Annals of Coloproctology

Volume 21(4); August 2005

Original Articles

Expression of MUC2 and MUC6 in Colorectal Adenomas and Adenocarcinomas.: Park, Ho Sung , Kong, Tae Shik , Jang, Kyu Yun , Chung, Myoung Ja , Moon, Woo Sung , Lee, Dong Geun , Kang, Myoung Jae; J Korean Soc Coloproctol. 2005;21(4):193-200.

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Abstract PDF: PURPOSE
Although the expression of MUC2 is seen in colorectal tumors, there have been few reports about the expression of MUC6 in colorectal tumors. The aim of this study was to investigate the expressions of MUC2 and MUC6 in normal colorectal tissues and in tumors, as well as the association of MUC2 and MUC6 expressions with prognostic factors.
METHODS
Twenty (20) cases of colorectal adenomas treated by using a endoscopic polypectomy and 30 cases of colorectal carcinomas treated by using a resection were collected. Ten (10) normal tissue samples were obtained apart from the carcinomas. Sections were used for MUC2 and MUC6 immunostaining. The expressions of MUC2 and MUC6 were scored by using the sum of the percentages of the stained cells and the intensity of staining.
RESULTS
All of the ten normal colorectal tissues expressed MUC2 and MUC6. Of the 20 adenomas, 19 cases (95%) were MUC2 positive, and 17 cases (85%) were MUC6 positive. Adenomas with severe atypia tended to express lower levels of MUC2 and MUC6 than those with mild or moderate atypia. Of the 30 carcinomas, 28 cases (93%) were MUC2 positive and 19 cases (63.3%) were MUC6 positive. Colorectal mucinous carcinomas differed significantly from non-mucinous carcinomas in strong MUC6 expression. MUC2 expression showed a significant association with lymph-node metastasis.
CONCLUSIONS
The results suggest that MUC6 is expressed in normal colorectal tissues and tumors, that MUC6 expression is especially strong in mucinous carcinomas, and that MUC2 expression is associated with lymph-node metastasis, among the prognostic factors.

Difference in Clinical Features between Appendicitis and Right-Sided Colonic Diverticulitis on Initial Diagnosis.: Lee, Eun Kyu , Kim, Hungdai , Son, Beong Ho , Han, Won Kon; J Korean Soc Coloproctol. 2005;21(4):201-206.

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Abstract PDF: PURPOSE
Most patients who are finally diagnosed as having cecal and right-sided colonic diverticulitis complain of pain in the right lower quadrant of the abdomen, many of them unfortunately undergo an emergency operation for presumed appendicitis. Our purpose was to differentiate the diagnosis of right-sided colonic diverticulitis from appendicitis in an emergency setting.
METHODS
We retrospectively reviewed the medical records of 450 patients between January 1997 and July 2003. Among them, 92 patients who had been diagnosed as having right-sided colonic diverticulitis were classified as Group I. In the remaining 358 patients with appendicitis, 268 patients with simple appendicitis were classified as Group II and 90 patients with perforated appendicitis were classified as Group III.
RESULTS
The sex ratios were similar among 3 groups. The mean age of Group I (36.5+/-10.1 years) was significantly different from that of Group II (30.7+/-14.8 years, P=0.002), but not from that of Group III (38.7+/-20.9). Incidences of fever/chill and nausea/vomiting were less common in Group I (P<0.05). The duration of prodromal symptoms in Group I (2.6 days) was longer than that of Group II (1.6 days, P=0.02), but was not significantly different from that of Group III (3.3 days, P=0.83). The mean WBC count was significantly smaller in Group I (10913.8/mm3) than in Group II (13238.3/mm3) and III (15589.3/mm3, P<0.001). The percentage of segment form in differential counts was smaller in Group I (73.6%) than in Group II (79.1%) and III (81.8%, P<0.001). The percentage of lymphocytes in differential counts was larger in Group I (17.7%) than in Group II (13.9%) and Group III (9.4%, P<0.001).
CONCLUSIONS
Among the patients who complain of pain in the right lower quadrant abdomen in an emergency setting, cecum and right-sided colonic diverticulitis must be considered in the following conditions to avoid unnecessary emergency operations, relatively younger patients (20~40 years), infrequent prodromal symptoms, absent rebound tenderness with a laterally deviated maximal tenderness point, and absent or mild leucocytosis with a relatively low fraction of segment forms associated with a higher fraction of lymphocytes in CBC.

Safety of a One-stage Operation for an Obstructed Left Colon Carcinoma.: Oh, Soo Youn , Ahn, Eun Jung , Chung, Soon Sup , Lee, Ryung Ah , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2005;21(4):207-212.

