Annals of Coloproctology

Volume 20(6); December 2004

Original Articles

Appendiceal Mucocele.: Lim, Young Chul , Choi, Dae Hwa , Cho, Hong Rae , Ko, Byung Kyun , Nam, Chang Woo , Nah, Yang Won , Kim, Gyu Yeol; J Korean Soc Coloproctol. 2004;20(6):339-343.

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Abstract PDF: PURPOSE
An appendiceal mucocele refers to an abnormal dilatation of the appendiceal lumen by mucus. It is a rare clinical entity with a reported prevalence rate of 0.2~0.3% of all appendectomies. The purpose of our study was to identify the clinical characteristics of and the proper surgical management for appendiceal mucoceles.
METHODS
The hospital records of 24 eligible patients were reviewed. We analyzed demographic data, and pathological and clinical data.
RESULTS
There was a significant difference in size (P<0.009) between simple mucoceles (mean, 1.95 cm) and cystadenomas (mean, 3.6 cm). While ultrasonography was the most commonly used test to establish the diagnosis (14 patients), computed tomography and colonoscopy also provided fundamental information in 5 and 2 patients, respectively. An appendectomy was performed in most cases (20 cases, 83%). A cecectomy was performed in 3 cases, and an ileocecal resection was performed in only one case. Among the cases requiring a cecectomy, a laparoscopic cecectomy was performed in one case. A synchronous tumor was present in 5 cases. Three patients had gastric cancer, 1 patient had gallbladder cancer, the other one had endometriosis.
CONCLUSIONS
Our study shows that appendiceal mucoceles most frequently present as acute appendicitis and that preoperative diagnosis is difficult to make. All mucoceles should probably be removed to eliminate the chance of progression to malignancy. Also of note was the elevated incidence of associated neoplasms, especially gastrointestinal carcinomas. Some recommend surveillance colonoscopy in patients with a diagnosis of an appendiceal mucocele. We had three cases accompanied by gastric malignancy. Therefore, we suggest that surveillance gastrofiberscopy may be indicated.

Laparoscopic Total Proctocolectomy with Ileal pouch-anal Anastomosis for Patients of Familial Adenomatous Polyposis with or without Coexisting Colorectal Cancer.: Choi, Gyu Seog; J Korean Soc Coloproctol. 2004;20(6):344-350.

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Abstract PDF: PURPOSE
Familial adenomatous polyposis (FAP) normally appears in the early twenties and needs a restorative total proctocolectomy with ileal pouch-anal anastomosis (TPC/ IPAA). Thus, most patients with FAP are young, in socially active stage, and very concerned about their body image. Vast experience with laparoscopic colorectal surgery led us to perform laparoscopic-assissted TPC/IPAA for patients with FAP with or without cancer, and we evaluated the results from technical and oncologic aspects.
METHODS
Seventeen of 20 FAP patients underwent laparoscopic- assisted surgery between July 1996 and June 2004. All procedures were done in a totally laparoscopic, a laparoscopic-assisted, or a hand-assisted laparoscopic fashion.
RESULTS
Fifteen patients underwent laparoscopic-assisted TCP/IPAA; two others had a total colectomy with ileorectal anastomosis and a TCP with permanent ileostomy laparoscopically. Eight patients showed coexisting colorectal cancers. The mean operation time was 396.5 min. Patients passed flatus or liquid at the 2.2 post-operative day (POD), resumed meals at the 4th. POD, and were discharged at the 10th. POD. There were no intra-operative complications or open conversions. Post-operative complications occurred in 5 different patients. One patient with colon cancer had multiple hepatic metastases at 11 months after the operation and died at 24 months after the operation.
CONCLUSIONS
Laparoscopic-assisted surgery for the patients with FAP was technically feasible and could be an alternative method. The systematized and experienced approach could reduce a operation time to be acceptable. In selected cases and with a vast of experience, coexisting colorectal cancer would not be contraindicated for laparoscopic approach for the treatment of FAP.

Comparison of Recovery of Bowel Motility after Laparoscopic-assisted and Open Surgery for Right Colon Cancer: A Study of Gastric Emptying by Using Sitz-marker(TM) and Changes of Intraperitoneal Temperature.: Park, Chan Wook , Choi, Gyu Seog , Jun, Soo Han; J Korean Soc Coloproctol. 2004;20(6):351-357.

