Annals of Coloproctology

Volume 22(3); June 2006

Original Articles

Effect of Ionizing Radiation on Homotypic Cell Adhesion, Cell-Matrix Adhesion, Matrix Metalloproteinases Excretion of High Mucin Producing HM7 Colon Cancer Cells.: Kim, Hye Gyong , Kim, Tae Dong , Li, Ge , Yoon, Wan Hee; J Korean Soc Coloproctol. 2006;22(3):153-161.

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Abstract PDF: PURPOSE
To investigate the effect of ionizing radiation on high mucin-producing colon cancer cells, we evaluated homotypic cell adhesion, cell-matrix adhesion, and matrix metalloproteinases (MMPs) on HM7 cells.
METHODS
After an irradiation of 60 Gy for 48 hours on HM7 cells, we evaluated cellular proliferation, colony-forming ability, homotypic adhesion, cell-matrix binding, and integrin subunit expressions. Also, alterations of MMPs expression were analyzed by using zymography.
RESULTS
Cell proliferation of HM7 colon cancer cells was not remarkably affected even after high doses of radiation; however, clonogenic cell growth was significantly affected. Homotypic cell-cell adhesion and cell adhesion to ECM components and basement membrane protein matrigel were significantly increased after irradiation. Radiation induced expressions of cell surface integrin alpha2, alpha3, and beta1 subunits of HM7 cells. The activities of secreted MMPs (MMP-9 and MMP-2) were remarkably inhibited by radiation.
CONCLUSIONS
These finding suggest the biologic characteristics of high-mucin-producing colorectal carcinomas. Even though the radiation-associated cellular alterations of HM7 cells with or without matrix proteins were not remarkably different from other cancer cell types studied, the radio-resistant behavior of high mucin producing HM7 cells may explain the aggressive characteristics of mucinous colorectal carcinomas.

Are There Anorectal Physiologic Factors Prior to Biofeedback Treatment for Constipation that Affect Compliance Rate?.: Shin, Dong Ho , Kim, Seung Cheol , Kim, In Kyoung , Hong, Hyun Ki , Joo, Jae Sik; J Korean Soc Coloproctol. 2006;22(3):162-168.

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Abstract PDF: PURPOSE
The most important factor for the success of biofeedback treatment of constipation is patients' enthusiastic participation and willingness to comply with the treatment protocol. The purpose of this study was to analyze differences among groups of patients classified according to the number of biofeedback sessions and to identify any anorectal physiological and clinical factors related with better compliance with biofeedback treatment.
METHODS
From Aug. 2001 to July 2003, 80 patients who had undergone biofeedback treatment for constipation by a single therapist were classified into three groups according to the number of sessions: only one session (Group I, n=26), two or three sessions (Group II, n=27), and more than four sessions (Group III, n=27). We reviewed the clinical and the anorectal physiological characteristics retrospectively.
RESULTS
The mean age was 39.1 (range, 8~77) years, and the mean duration of constipation was 7.7 (range, 0.5~30) years and mean frequency of defecation was 2.2 times/week. Patients' pretreatment use of laxatives was significantly lower in Group I (38.5 percent) than in Group II (70.4 percent) or Group III (51.9 percent) (P<0.05). There were no significant differences in anal manometric parameters (mean and maximal resting pressure, maximal squeezing pressure, sensitivity, and rectal capacity). In the cinedefecographic findings, the megarectum was significantly higher in Group III (58.3 percent) than in Group I (38.9 percent) or Group II (27.8 percent) (P=0.02), but other findings of anismus, rectocele, intussusception, and delayed emptying showed no significant differences. The cinedefecographic parameters (anorectal angle, perineal descent, anal canal length, and puborectalis length), were not significantiy different among the groups.
CONCLUSIONS
We strongly recommend biofeedback treatment for constipation patients who abuse laxatives and/or for whom cinedefecography reveals megarectum.

The Clinical Characteristics and Outcomes of Biofeedback Treatment for Patients with Nonrelaxing Puborectalis Syndrome.: Ahn, Eun Jung , Jeong, Gyu Young , Cheon, Seung Hui , Lee, Eun Joung , Oh, Soo Youn , Chung, Soon Sup , Lee, Ryung Ah , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2006;22(3):169-176.