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Abstract PDF: PURPOSE
For a left-sided colonic obstruction, the traditional method of a staged defunctioning colostomy and resection has been performed. Recently, there has been a trend towards a one-stage primary resection and anastomosis. The aim of this study was to assess the safety and the efficacy of a one-stage resection and anastomosis for obstructed left colon cancer.
METHODS
We retrospectively reviewed the records of 29 patients who had been diagnosed as having an obstructed left-sided colon cancer during the period from January 1995 to December 2003 at Ewha Womans University Hospital. We compared two techniques, a one-stage operation (10 cases) and a staged operation (13 cases).
RESULTS
The mean age of the one-stage group was 58.5+/-16.1, and that of the staged operation group was 65.0+/-13.4. Both groups had similar co-morbidities, TNM stages, and tumor locations. In the one-stage operation group, a subtotal colectomy (n=3), a resection and anastomosis with intraoperative lavage (n=5), and a resection and anastomosis following stent insertion (n=2) had been performed. Patients who had undergone a colostomy as the first operation, resection and anastomosis (n=3), and a resection and anastomosis following a defunctioning colostomy (n=10) were included in the staged operation group. The mean postoperative hospital stay showed no significant differences between the two groups. One patient who had undergone a one-stage operation presented with an intestinal partial obstruction five months later. There were no anastomotic leakages, intraabdominal absceses, and wound infections, nor were there any mortalities.
CONCLUSIONS
A one-stage resection and primary anastomosis for obstructed left-sided colon cancer can be done safely without significant morbidity.

Early Postoperative Complications following a Resection for Colorectal Cancer.: Park, In Ja , Kim, Hee Cheol , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2005;21(4):213-219.

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Abstract PDF: PURPOSE
Understanding of early postoperative course is very important for planning of operation and postoperative management. However, reports regarding early postoperative complications following colorectal cancer surgery are rare. The aim of this study was to report the incidence of immediate postoperative complications associated with colorectal cancer surgery.
METHODS
This prospective study examined clinicopathological data on 869 patients who underwent a resection for colorectal cancer between November 2002 and October 2003. Patients who underwent a palliative stoma, bypass, or emergent operation were excluded. Early postoperative complications were defined as complications occurring within 30 days of surgery. The male-to-female ratio was 518:351, and the mean age was 59 (range, 18~90) years.
RESULTS
The tumor was located at right colon in 176, at left colon in 169, and at rectum in 510 patients. In 158 patients (18.2%), at least one postoperative complication occurred. The most common complication was ileus (5.5%), followed by wound complication (4.1%), the voiding disturbance (3.3%), anastomotic bleeding (1.4%), anastomotic leakage (1.1%), and bleeding (0.6%). The complication rate was 21.6% in patients with right colon cancer, 16% in those with left colon cancer, and 17.3% in those with rectal cancer. Ileus occurred on mean postoperative day 8 and required a mean of 12 days for resolution. The wound complications occurred on mean postoperative day 9 and were resolved after a mean of 10 days. Of the 8 anastomotic leakage patients, proximal stoma construction was required in 5 patients. Intra-luminal bleeding occurred most common in patients with right colon cancer. Higher frequency of postoperative complications occurred in male patients (P=0.008), patients older than 70 years (P=0.02), and patients with co-morbid medical conditions (P=0.01).
CONCLUSIONS
The overall early postoperative complication rate following colorectal cancer surgery was 18.2%. The postoperative complication rate was higher in male, elderly, and patients with co-morbid medical conditions. Our results have allowed us to identify major complications and to better understand the postoperative course in patients undergoing colorectal cancer resections.

Survival after Curative Surgery for a Colorectal Mucinous Carcinoma.: Kim, Jun Ho , Baek, Jeong Heum , Lee, Jung Nam , Cho, Chung Yon , Min, Seung Kee , Lee, Woon Kee , Park, Heung Kyu , Chung, Min , Lee, Young Don , Oh, Jae Hwan; J Korean Soc Coloproctol. 2005;21(4):220-224.