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Abstract PDF: PURPOSE
Early recovery of gastrointestinal motility is one of the main advantages of laparoscopic intestinal surgery. However, the reasons for this advantage are still not well known. To compare recovery of bowel motility after laparoscopic-assisted and open surgery for right colon cancer, we analyzed early clinical results, including both the gastric emptying time by using a Sitz-marker(TM) and the intraperitoneal temperature.
METHODS
From January 1996 to December 1999, 80 curative right hemicolectomies, which were divided into a laparoscopic-assisted surgery group (LS) with 36 patients and an open surgery group (OS) with 44 patients, were prospectively, but not randomly, studied for recovery of bowel motility. Clinical results, such as the pain score, the time to gas passage, the time to resumption of meals the hospital stay and the gastric emptying time obtained by using a Sitz-markers(TM), were evaluated. At the beginning and the end of the operation, the intraperitoneal temperature was checked at three different points.
RESULTS
In the LS and OS groups, the first flatus passed at the 3.0 and the 3.67 postoperative day (POD) and oral intake resumed at the 3.9 and the 5.2 POD, respectively (P<0.05). The numbers of Sitz-markers(TM) remaining in the stomach after surgery were 15.0 and 18.7 at the 1st POD (P<0.0001), 6.4 and 10.8 at the 2nd POD (P>0.05), 1.7 and 4.2 at the 3rd POD (P<0.05) and 0 and 1.1 at the 4th POD (P<0.05), respectively. No difference in intraperitoneal temperature was noted.
CONCLUSIONS
We found earlier recovery of bowel function after laparoscopic surgery than after open surgery, but could not identify any relationship between bowel function and the possible parameter of intraperitoneal temperature.

Sphincter Preserving Method for Distal Rectal Cancer: Treatment Experience of Ultra-low Anterior Resection and Hand Sewn Coloanal Anastomosis.: Baik, Seung Hyuk , Kim, Nam Kyu , Lee, Kang young , Sohn, Seung Kook , Cho, Chang Hwan; J Korean Soc Coloproctol. 2004;20(6):358-363.

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Abstract PDF: PURPOSE
As the oncologic safety of coloanal anastomosis (CAA) has been proven by many other authors, the incidence of CAA following a ultra-low anterior resection has increased. The purpose of this study is to evaluate the functional outcomes and complications for patients who underwent an ultra-low anterior resection and CAA for distal rectal cancer.
METHODS
57 patients underwent CAA following an ultra-low anterior resection between July 1997 and November 2003. 44 patients, who were followed up for more than 6 month after diverting ileostomy repair were evaluated for recurrence pattern, complications, and functional outcomes.
RESULTS
The median follow-up period was 32.0+/-22.8 (8~83) months. The mean age of the patients was 54.3+/-10.4 (23~74) years. The types of anastomosis were straight CAA (n=20) and J pouch CAA (n=37). The mean tumor size was 4.1+/-1.9 (2~8) cm, the mean distal resection margin was 1.3+/-0.9 (0.2~4) cm. Six months later, the anastomosis distance following diverting ileostomy repair was measured at 3.24+/-0.6 (2~4) cm from the anal verge. The complications were multiple fistulas (n=3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n=1), anal stenosis (n=7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements more than 6 times per day were observed in 16 patients. Overall recurrence occurred in 6 patients (13.6%). The 5-years survival rate was 84.4%, and the 5-year disease-free survival was 68.9%.
CONCLUSIONS
Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, in tolerable function, complications, and poor functional outcomes have been observed with CAA; therefore, the choice of this method should be considered carefully.

Intersphincteric Resection for Very Low Rectal Cancer.: Kim, Jae hun , Oh, Nahm gun; J Korean Soc Coloproctol. 2004;20(6):364-370.