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Abstract PDF: PURPOSE
Biofeedback treatment is thought to be appropriate for patients with nonrelaxing puborectalis syndrome (NRPR). The aim of this study is to analyze the physiologic characteristics and to assess the outcomes of biofeedback treatment for patients with NRPR.
METHODS
Forty-six (46) patients with NRPR were evaluated with anorectal physiologic studies, including colonic transit time (n=26), anorectal manometry (n=41), defecography (n=46), anal sphincter EMG (n=28), and colonoscopy or barium enema (n=33). The treatment consisted of a training program with EMG-based biofeedback for 30 minutes once a week and routine supportive care, including Kegel practice.
RESULTS
The mean age was 52.8 years, and the sex ratio was 1 male to 0.6 female. A delayed colonic transit time was noted in 5 patients (19.26%). In the NRPR group, the maximal voluntary contraction and the mean squeezing pressure were higher than they were for other patients with pelvic outlet obstructive disease. Also, the perineal descents and the dynamic change of anorectal angle were shorter. Polyps were observed in 6 patients (18.2%), melanosis coli in 4 patients (12.1%), and diverticula in 3 patients (9.1%). The rectoanal inhibitory reflex (RAIR) was negative in 3 patients (7.3%). The patients underwent a mean of 4.0 sessions, and the mean follow-up was 7.4 months. Twenty-three (23) patients (82.1%) experienced improved of symptoms or EMG findings. The patients (17.9%) who did not improve had several abnormal findings: neuro-psychologic disease with delayed colonic transit time in 2 cases, negative RAIR in 2 cases, and melanosis coli in one case.
CONCLUSIONS
We think that biofeedback training is an effective treatment for patients with NRPR. In addition, several factors, such as neuro-psychologic diseases, delayed colonic transit time, negative RAIR, or melanosis coli may influence the prognosis for biofeedback treatment, so further large-scaled studies will be needed to confirm these findings.

Sphincter Preserving Operation by Coloanal Anastomosis: Long Term Survival.: Lee, Sun Il , Park, Yoon Ah , Sohn, Seung Kook; J Korean Soc Coloproctol. 2006;22(3):177-183.

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Abstract PDF: PURPOSE
Abdominoperineal resection (APR) was the conventional operation for the last 100 years, however it decreased recently for the improvement of sphincter preserving operations, especially of hand-sewn coloanal anastomosis (CAA). The aim of this study is to evaluate oncological results for the CAA.
METHODS
From January 1992 to August 2000, 107 consecutive patients with rectal cancer within 7 cm from anal verge who underwent a curative resection were evaluated retrospectively by operations (APR, CAA, and stapled low anterior resection, LAR). No temporary stoma was made for CAA and LAR.
RESULTS
The mean age is 57.4 and the distance from the anal verge was 4.12 cm (+/-1.55) for 65 males and 4.13 cm (+/-1.67) for 42 females (p>0.05). The age, gender, tumor location, size, resection margin, and stage were not statistically significant according to the operations. The CAA increased from 8% (early) to 64% (late), and the APR decreased from 59% (early) to 16% (late). The 5 year survival rate was 70.1% (84.3% for Dukes B and 40.8% for Dukes C). Survivals were not statistically significant according to the type of operation. The local recurrence rate was 7.4% (13.8% for stapled low anterior resection, 7.0% for APR, and 2.8% for CAA). Of the patients with a CAA, 54% had received preoperative radiation therapy (45~55 Gy). In the late period, tumors located within 5 cm from the anal verge with fat or perirectal lymph nodes involved received preoperative radiation, and the sphincter-preserving rate was 80%.
CONCLUSIONS
CAA is an effective technique, with a safe oncologic result, for sphincter preservation in very low rectal cancer.

Efficacy of hMLH1/hMSH2 Immunohistochemical Staining as Representative Index for Microsatellite Instability Status in Sporadic Colorectal Cancer.: Jung, Sang Hun , Kim, Hee Cheol , Kim, Jung Sun , Choi, Jene , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(3):184-191.

