal Cancer.: Boo, Yoon Jung , Min, Byung Wook , Um, Jun Won , Moon, Hong Young; J Korean Soc Coloproctol. 2004;20(5):333-336.

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Abstract PDF: Necrotizing fasciitis is a rare disease characterized by rapidly progressive soft tissue infection primarily involving the superficial fascia and is associated with significant morbidity and mortality. Necrotizing fasciitis of the genitalia and the perineum, also known as Fournier's gangrene, usually occurs after local trauma, perirectal or perineal infections, and complicated surgery, such as circumcision and herniorraphy. The lack of initial external clinical signs, because the process begins in the deep subcutaneous tissue, make early diagnosis and adequate surgical management difficult. The progression of the disease is often fulminant, and the prognosis hinges on accurate diagnosis and immediate surgical debridement. The present case report documents the rare development of fulminant necrotizing fasciitis associated with a rectal cancer surgery and radiation therapy.

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