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Abstract PDF: PURPOSE
In the treatment of rectal cancer, sphincter saving resection is increased but low anterior resection is limited in treatment for low rectal cancer below 4 cm from the anal verge. In other reports intersphincteric resection can allow an oncologically safe resection margin and has good functional results in very low rectal cancer. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection.
METHODS
Between 2000 and 2002, 18 patients (mean age 54 years, range 35~70) with adenocarcinoma of the rectum underwent intersphincteric resection by an transanal approach with a colonic J-pouch anal anastomosis and ileostomy. The mean distance between the tumor and anal verge was 3.75 (range 2.5~5) cm. Patients with T3 lesion were 8 and they were received preoperative radiochemotherapy. Others with T2 lesion were not received preoperative radiochemotherapy.
RESULTS
There was no postoperative mortality and local recurrance after median follow up of 32 (18~54) months. Morbidity occurred in 9 patient but were not serious. Two anastomotic leakages occurred. One was recovered after only conservative therapy, but the other one was received colostomy because of functional problem. Downstaging was observed in 62.5% (5/8) of the patients. Continence was good (Kirwan classification I, II) in 72% (13/18) of patients.
CONCLUSIONS
These results suggest that intersphincteric resection can be an alternative procedure to abdominoperineal resection for very low rectal cancer without losing chance of cure.

Clinicopathologic and Immunohistochemical Features of Gastrointestinal Stromal Tumors (GISTs) in the Colon & Rectum.: Park, Kil Chun , Kim, Hee Cheol , Park, In Ja , Yu, Chang Sik , Kim, Jung Sun , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(6):371-377.

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Abstract PDF: PURPOSE
A gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. There are only few reports in the literature describing colorectal GISTs. The aim of this study was to evaluate the clinicopathologic features of colorectal GISTs and to verify prognostic factors.
METHODS
We reviewed 14 patients diagnosed as having primary colorectal GISTs between 1992 and 2003. Clinicopathologic variables and immunohistochemical expressions were analyzed. The diagnostic criteria and grading system for the GISTs were based on the proposal by the National Institutes of Health in April 2001. The median follow-up period was 27 (1~137) months.
RESULTS
The male-to-female ratio was 9 : 5, and the mean age was 61 (37~76) years. The primary location was the rectum (11 cases, 78.6%). The mean tumor size was 7.7 (1.5~17) cm, and the mean number of mitoses was 33.4 (1~150) per 50 HPF. Of the 14 patients, 10 patients (71.4%) were regarded as a high-risk group and four patients as an intermediate-risk group. KIT protein and CD34 were expressed in 92.9% and 78.6% of the cases, respectively. The patients were subclassified based on immunohistochemical expressions as an uncommitted type in 11 cases (78.6%), a combined type in 2 cases (14.3%), and a myoid type in 1 (7.1%) case. Recurrence occured in three patients (21.4%) who were in the high-risk group.
CONCLUSIONS
Colorectal GISTs occurred predominantly in the rectum and tended to be classified as high risk, which was the most important risk factor for recurrence. Accurate diagnosis and grading are important for adequate treatment and accurate prognosis.

Comparative Analysis of Colorectal Cancer with Liver Metastasis Identified Preoperatively vs. Intraoperatively.: Park, In Ja , Kim, Hee Jeoung , Kim, Hee Cheol , Yu, Chang Sik , Chang, Heung Moon , Ryu, Min Hee , Kim, Jong Hoon , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(6):378-383.

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Abstract PDF: PURPOSE
Current diagnostic modalities frequently carry false negative evaluations, especially in micro-metastasis. Some metastases are identified incidentally during the operation for primary colorectal cancer. Our study was performed to assess the clinicopathological characteristics of intraoperatively diagnosed liver metastases, to analyze the survival and the prognosis, to compare the results with those for preoperatively diagnosed liver metastases.
METHODS
Between July 1989 and December 2001, the cases of 78 patients who underwent treatment for intraoperatively diagnosed liver metastasis at our hospital were analyzed retrospectively. There were 375 patients who were diagnosed with liver metastasis preoperatively during the same period. Metachronous liver metastases were excluded.
RESULTS
Intraoperatively diagnosed liver metastases mostly showed clinicopathological characteristics of primary colorectal cancer similar to those for preoperatively diagnosed liver metastases. On the other hand, the preoperative serum CEA level was significantly lower in the intraoperatively diagnosed group than it was in the preoperatively diagnosed group (P<0.001). For the metastatic lesion, the size of the metastasis was smaller in the intraoperatively diagnosed group than it was in the preoperatively diagnosed group (P=0.03). The two-year survival rate of the intraoperatively diagnosed group was significantly better than that of the preoperatively diagnosed group (71.6% vs. 58.4%; P=0.031). Prognostic factors of the intraoperatively diagnosed group were the number of liver metastases, a curative operation for the primary cancer, and an operation for the metastatic lesion.
CONCLUSIONS
Intraoperatively diagnosed liver metastases had biologic features similar to those of preoperatively diagnosed liver metastases. The survival rate of the intraoperatively diagnosed group was better than that of the preoperatively diagnosed group, possibly due to the curative resection for the hepatic metastases. Therefore, aggressive treatment for primary and metastatic lesions is the therapeutic choice to improve patient's survival for intraoperatively diagnosed synchronous liver metastases.