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Abstract PDF: PURPOSE
The clinicopathological significance of a colorectal mucinous carcinoma remains controversial. Previous reports have suggested that mucinous carcinomas affect young patients, are more advanced at diagnosis, and have a worse prognosis than non-mucinous carcinomas, but more recent reports have refuted those results. The principal aim of this study was to evaluate whether colorectal mucinous carcinomas are associated with a worse prognosis than colorectal non-mucinous carcinomas for patients who undergo curative surgery.
METHODS
A total of 534 patients with colorectal carcinomas, including 42 cases of mucinous carcinomas, underwent surgery in the Department of Surgery of Gil Medical Center, Gachon Medical School, between March 1997 and February 2003. Of these, we retrospectively evaluated 33 patients with mucinous carcinomas and 407 patients with non-mucinous carcinomas who had undergone a curative resection. The age and the sex distributions, the primary location of the tumor, the stage at diagnosis, the curability, and the 3-year survival of mucinous- carcinoma patients were compared with those of non- mucinous-carcinoma patients. Thirteen patients were lost to follow-up, so we evaluated 427 patients for the overall survival rate by using the Kaplan-Meier method and the long-rank test for quality of curves.
RESULTS
The proportion of mucinous carcinomas was 7.8% (42/534). There were no significant differences in sex and curability, but the mucinous-carcinoma patients were found to be younger (P=0.014), to have a Right-side dominancy (P=0.038), and to have a more advanced stage at diagnosis (P=0.004). The 3-year survival rates in stage-B patients with mucinous carcinomas and non-mucinous carcinomas were 92.3% and 80.9%, respectively (P>0.05); in stage C, they were 62.2% and 73.8%, respectively (P>0.05). The difference of the survival rates for each stage was not statistically significant.
CONCLUSIONS
Many reports suggest that patients with colorectal mucinous carcinomas have worse survival than patients with non-mucinous carcinomas. However, there was no significant difference in the 3-year survival rates between patients with mucinous carcinomas and those with non-mucinous carcinomas in our study.

Case-Control Study for MTHFR and HFE Polymorphisms in Colorectal Cancer.: Lee, Ryung Ah; J Korean Soc Coloproctol. 2005;21(4):225-232.

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Abstract PDF: PURPOSE
A single nucleotide polymorphism is an important genetic variation in various pathologic situations. We examined MTHFR and HFE polymorphisms in a colorectal cancer group compared to those in a normal, healthy control group.
METHODS
Genomic DNA was isolated from whole blood of 99 colorectal cancer patients and 146 normal control patients and was subjected to MTHFR and HFE genotyping by using PCR-based restriction fragment length polymorphism analyses for the MTHFR C677T and A1298C sequences and for the HFE H63D and C282G sequences. Statistical analysis was done using SPSS 11.0.
RESULTS
The total allele frequencies of MTHFR C677T, A1298C, HFE H63D and C282Y were 0.398, 0.224, 0.014 and 0.022, respectively. The frequencies of homozygous mutants of MTHFR C677T and A1298C were 14.4% and 4.1% in the control group and 6.1% and 1.0% in the case group. There were no homozygous mutants of HFE in either group. Heterozygous mutants of H63D and C282Y were 2.1% and 4.1% in the control group and 4.0% and 5.1%, respectively in the case group. The odds ratio of a MTHFR C677T homozygous mutant was 0.604 (95% CI 0.375~0.973), and that of a MTHFR A1298C heterozygous and homozygous mutants were 0.513 (95% CI 0.298~0.883), but the difference was not statistically significant.
CONCLUSIONS
A homozygous mutant of MTHFR C677T and a homozygous and heterozygous mutant of A1298C showed a protective tendency against colorectal cancer. The HFE polymorphic mutant is quite rare in Korean population, which restricts the application of this polymorphism in a cancer epidemiologic study. The MTHFR C677T and A1298C variations should be useful predictive markers for colorectal cancer.

Oncologic Results according to Operative Method after a Curative Resection for Low Rectal Cancers.: Kim, Kwang Hee , Sin, Jin Yong , Hong, Kwan Hee; J Korean Soc Coloproctol. 2005;21(4):233-240.

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Abstract PDF: PURPOSE
Although the current trend is to use a sphincter- saving operation (SSO) for management of distal rectal cancer, an abdominoperineal resection (APR) is widely performed in low rectal cancers. Numerous studies have reported that lateral margin is an important prognostic factor for recurrence in low rectal cancers. In regard to curability, the presence of an involved lateral margin after a resection of a low rectal cancer is currently accepted as being an indicator of a non-curative resection. Indeed, the higher rate of positive lateral margins after APRs than after a SSO may explain the inferior oncologic outcomes of APRs. Therefore, the purpose of this study was to analyse the oncologic results of 'curative' APRs and SSOs.
METHODS
This retrospective study included 111 patients who had undergone surgical treatment between 1995 and 2000 with either an APR (n=65) or a SSO (n=46). The oncological outcomes of the patients who had undergone an APR were compared with those of the patients who had undergone a SSO. Univariate and multivariate analyses were used to evaluate the data.
RESULTS
The distal resection margin and the mean distance between the tumor low margin and the dentate line were significantly different between the two groups. However, the disease-free and the overall survivals, as well as the frequency of local recurrence and that of overall recurrence, after rectal excision did not differ between the two groups. Multivariate analyses showed that the method of surgery was not a significant independent factor in predicting either disease-free survival or overall survival. However, advanced stage III was a significant predictor of outcome after the operation.
CONCLUSIONS
The type of operation did not affect the oncological outcome after a 'curative' resection for distal rectal cancer.

