Annals of Coloproctology

Volume 21(5); October 2005

Original Articles

Post-hemorrhoidectomy Secondary Hemorrhage.: Choi, Dong Ha; J Korean Soc Coloproctol. 2005;21(5):271-278.

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Abstract PDF: PURPOSE
Post-hemorrhoidectomy secondary hemorrhage is a rare but serious complication after a hemorrhoidectomy. This study analyzed the factors associated with secondary hemorrhage following a surgical hemorrhoidectomy.
METHODS
A total of 1,751 patients received a semiclosed hemorrhoidectomy for symptomatic hemorrhoidal disease from May 2001 to January 2004. A retrospective study of 17 patients with post-hemorrhoidectomy secondary hemorrhage was done. Fourteen patients (82 percent) underwent surgery primarily for hemorrhoidal disease, two patients (12 percent) had hemorrhoids removed in addition to a sphincterotomy for anal fissure, and the remaining patient (6 percent) had a hemorrhoidectomy with fistulectomy. The variables analyzed included age, gender, incidence, recurrence, hospitalization, bleeding tendency, blood transfusion, and management.
RESULTS
The male to female ratio was 1.83:1 (P>0.05), and the mean age was 38.9 (range 19~55) years. The incidence of post-hemorrhoidectomy secondary hemorrhage was 0.98 percent. The mean interval from the operation to hemorrhage was 8.9 (range 4~18) days. The period of mean hospitalization was 4.5 (range 2~8) days. As predisposing factors, 3 patients had suspected liver disease with normal platelet count. The mean 1.90 gm/dl of Hgb at the time of secondary hemorrhage was lower than the preoperative values. One patient (5.9 percent) required 3 units of red blood cell transfusions. Treatment modalities included observation alone in three patients (18 percent), and suture ligation in the operating theater in fourteen patients (82 percent). None of the patients developed recurrent bleeding.
CONCLUSIONS
Post-hemorrhoidectomy secondary hemorrhage is an inevitable and a troublesome complication. The patient will need to be transferred rapidly to a hospital and resuscitated if necessary. The author favors suture ligation in controlling secondary hemorrhage. Suture ligation offers a good outcome with virtually no risk of recurrent bleeding. Post- hemorrhoidectomy secondary hemorrhage usually occurs at home between the fourth and eighteenth postoperative day and takes place in 0.98 percent of hemorrhoidectomies. In the author's opinion, post-hemorrhoidectomy secondary hemorrhage usually is not a preventable complication.

Predictors of Outcome Following Anterior Sphincter Repair in Obstetric Fecal Incontinence.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2005;21(5):279-285.

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Abstract PDF: PURPOSE
This study was designed to evaluate the outcome of anterior sphincter repair and factors influencing the outcome in patients with obstetric fecal incontinence.
METHODS
Thirty-three patients undergoing sphincter repair for obstetric fecal incontinence were prospectively evaluated. Preoperatively, standardized interviews and physiologic studies were performed. The severity of incontinence was graded according to the Parks' classification. Patients' satisfaction was classified as excellent, good, fair, and no improvement. An anterior overlapping sphincteroplasty was performed with or without levatorplasty. Interviews and manometry were repeated three months after the operation. Four years after the operation, the severities of incontinence and patients' satisfaction were reevaluated.
RESULTS
Preoperatively, all patients showed high-grade incontinence (grade 3 or 4). Three months after the operation, 28 patients (84.8%) had successfully recovered continence (incontinence grade 1 or 2), and 25 of those patients (75.8%) replied with satisfaction (excellent or good). The maximal average squeeze pressure (MASP) and the high-pressure zone (HPZ) length, but not the maximal average resting pressure (MARP), had significantly increased in patients with successfully recovered continence. At the 4-year follow ups, the outcomes were significantly worse than thase at 3 months, but 24 patients (72.7%) still maintained good outcome, and 25 patients (66.7%) still replied with satisfaction that was not significantly worse than that at 3 months. Patients with a young age (<45 years), a shorter duration of incontinence (<10 years), a larger increase in MASP or MASP at 3 months after the operation, no pudendal neuropathy, and a good result at 3 months were more likely to maintain low-grade incontinence. The addition of levatorplasty and an increase in the HPZ length at 3 months did not affect the outcome.
CONCLUSIONS
At the 4-year follow-ups, the outcomes had significantly deteriorated, but patients' satisfaction had not. Age, the duration of incontinence, a postoperative increment in MASP or MASP, pudendal neuropathy, and a short-term good outcome were closely related to the long-term outcome.