Comparison of Long-term Survival for Laparoscopic-assisted Surgery and Open Surgery for Right Colon Cancer: A Case-Control Study.: Choi, Seok Kyoung , Lee, Jong Ho , Choi, Gyu Seog; J Korean Soc Coloproctol. 2004;20(6):384-390.

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Abstract PDF: PURPOSE
The aim of this study was to compare the long-term oncologic outcomes of laparoscopy assisted and open surgery for patients with right colon cancer.
METHODS
From June 1996 to May 2000, 35 patients underwent curative surgery with a laparoscopic-assisted right hemicolectomy (LAC), and from among the patients who had curative open surgery, 35 patients with clinicopathologic characteristics comparable to those of the LAC group were selected and matched as a control group (OC). A comparative analysis of long-term survival and patterns of recurrence between these two groups was done.
RESULTS
There were no statistical differences in demographic, laboratory and pathologic characteristics between the two groups. The mean follow-up period was 54.5 months. The overall five-year survival was 82.9% in the LAC group and 68.6% in the OC group, but was not statistically significant (P=0.17). Interestingly, the five-year survival of patients with TNM stage III tumors was significantly higher in the LAC group (84.2%) than in the OC group (52.6%) (P=0.04). There were no port-site recurrences or operative deaths.
CONCLUSIONS
The long-term oncologic outcomes of laparoscopic surgery for right-sided colon cancer were similar to those of open surgery. Interestingly, laparoscopic surgery for stage III tumors showed better survival than open surgery. However, a more large-scaled randomized study will be needed to clarify the oncologic safety of laparoscopic surgery for colon cancer.

Expression of beta-catenin in Colorectal Cancer with Liver Metastasis.: Han, Sang Ah , Park, Chi Min , Kang, Sin Jae , Song, Sang Yong , Kim, Sang Hee , Son, Dae Soon , Yun, Seong Hyeon , Lee, Woo Yong , Chun, HoKyung; J Korean Soc Coloproctol. 2004;20(6):391-398.

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Abstract PDF: PURPOSE
Decreased expression of beta-catenin has been known to be associated with tumor metastasis. However, the clinical relationship between the degree of expression and the prognosis in colorectal cancer (CRC) remains unclear. In this study, we evaluated the prognostic value of beta-catenin expression in CRC patients with liver metastasis.
METHODS
Paraffin embedded blocks were obtained from 70 patients who underwent potentially curative resection for CRC with liver metastasis. Samples from normal colon mucosa, primary CRC and metastatic liver lesion were prepared in tissue microarrays and were stained by immunohistochemistry with monoclonal antibody against beta- catenin. The membranous beta-catenin expression was assessed and the beta-catenin expression difference between primary CRC and metastatic liver lesion was analysed in relation to overall survival as well as disease free survival rates.
RESULTS
In beta-catenin expression, preserved expression (score >6) was observed in 42.0%, and 21.9% of primary CRC tumor samples and tumor samples from metastatic liver lesion respectively. The degree of beta-catenin expression in metastatic liver lesion was significantly lower than that in primary CRC (P=0.022). According to the difference of beta-catenin expression score between primary CRC and liver metastasis, patients were classified as group 'A' and 'B'. Group 'A' was defined as patients showing remarkably decreased expression of beta-catenin in metastatic liver lesion in that the difference of the score was three or more. Group 'B' was defined as patients showing maintained or increased beta-catenin expression in metastatic liver lesion in comparison to primary CRC, in that the difference of beta-catenin expression score was less than three. Overall survival rate and disease free survival rate were significantly better in group 'B' than group 'A' (P=0.02, P=0.002).
CONCLUSIONS
Decreased expression of beta-catenin in metastatic liver lesion may be a poor prognostic marker in colorectal cancers with liver metastasis. A further large-scaled investigation is necessary to define the role of beta-catenin in CRC.