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Abstract PDF: PURPOSE
Sporadic colorectal cancer with micosatellite instability (MSI) is supposed to have a distinct molecular profile, distinct clinocopathologic feature, and a distinct prognosis. However, the test for MSI is still expensive, and a big machine is needed for routine screening. This study was performed to examine the clinicopathologic of characteristics of MSI sporadic colorectal cancer and the efficacy of immunohistochemical staining for hMLH1 and hMSH2.
METHODS
Five hundred sixty nine colorectal adenocarinomas resected from September 2003 to August 2004 at Asan Medical Center were prospectively collected. FAP (familial adenomatous polyposis), HNPCC (hereditary non-polyposis colo-rectal cancer), and incomplete tests of immunohistochemical staining or MSI were excluded. The MSI status was determined by using PCR (polymerase chain reaction). A first round of immunohistochemical staining for hMLH1/hMSH2 was performed, and a second round was performed for cases showing a disparity between the two exams. The clinicopathologic variables regarding the MSI status were analyzed, and the sensitivity and the specificity of immunohistochemical staining were evaluated.
RESULTS
Sporadic colorectal cancers with MSI-H were 8.4% (n=48) and were associated with age (< or = 60 years), colorectal cancer familial history, synchronous colorectal cancer, right side tumor location, and poorly differentiated or mucinous cell type. However, age, synchronous colorectal cancer, and right side tumor location were associated an the multivariate analysis. In the first round of immunohistochemical staining, no expression of hMLH1 and/or hMSH2 was obserred in 71 cases (12.5%), and the sensitivity and the specificity were 50.0% and 91.9%, respectively. After repetitive immunohistochemical staining for the 71 cases showing disagreement with the to MSI status, the sensitivity and the specificity of the second round of immunohistochemical staining were 53.3% and 97.6%, respectively.
CONCLUSIONS
Sporadic colorectal cancer with MSI appears to have distinct characteristics. However, immunohistochemical staining for hMLH1 and hMSH2 is not accurate enough to be used instead of MSI.

Case Reports

Laparoscopy-assisted Surgical Removal of a Retained Wireless Capsule Endoscopy: A case report.: Lee, Sang Hoon , Han, Sang Ah , Park, Chi Min , Yun, Seong Hyeon , Lee, Woo Yong , Chun, HoKyung; J Korean Soc Coloproctol. 2006;22(3):192-196.

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Abstract PDF: Occult bleeding of the gastrointestinal tract is a major cause of iron deficiency anemia. Even with endoscopic evaluation of the upper and the lower gastrointestinal tract in these patients, in 30~50% of the cases, the cause of bleeding still remains undiscovered. Wireless capsule endoscopy (WCE) is a novel method of evaluating the small bowel mucosa by using a small capsule equipped with a camera and transmission device. Complications of WCE include impaction within the gastrointestinal tract, sometimes requiring surgical removal. The authors report a case of capsule impaction in the small bowel in a patient evaluated for anemia due to occult gastrointestinal tract bleeding. The patient is a 19 year-old female with a history of anemia since age 4. The stool guaiac test was positive, but upper and lower gastrointestinal tract endoscopy showed no abnormalities, so WCE was done. A short segment of circular ulcers with lumen narrowing were seen in the distal jejunum. Seven days after ingestion of the capsule, the patient denied passage of the capsule. Small bowel enteroclysis was performed, and the capsule was seen along with a segment of lumen narrowing distal to the site of retention. Surgery was done, and upon laparoscopic examination, the entire bowel appeared normal. Retrieval of the capsule was done along with a resection of an 8 cm segment of the small bowel. Three linear ulcers were seen in the resected bowel specimen. Pathology revealed no evidence of Crohn's disease or tuberculosis. The patient is still on iron supplements, but her hemoglobin level remains stable at 11~12 g/dl.

A Case of Stercoral Perforation of the Sigmoid Colon.: Park, Chan Sup , Cho, Dong Ho , Kim, Hungdai , Han, Won Kon; J Korean Soc Coloproctol. 2006;22(3):197-199.

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Abstract PDF: A stercoral perforation of the colon is a rare phenomenon and is caused by severe prolonged constipation. Since the first reported case in 1894, approximately 80 additional cases have been reported. However, this rare condition seems to have been underestimated because of not only obscure diagnostic standards but also ignorance and failure to notice by surgeons. Due to its high mortality rate of about 35~40%, a stercoral ulcer perforation should be considered in any patient with chronic constipation who presents with peritonitis. We report a case of a 75-year-old female who was diagnosed as having a stercoral perforation of the sigmoid colon and review the clinical features, the diagnosis, and the treatment.