Characteristics of Crohn's Disease in Korea according to the Vienna Classification.: Yoon, Eyi Sang , Chang, Yeon Soo , Lee, Kil Yeon , Lee, Suk Hwan , Yoon, Choong , Kim, Hyo Jong; J Korean Soc Coloproctol. 2005;21(5):286-292.

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Abstract PDF: PURPOSE
Crohn's disease (CD) is a chronic inflammatory disease that is difficult to treat due to various complications and frequent recurrences. There have been many studies on the clinical aspects of CD in Western countries; however, there have been few studies in Korea. We performed this study to evaluate the clinical features of CD in Korea and to assess the stability over the course of the disease according to the Vienna classification.
METHODS
We reviewed the medical records of 85 patients diagnosed as having CD in Kyung Hee University Hospital from March 1986 to July 2004.
RESULTS
The male-to-female ratio was 1.9:1, and the mean age at diagnosis was 27.5 years. The most common symptom was abdominal pain (82%). Perianal lesions were observed in 29 cases (34%). Fistula was the most common (26%) lesion. Extraintestinal manifestations were observed in 13 cases (15%). Stomatitis was the most common (7%) lesion. According to the Vienna classification, the group with ages at diagnosis below 40 years (A1) was 88%, and that with ages equal to or above 40 years (A2) was 12%. The location of the disease was classified as terminal ileum (L1)(15%), colon (L2)(32%), ileocolon (L3)(33%), and upper gastrointestinal (L4)(20%). The behavior of disease was classified as nonstricturing nonpenetrating (B1)(41%), stricturing (B2)(14%), and penetrating (B3)(45%). Empirical anti-tuberculous medications were administered in 23 cases (27%) before the CD had been diagnosed.
CONCLUSIONS
There are differences in the locations and behaviors of Crohn's disease between Korea and Western patients. The cause of the difference is uncertain.

Transanal Endoscopic Microsurgery after Preoperative Concurrent Chemoradiation Therapy in Selected Distal Rectal Cancer Patients.: Park, Chi Min , Jung, Keuk Won , Han, Sang Ah , Yun, Seong Hyeon , Lee, Woo Yong , Chun, HoKyung; J Korean Soc Coloproctol. 2005;21(5):293-299.

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Abstract PDF: PURPOSE
Preoperative concurrent chemoradiation (CCRT) therapy may allow higher rates of tumor resectability and sphincter-saving procedures. Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of selected patients with early rectal cancer. The aim of this study is to evaluate the clinical outcomes of selected patients with distal rectal cancer treated with TEM after CCRT.
METHODS
Between June 2000 and August 2004, 7 patients with clinically T2 or T3 rectal cancer underwent TEM after CCRT. Pretreatment and preoperative clinical stages were estimated by using endorectal ultrasound or computed tomography and digital rectal exam. CCRT was performed with radiation therapy of 4,500 cGy/25 fractions over 5 weeks with 5-FU based chemosensitization. TEM was performed 4~7 weeks following the completion of therapy.
RESULTS
The mean age was 54.9 (35~70) years and the median follow-up period was 23.0 (5~57) months. The lesions were located between 2 to 6 cm above the anal verge (median 3.0 cm). Pre- treatment T staging was estimated as T3 in 1 case and T2 in 6 cases, and post-treatment T staging was estimated as complete remission (CR) in 2 cases, T1 in 3 cases, and T2 in 2 patients. Pathologic evaluation revealed tumor downstaging in 6 patients, including 3 patients (42.9%) with CR. In all cases, there was no tumor on the resection margin. There have been no recurrences during the follow-up period.
CONCLUSIONS
TEM after CCRT therapy appears to be an effective alternative treatment to radical resection for highly selected patients with T2 and T3 distal rectal cancer.