Local Resection for Treatment of Early Colorectal Cancer.: Lee, Eun Joung , Chung, Soonsup , Lee, Ryung Ah , Lee, Suk Hwan , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2004;20(6):399-404.

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Abstract PDF: PURPOSE
Early colorectal cancer is defined as invasive tumor, limited to the mucosa or submucosa. The incidence of early colorectal cancer detection has been increased due to well designed screening technology and development of colonoscopy. The novel treatment of early colorectal cancer is still not settled despite of this advancement. We performed retrospective study about outcomes of colorectal cancer after radical resection or local resection.
METHODS
Sixty two patients, diagnosed as early colorectal cancers by pathology, were selected for this case study. The hospital records were reviewed retrospectively and the following was found: Twenty four patients received local resection such as colonoscopic polypectomy or local resection of colon. Remaining thirty-eight patients received radical resection. The clinicopathologic features of two groups were analyzed statically and survival rate was compared.
RESULTS
The clinical features were similar between two groups including sex, age, stage, tumor size and differentiation. The median follow-up duration was 47.3 months (range: 2~152 months). Survival rate was not different according to resection type. Recurrent cases were one patient from each group. They were all submucosal tumors.
CONCLUSIONS
The local resection is safe treatment modality for early colorectal cancer. However, case selection for local resection should be cautious because submucosal cases have more recurrent potential. Longterm follow-up will be needed to achieve safety of early colorectal cancer.

Case Reports

Intraoperative Enteroscopic Total Polypectomy for the Patients with Peutz-Jeghers Syndrome.: Yoo, Sang Bum , Kim, Ik Yong , Sung, Seong Hoon , Kim, Dae Sung , Rhoe, Byoung Seon; J Korean Soc Coloproctol. 2004;20(6):405-410.

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Abstract PDF: Patients with Peutz-Jeghers syndrome often suffer complications of the polyps, such as intussusception, bowel obstruction, and bleeding. Furthermore, repeated operations may be required in some patients, which may result in short-bowel syndrome. Intraoperative enteroscopy during a laparotomy for this syndrome was introduced. This can avert multiple enterotomies and decrease bowel resection segments. We report the cases of three consecutive patients with Peutz-Jeghers syndrome who recently underwent intraoperative enteroscopy via enterotomy with successful removal of most small-bowel polyps. The large polyps of the jejunum required an enterotomy for their removal, but smaller polyps at the lower ileum were identified and removed by using intra-operative total enteroscopy. A more complete polypectomy can be performed using this technique, thus allowing patients with Peutz- Jeghers syndrome a longer interval between laparotomies and a reduction in the symptoms attributed to polyps.

Peritoneal Metastasis of an Carcinoma in the Appendix.: Lim, Chi Young , Kim, Jong Woo , Kim, Seung Ki , Lee, Kyong Po; J Korean Soc Coloproctol. 2004;20(6):411-414.

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Abstract PDF: An adenocarcinoma of the appendix is a rare tumor, and so far only 130 cases have been reported worldwide. We report one patient with peritoneal seeding of an adenocarcinoma. A 51-year-old man was admitted to our hospital with the impression of intestinal obstruction. He had undergone an appendectomy 5 years ago due to acute appendicitis. At that time, postoperative histopathological analysis had revealed an adenocarcinoid tumor in the appendix. The patient had been told to visit our hospital for follow-up but he hadn't visited. When he finally visited our hospital diagnostic laparoscopy revealed the peritoneal seeding of a recurrent adenocarcinoma. A palliative right hemicolectomy was done to relieve the bowel obstruction. After recovering from operation, the patient was treated with the 5-fluoruracil, leucovorin, and oxaloplatin (FOLFOX). The patient was discharged in improved general condition with a future plan for regular cyclic chemotherapy.