Methylenetetrahydrofolate Reductase C677T and A1298C Polymorphisms in Colorectal Cancer.: Park, Won Cheol , Lee, Jeong Kyun; J Korean Soc Coloproctol. 2005;21(4):241-246.

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Abstract PDF: PURPOSE
Recently, the role of vitamins, folate in particular, has been emphasized in the maintenance of health. Folate deficiency is known to give rise to developmental delay, pre-mature vascular disease, neural tube defects, acute leukemia, atherosclerotic vascular disease, delivery defects, breast cancers and gastrointestinal neoplasia. Methylenetetrahydrofolate reductase (MTHFR) is an essential enzyme in folate metabolism, and influences DNA synthesis and DNA methylation. Generally, a low folate level is known to be associated with gastrointestinal neoplasms. Also, the amino- acid-changing and enzyme-activity-reducing nucleotide polymorphism (677C-->T/Ala222Val) has been described in the MTHFR polymorphism and it brings about low enzyme activity, which may reduce DNA methylation and uracil misincorporation into DNA. These processes may be critical for the oncogenic transformation of human cells. Two common single nucleotide polymorphisms (SNPs) resulting in amino-acid changes (677C T/Ala222Val and 1298A C/Glu428Ala) have been described in MTHFR. We investigated the relation between the MTHFR C677T and A1298C polymorphisms derived from colorectal cancers and from controls in the Korean population.
METHODS
One hundred forty-eight (148) individuals with colorectal cancer and 288 healthy persons were analyzed. Blood sampling of each group was performed by using a PCR- RFLP analysis, and MTHFR polymorphism genotypes of 677C/C, 677C/T, 677T/T, 1298AA, 1298AC, and 1298CC were obtained.
RESULTS
The genotype frequencies of MTHFR C677T polymorphisms were 25.0% (CC), 48.0% (CT), 27.0% (TT), and 75.0% (CT+TT), respectively, in case patients and 39.2% (CC), 36.8% (CT), 24.0% (TT), and 60.8% (CT+TT) in controls. The genotype frequencies of MTHFR A1298C polymorphisms were 56.1% (AA), 372% (AC), 6.8% (CC), and 43.9% (AC+CC), respectively, in case patients and 55.6% (AA), 40.3% (AC), 4.2% (CC), and 44.4% (AC+CC) in controls. The 677TT and the 677CT genotypes were associated with significantly increased risks for colorectal cancer (adjusted OR=1.77 and 95% CI=1.02~3.04 in TT; adjusted OR=2.07 and 95% CI=1.28~3.35 in CT) than was the 677CC, genotype but the the 1298CC and 1298 AC genotypes were not associated with significantly increased risks for colorectal cancer (adjusted OR=1.75 and 95% CI= 0.71~4.26 in CC; adjusted OR=0.95 and 95% CI=0.62~1.45 in AC).
CONCLUSIONS
The MTHFR C677T polymorphism may be influenced by colorectal cancer, but the role of the MTHFR A1298C polymorphism needs careful interpretation and confirmation in larger studies.

The Quality Evaluation of Information of Websites on Colorectal Cancer Using the DISCERN Instrument.: Sohn, Dae Kyung , Choi, Hyo Seong , Lee, Dong Uk , Lee, Sang Jeon , Lee, Jin Seok , Lee, Young Sung; J Korean Soc Coloproctol. 2005;21(4):247-254.

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Abstract PDF: PURPOSE
Many patients rely on the Internet for medical information. In Korea, there are many websites providing medical information, but the quality of these websites relating to colorectal cancer remains to be clarified. This study was performed to evaluate the quality of websites providing information on colorectal cancer.
METHODS
Firstly, sites were identified using four major domestic search engines and were classified according to the administrator. Then, two surgical oncologists used the 'DISCERN' instrument to assess 12 sites (including 2 foreign sites) for the reliability and the quality of the information on treatment choice.
RESULTS
Total 297 sites were identified using the search term 'colorectal cancer'. Excluding dead links or duplicated sites, 148 sites were identified. When the sites had been classified according to the administrator of the websites, 115 (77.7%) were identified as local clinic or hospital sites, 8 (5.4%) as medical school sites, 7 (4.7%) as institute or public health sites, 11 (7.4%) as commercial sites, and 7 (4.7%) as private sites. The results of the evaluations by the two examiners showed moderate inter-examiner reliability (K=0.41). The evaluations of the domestic sites by using DISCERN showed serious or important shortcomings in the quality of information on treatment choices and in reliability. Among these domestic websites, the quality of information provided at private or local hospital sites was poorer than that provided at institute or public health sites.
CONCLUSIONS
About 80% of the websites providing medical information on colorectal cancer were identified as private or local hospital sites. Evaluations of the information provided at domestic sites showed serious or important shortcomings.