Usefulness of a Self-expandable Metallic Stent for a Malignant Colorectal Obstruction.: Chang, Yeon Soo , Lee, Kil Yeon , Lee, Suk Hwan , Yoon, Choong; J Korean Soc Coloproctol. 2005;21(5):300-306.

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Abstract PDF: PURPOSE
Malignant colorectal obstruction is a common emergency situation showing high morbidity and mortality because of the poor general condition of the patients, unprepared bowel and advanced diseases. Recently, the self-expandable colorectal stent has allowed an elective one-stage resection without the risk of an emergency operation and stoma formation. We evaluated the usefulness of the self-expandable metallic stent for a malignant colorectal obstruction in terms of the preoperative preparation of the patients.
METHODS
Seventeen patients who underwent a surgical resection following self-expandable metallic stent insertion for a malignant colorectal obstruction were included in this study. The patients' characteristics, clinical courses, and complications after stent insertion, the changes in physical status of the patients, the operative method, and the postoperative complications were investigated. The APACHE II score was applied for evaluating the physical status of the patients.
RESULTS
Obstructions were located at the transverse (n=1), the descending (n=3), and the sigmoid colon (n=6) and at the rectum (n=7). Stents were successfully inserted and obstructions were relieved in all patients. Preoperative evaluations were performed in all cases. Fourteen of the 17 patients (82.4%) showed abnormal laboratory findings on admission. The average APACHE II score was 10.6 on admission and decreased to 7.8 after stent insertion (P<0.05). Nine patients (52.9%) could resume oral feeding after stent insertion. There were 2 stent-related complications, one case of stent migration and one case of minor bleeding; both were managed conservatively. At an average of 9 days after the stent insertion, an elective radical resection was conducted in all cases. Laparoscopic resections were attempted in 7 (41.2%) patients and were successful in 6. In 15 cases (88.2%), resection with primary anastomosis was possible. Postoperatively, there were 3 cases of wound infections and a temporary ileus. The TNM stage was stage II in 9 patients (52.9%), III in 6 (35.3%), and IV in 2 (11.8%). The patients were discharged from the hospital at an average of 11 days postoperatively.
CONCLUSIONS
Self-expandable colorectal stent insertion is a safe and effective treatment strategy and can change the emergency setting to permit an elective one-stage curative operation by allowing the general condition of a patient with malignant colorectal obstruction to recover.

Prognostic Significance of Circumferential Resection Margin following a Total Mesorectal Excision in Rectal Cancer.: Baik, Seung Hyuk , Kim, Nam Kyu , Lee, Kang Young , Sohn, Seung Kook , Cho, Chang Hwan , Kim, Ho guen , Rha, Sun Young , Chung, Hyun Cheol; J Korean Soc Coloproctol. 2005;21(5):307-313.

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Abstract PDF: PURPOSE
Studies of the circumferential resection margin (CRM) in rectal cancer surgery have revealed that inadequate surgical excision correlates with a high risk of recurrence. This study was designed to evaluate the prognostic value of the CRM in rectal cancer.
METHODS
All 504 patients who underwent a total mesorectal excision for rectal cancer between 1997 and 2001 were studied. The distance between the CRM and the tumor on pathology slides (HE stain, x 20 times) was measured. The CRM was stained by using the Davidson marking system(R) (Bradley Product, Inc. USA), and a micrometer was used for the measurement. We divided the patients into a negative CRM group (CRM >3 mm), an abutting CRM group (CRM < or =3 mm without involvement), and a positive CRM group (CRM was in the tumor), and compared the oncologic results among the groups.
RESULTS
The numbers of patients in the negative CRM, the abutting CRM, and the positive CRM groups were 452, 18, and 34 respectively. The mean follow- up durations were 45.1 months (range, 1.1~88.7), 41.9 months (range, 10.7~75.2), and 33.0 months (range, 4.8~83.4), respectively. The Aslter-Coller stages of all patients were from B2 to C3. The local recurrence rate, the systemic recurrence rate, and the combined recurrence rate were, respectively, 5.5%, 17.3%, and 3.8% in the negative CRM group (>3 mm), 5.6%, 38.9%, and 5.6% in the abutting CRM group, and 8.8%, 44.1%, and 8.8% in the positive CRM group. The five-year survival rates for the negative CRM, the abutted CRM and the positive CRM groups were 73.3%, 48.4%, and 25.5% (P<0.001), respectively, and the disease-free 5-year survival rates were 63.1%, 30.6%, 24.0% (P<0.001). The CRM was shown to be an independent prognostic factor by multivariate analyses adjusted for known predictors of outcome (P<0.001).
CONCLUSIONS
The prognosis for a member of the abutting or the positive CRM group was more unfavorable than it was for a member of the negative CRM group; therefore, measurement of the CRM should be reported in the pathologic report. For patients with an abutting or a positive CRM, neoadjuvant or adjuvant chemoradiotherapy should be considered for better oncologic outcomes.