A Case of Gastrocolic Fistula by Primary Colon Cancer.: Yoon, Ho Young , Kim, Byung Chun , Sohn, Tae Kyung , Cho, Ji Woong , Chung, Bong Wha , Chung, Kyung Suk , Lee, Myung Seok , Yoo, Chong Woo , Ahn, Hye Kyung; J Korean Soc Coloproctol. 2004;20(6):415-419.

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Abstract PDF: A gastrocolic fistula is a fistulous communication between a segment of colon and the stomach. It is a rare complication and is caused most commonly by a carcinoma of the colon or the stomach. Among the less common causes of a gastrocolic fistula are a benign gastric ulcer, chronic ulcerative colitis, Crohn's disease, a carcinoid tumor, syphillis, an intraabdominal abscess, a lymphoma, trauma, intestinal tuberculosis, and iatrogenic factors. Recently, the incidence of gastrocolic fistulas has decreased due to earlier diagnosis and treatment of stomach and colon cancer. The classic triad of symptoms are lienteric diarrhea, feculent vomiting, and foul eructations, but all patients do not necessarily present with these symptoms. A gastrocolic fistula is usually diagnosed by using a barium enema, but occasionally can be detected by using an upper gastrointestinal series or endoscopy. Here, we report experience with a fistula between a cancerous transverse colon and the stomach and give a review of the literature.

Appendiceal Mucinous Adenocarcinoma with Pseudomyxoma Peritonei.: Park, Tae Jin , Jeong, Chi Young , Jung, Eun Jung , Lee, Young Joon , Hong, Soon Chan , Choi, Sang Kyung , Ha, Woo Song , Park, Soon Tae; J Korean Soc Coloproctol. 2004;20(6):420-423.

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Abstract PDF: Pseudomyxoma peritonei is a relatively rare and poorly understood condition in which mucus accumulate within the peritoneal cavity. The presence of cells in the mucin, either inflammatory or neoplastic, distinguishes it from simple acellular mucus ascites caused by mucinous spillage. There are widespread seedings on the peritoneal and omental surfaces with a heavy cancerous glaze. This is principally a complication of borderline or malignant neoplasm of the ovary and/or appendix. We report one female case with pseudomyxoma peritonei from mucinous adenocarcinoma of appendix which was diagnosed incidentally during laparoscopic cholecystectomy.

Review

Anatomic Basis of Sharp Pelvic Dissection for Total Mesorectal Excision with Pelvic Autonomic Nerve Preservation for Rectal Cancer.: Kim, Nam Kyu; J Korean Soc Coloproctol. 2004;20(6):424-434.

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Abstract PDF: Optimal goals of rectal cancer surgical treatment should include appropriate local control, higher survival rates, scrupulous operation procedures and good quality of life with maintained sexual and voiding function through the conservation of anal sphincter. Complete surgical removal of rectal cancer mass and adjacent lymph nodes in en-bloc package decreases the risk of local recurrence. Furthermore heightened awareness of better surgical techniques has created much interest in the anatomy involved in total mesorectal excision (TME), with particular focus on the fascial planes, nerve plexuses and their relationship to the surgical planes of excision. Total mesorectal excision focuses on several technical components and the quality of operated specimen. Sharp anatomic pelvic dissection along the visceral pelvic fascia must avoid any breach from the mesorectum haboring metastatic tumor deposits and lymph nodes. Also any coning down or blunt dissection should not be allowed. The rectal cancer mass and its surrounding mesorectum must be removed as one complete unit. Circumferential and distal resection margin must be also adequately obtained. Such sharp pelvic dissection instead of blunt dissection requires precised knowledge of the pelvic anatomy. Studying the hemisected cadevaric pelvis shows a clear relationship between the fascia and rectum. Also pelvic autonomic nerves can be saved to preserve the patient's sexual and voiding functions. Therefore the clincial importances of anatomical structures must be emphasized at each step of surgery. Upon such understanding of techniques, TME was performed in rectal cancer patients routinely and was able to obtain fair oncologic results and improved quality of life regarding sexual and voiding functions.

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