Case Report

Laparoscopic Appendectomy for Acute Appendicitis Caused by Enterobius Vermicularis.: Lee, Yoon suk , Lee, In kyu , Oh, Seung teak , Kim, Jun gi , Jang, Suk kyun , Kim, Young ha , Kim, Kyung Mee; J Korean Soc Coloproctol. 2005;21(4):255-257.

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Abstract PDF: Enterobius vermicularis (pinworm) infection occurs in 4~28% worldwide. Although the most common clinical manifestation is perianal pruritis, it may cause gastrointestinal manifestations, including acute appendicitis in about 0.2~41.8% of infections. Preoperative diagnosis of pinworms in patients with acute appendicitis is not routinely performed. We performed a laparoscopic appendectomy for an acute appendicitis caused by Enterobius vermicularis. To our knowledge, this is the first report of a laparoscopic appendectomy for acute appendicitis caused by Enterobius vermicularis in Korea.

Review

Sharp Pelvic Dissection for Abdominoperineal Resection for Distal Rectal Cancer Based on Anatomical and MRI Knowledge.: Kim, Nam Kyu; J Korean Soc Coloproctol. 2005;21(4):258-267.

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Abstract PDF: Even though sphincter saving surgery such as coloanal anastomosis or intersphincteric resection have been popular in era of Total Mesorectal Excision (TME) in distal rectal cancer, unreasonable sphincter saving surgery might cause a couple of troublesome complications in terms of oncologic or functional outcomes. Since preoperative staging work up recently have been developed with MRI or MDCT, it is important to assess whether rectal cancer invaded into surrounding sphincter or levator ani muscle based on MRI or MDCT coronal image study. If tumor is located at a very close distance or has invaded the adjacent sphincter muscle, the need of abdominoperineal resection is definite without any hesitation for curative resection. But, the actual number of cases of APR have been decreased in favor of sphincter preserving surgery even APR remains an important therapeutic option in the surgical treatment of low rectal cancer. Indication case for APR have become a intersphincteric resection or ultralow anterior resection and coloanal anastomosis Even patients who showed invasion of sphincter underwent sphincter saving surgery, lately proven safe in terms of recurrence and defecation functions. On practical view points on operative techniques, abdominal phase are same as TME techniques. Sharp pelvic dissection must be carried out along the visceral fascia enveloping the mesorectum to the levator ani muscle with preservation of pelvic autonomic nerve. Perineal phase dissection is a key process in APR. During perineal dissection, inadequate resection margin and blunt tissue dissection along the nonanatomical plane encourage implantation of a malignant cell and local recurrence. Moreever, it could lead to serious complications such as prostatic urethral injury, vaginal wall perforation, perineal sinus and fistula. Massive bleeding from pelvic side wall major vessels injury. Especially in males with very narrow pelvis, pelvic dissection is very difficult due to deep narrow and blunt sacral curvature of the pelvis. It is nearly impossible to reach the levator ani muscle and result in perineal dissections performed on excessively high levels. For colorectal surgeons with insufficient experience, it is difficult to dissect the rectum from the perineum upto the seminal vesicle level. In the classic pattern, anterior and lateral dissection from the prostate or vagina after the completion of posterior dissection. The dissected proximal colon was delivered outward through the perineal wound and with traction of the delivered portion of the colon, anterior dissection was performed. However, in patients with narrow pelvis, such delivery of the proximal colon through perineal wound can result in fractured tumor and local recurrence due to limited operation field. Therefore, it is mandatory that specimen must be delivered in situ after posterior, anterior and lateral dissection. During posterior dissection, gluteus muscle must be observed and removal of the ischiorectal fat tissue should be accomplished. In lateral dissection, levator ani muscle must be divided near the bony insertion. Finally, during anterior dissection, seminal vesicle and prostate gland must be exposed and neurovascular bundle observed at the 10 and 2 o'clock direction. In addition to TME on abdominal phase, Sharp Anatomical Perineal Dissection (SAPD) empowered by 3D concept based on MRI is a key process for prevention of local recurrence in APR.

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