Pelvic Exenteration as the Treatment for Recurrent or Locally Advanced Rectal Cancer.: Song, Seong Kyu , Park, Yong Keun , Suh, Kwang Wook; J Korean Soc Coloproctol. 2005;21(5):314-319.

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Abstract PDF: PURPOSE
The purpose of this study is to evaluate the value of pelvic exenteration (PE) for recurrent or locally advanced rectal cancer.
METHODS
This retrospective study analyzed 20 patients who underwent PE for rectal cancer from June 1994 to October 2003 in Ajou University Hospital. The surgical severity, the postoperative complications, and the survival rate were analyed based on the medical records.
RESULTS
The mean operation time was 221.5+/-93.0 minutes, the mean blood loss 750.5+/-223.3 cc, and the mean transfusion amount RBC 6.5+/-4.3 units. Operative mortality was 5% (1/20). A bleeding-associated complication was noted in one patient who underwent a reoperation for hemostasis. Other minor complications were small bowel obstruction (n=3), abdominal wound infection (n=5), vesicocutaneous fistula (n=2), delayed healing of the perineal wound (n=10). The overall 5-year survival rate was 52.6% (10 of 19 patients, excluding the operative mortality case).
CONCLUSIONS
Our study showed acceptable surgical severity and postoperative complications and a favorable 5-year survival rate (> or =50%) for pelvic exenteration as a treatment for recurrent or locally advanced rectal cancer. With strictly selected patients, PE may be one of the treatment options for recurrent or locally advanced rectal cancer.

Analysis of Clinicopathological Factors Affecting Local Recurrence of Colorectal Cancer after Curative Resection.: Park, Chan Ho , Lee, Ho Kil , Yun, Min Young , Choi, Sun Keun , Hur, Yun Suk , Lee, Kun Young , Kim, Sei Joong , Cho, Young Up , Ahn, Seung Ick , Hong, Kee Chun , Shin, Suk Hwan , Kim, Kyung Rae , Woo, Ze Hong; J Korean Soc Coloproctol. 2005;21(5):320-324.

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Abstract PDF: PURPOSE
Local recurrence after curative resection of colorectal cancer has an important influence on both survival and quality of life. The ability to predict local recurrence after a curative resection of colorectal cancer may be useful for an intensive follow-up program and for a decision on adjuvant radiation or chemotherapy. The aim of this study was to analyze the factors affecting the incidence of local recurrence after a curative resection of colorectal cancer.
METHODS
A retrospective review of 390 patients who had a curative resection for a primary colorectal cancer by a single surgeon at the Department of Surgery, Inha University Hospital, between June 1996 and July 2002 was done. The medical records of patients diagnosed with a local recurrence were reviewed. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis, that was diagnosed by using colonoscopy with biopsy and/or radiologic imaging.
RESULTS
Local recurrences were detected in 40 patients (10.3%). The gender distribution of patients with local recurrence was 24 males and 16 females with a mean age of 59.8 years. The median time to local recurrence was 15 months. The most common site of local recurrence was the anastomosis site, followed by a regional lymph node, the pelvicoperineal area, and the presacral area. Local recurrence was related to the depth of the primary tumor (P=0.027), lymphatics or vascular invasion (P=0.003), perineural invasion (P= 0.000), nodal status (P=0.000), and distant metastasis (P= 0.002). However, there was no statistically significant relation between local recurrence and primary tumor location (P=0.053), primary tumor size (P=0.982), tumor differentiation (0.256), and preoperative CEA level (P=0.481).
CONCLUSIONS
The depth of the primary tumor, lymphatics or vascular invasion, and perineural invasion were significant clinicopathologic factors of local recurrence, but tumor location, tumor size, tumor differentiation, and preoperative serum CEA level were not.