Giant Transverse Colon Diverticulitis Presenting as Indirect Right Inguinal Hernia Strangulation.: Park, Weon Cheol , Lee, Jeong Kyun , Yoon, Seong Eon , Yun, Ki Jung; J Korean Soc Coloproctol. 2006;22(3):200-203.

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Abstract PDF: A giant colonic diverticulum is a rare complication of diverticulosis, and an inguinal hernia is a common diagnosis for patients presenting with a painful groin mass. A 52-year-old male presented to the emergency room with a 3-hour complaint of progressive, constant, right-groin pain with an inguinal mass. After manual reduction of the inguinal hernia, the patient complained of pain in the right upper quadrant. Operative findings showed a transverse colon diverticulitis without perforation. We report here that case of a transverse colon giant diverticulum presenting as an atypical incarcerated inguinal hernia.

Primary Signet-ring-cell Carcinoma of the Right and the Sigmoid Colon in Crohn's Disease.: Kim, Hyoung Ran , Lee, In Kyu , Lee, Yoon Suk , Park, Jong Kyung , Oh, Seong Taek , Kim, Jun Gi , Lee, Kyungji , Park, Gyeoung Sin , Jung, Seong Eon , Park, Soo Heon , Chang, Suk Kyun; J Korean Soc Coloproctol. 2006;22(3):204-209.

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Abstract PDF: A 31-year-old woman with a 5-year history of Crohn's disease was admitted to our hospital because of recurrent right lower quadrant pain and diarrhea. Abdominal computed tomography showed multiple fistulas between the terminal ileum, the sigmoid colon, and the cecum, and mucosal wall thickenings due to an active inflammatory process and mucosal enhancements. Colonoscopic examinations showed a finger-like projection of a polypoid mass at the ileocecal valve, long-neck, finger-like pseudopolyps at the cecum, and soft, lumen narrowing and multiple pseudopolyps at the sigmoid colon and the intact rectum. There was healing scarring of the anal fistula. These findings were compatible with those of Crohn's disease. Histologic findings were chronic inflammation with erosion and regenerative crypt epithelium. The patient underwent infliximab therapy. She underwent a right colectomy, a Hartman's procedure, and a small bowel segmental resection due to multiple fistulas. The pathologic diagnosis was a signet-ring-cell carcinoma with non-caseating granuloma in the ascending colon, ileum, and sigmoid colon. We report this case of Crohn's disease associated with a colonic signet-ring cell carcinoma.

The Rectus Abdominis Myocutaneous Flap for the Immediate Reconstruction of Partial Vaginal Defects Following the Extended Abdominoperineal Resection of Recurrent Rectal Cancer.: Lee, Suk Hwan , Yoo, Young Chun; J Korean Soc Coloproctol. 2006;22(3):210-213.

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Abstract PDF: Extensive resection including posterior vaginal wall may be required for the advanced low rectal cancer or recurrent rectal cancer in order to achieve the tumor free circumferential margins. We describe closure of a vaginal defect with rectus abdominis musculocutaneous flap after extended abdominoperineal resection, hysterectomy and partial colpectomy in a patient with recurrent rectal cancer with the special reference to the surgical technique.

Review

Surgical Treatment of Anal Fistula.: Lee, Jong Kyun; J Korean Soc Coloproctol. 2006;22(3):214-220.

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Abstract PDF: Various methods of surgical treatments were introduced for the treatment of anal fistulas. A surgeon has to select carefully the method most ideal to each type of anal fistulas. The fistulotomy is an ideal technique for the treatment of intersphincteric or transsphincteric fistulas because less serious problems of incontinence and/or recurrence follow after it. For the treatment of suprasphincteric and extrasphincteric fistulas, fistulotomy is of no use because of high incidence of incontinence. In such cases, most surgeons like to use the seton technique, muscle filling method, muscle closure method, advancement flap, re-route procedure, or fibrin glue injection in order to decrease the incidence of incontinence. The techniques and indications of each surgical procedure are reviewed in detail.

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