Case Reports

Laparoscopic Giant Parastomal Hernia Repair.: Lee, Yoon Suk , Lee, In Kyu , Oh, Seung Teak , Kim, Jun Gi , Jang, Suk Kyun , Kim, Young Ha; J Korean Soc Coloproctol. 2005;21(5):325-328.

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Abstract PDF: Parastomal hernia is not an uncommon complication after stoma formation. Although there are a variety of open surgical techniques, rates of morbidity, recurrence and complications are high. Nowadays, with improvements in techniques and equipment, laparoscopic surgery is being increasingly used in every field of surgery. Herein, we present a case study of a patient suffering from a large parastomal hernia who underwent a laparoscopic hernia repair. A 71-year-old man who had undergone an abdominoperineal resection for an adenocarcinoma of the rectum 5 years ago was admitted to our hospital for a large parastomal hernia, which was repaired by using a laparoscopic approach with Gore-Tex and protack (auto-suture(R), USA). We found the laparoscopic approach for a large parastomal hernia to be technically feasible and to be a good alternative to conventional open surgery with the advantage of minimal invasivess.

Thrombophlebitis of the Inferior Mesenteric Vein.: Lee, In Kyu , Kim, Seong Ah , Lee, Yoon Suk , Oh, Seong Taek , Jeon, Hae Myung , Kim, Eung Kook , Chang, Suk Kyun , Jung, Seung Eun; J Korean Soc Coloproctol. 2005;21(5):329-332.

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Abstract PDF: Isolated thrombophlebitis of the inferior mesenteric vein (IMV) is a rare condition, but delayed diagnosis causes severe problems and serious long-term complications. Therefore, the early diagnosis and adequate management of the underlying disease and thrombus is very important. Here, a case of a 64-year-old man with isolated IMV thrombosis on computed tomography (CT) and CT angiography due to inflammation of an abdominal organ and spell our disseminate intravascular coagulation (DIC) is reported. The patient's condition improved without complication after treatments with an anticoagulant regimen and antimicrobials. In the follow up, there was no thrombus on the CT angiograph and no sign of recurrent disease.

Perforation of the Hepatic Flexure of Colon by an Ingested Toothbrush.: Lee, Min Joo , Cho, En Jung , Lee, Min Ro , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 2005;21(5):333-336.

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Abstract PDF: A Foreign body in the gastrointestinal tract is a common clinical problem seen in all age groups and rarely produces symptoms. However, the foreign bodies should be removed if they produce symptoms or remain in the gastrointestinal tract. A 31-year-old man with schizophrenia ingested a 20-cm-sized toothbrush. It passed through the ileocecal valve and penetrated the hepatic flexure of the colon and liver. It was removed successfully by using a surgical procedure. We report this unusual case of colonic perforation by an ingested toothbrush and review the related literature.

Review

Motility Disorders of the Colon.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2005;21(5):337-353.

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Abstract PDF: Human colonic motor activity is quite a complex issue and is a relatively difficult topic to investigate, still only partly understood and investigated, due to anatomic and physiological difficulties. Colonic motility measurement are hampered by the relative inaccessibility of the colon, especially in the unprepared state. Major motor events are infrequent, necessitating long observation periods. Moreover, correlating intraluminal pressure changes with stool transport is difficult. Disturbances of normal colonic motor activity may interfere with healthy colonic physiologic function. The pathophysiological mechanisms responsible for colonic motility disorders are still less understood. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, although only in part, some pathophysiological mechanisms of colonic motility disorders. In this review article, after a brief of relevant normal aspects of colorectal motility in man, we limit our discussion to more common motility disorders involving the colon and rectum. In particular, what is known or hypothesized regarding the underlying pathophysiology of slow-transit constipation, diverticular diseases, irritable bowel syndrome, and intestinal pseudo-obstruction is reviewed.

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