Annals of Coloproctology

Volume 22(4); August 2006

Original Articles

Distribution and Characteristics of Colorectal Polyps at Colonoscopy.: Lee, Jeong Eun , Yoon, Se Jin , Ahn, Eun Jung , Chung, Soon Sup , Lee, Ryung Ah , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2006;22(4):223-228.

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Abstract PDF: PURPOSE
The screening test for colorectal polyp is important for the early detection and prevention of colorectal cancer. The aims of this study were to evaluate the characteristic findings and the anatomical distribution of colorectal polyps observed during colonoscopy and to determine proper screening candidates to undergo colonoscopy for colorectal cancer.
METHODS
From March 1999 to February 2004, 3,454 asymptomatic individuals underwent total colonoscopy. The number, the location, and the histology of polyps were evaluated retrospectively in 634 patients who had colorectal polyps (453 males and 181 females). The relations among age, location, and histology were analyzed.
RESULTS
The mean age was 60 years (range, 15 to 95). Four hundred and twenty-two patients (67%) had a single polyp, and 212 (33%) had two or more polyps. Left-sided polyps were observed in 422 patients (67%), right-sided polyps in 134 patients (21%), and synchronous both-sided polyps in 78 patients (12%). Adenomas were present in 387 patients (61%), and adenocarcinomas were detected in 47 patients (7.4%). There was no definite correlation between location and histology. However the prevalence of right-sided polyps increased with age (P<0.01).
CONCLUSIONS
More than 30% of the polyps were located proximal to the splenic flexure. Thus, in the absence of left-sided lesions, an examination of the colon that is limited to the splenic flexure might miss 21% of such lesions. The increasing prevalence of right-sided polyps with age suggests that evaluation of the proximal colon is particularly important in the elderly, especially in those older than 60 years.

Application of the Alvarado Score to the Diagnosis of Acute Appendicitis.: Kim, Hea Eun , Park, Sung Bae , Woo, Sang Uk , Rho, Hye Rin , Chae, Gi Bong , Choi, Won Jin; J Korean Soc Coloproctol. 2006;22(4):229-234.

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Abstract PDF: PURPOSE
The purpose of this study is to confirm the clinical usefulness of the Alvarado score's application and the differences in diagnostic values between male and female for patients who were diagnosed with acute appendicitis when they came to the hospital for pain in the right lower abdomen.
METHODS
The subjects of this study were 211 patients who entered the surgical department of this hospital for doubtful acute appendicitis from June 2003 to May 2005. Using a retrospective method, we examined the patients' records and compared their ages, sex, symptoms, preoperative physical examinations, leukocyte and neutrophils figures, and the final postoperative pathological diagnosis.
RESULTS
One hundred twelve patients were male, and 99 were female. A clinical Alvarado score of above 7 in sensitivity, specificity, positive predictive value, and negative predictive value was the standard for being judged positive. In this study, the sensitivity of the Alvarado score was 86.2%, its specificity was 61.6%, and the accuracy of diagnosis was 82.9%. The positive predictive value was 92.6%, and the negative predictive value was 51.0%. The accuracies were 83.9% and 81.8%, respectively, that for males being a little higher than that for female, but with no statistically significant differences.
CONCLUSIONS
This study showed that the diagnosis of acute appendicitis was highly accurate for an Alvarado score above 7 (82.9%). The diagnosis of acute appendicitis by using the Alvarado score is simple, fast, reliable, and repeatable, and it can be used under any conditions without other expensive and complicated diagnostic tools.

Changes of Symptoms and Manometric Results after Hemorrhoidectomy for Hemorrhoids with Difficulty in Evacuation.: Park, Hye Won , Bang, Seung Ho , Kim, Chang Nam , Kang, Yun Jung , Hwang, Sung Eun , Cho, Byung Sun , Lee, Min Ku , Choi, Yoo Shin , Park, Joo Seung , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(4):235-240.

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Abstract PDF: PURPOSE
We aimed to identify the need for an adjunctive internal sphincterotomy based on an evaluation of the changes in the symptoms and manometric results after a hemorrhoidectomy for hemorrhoids with difficulty in evacuation.
METHODS
Twenty-five (25) patients who had hemorrhoids with difficulty in evacuation and 13 patients who had hemorrhoids without difficulty in evacuation were prospectively evaluated. Patients were interviewed about symptoms and underwent anorectal manometry before and 2 months after surgery. Difficulty in evacuation is defined as the difficulty that a patient has when trying to evacuate the rectum.
RESULTS
There were significant differences in the sex ratio, the frequency of bowel movements, and the duration of bowel movements between the two groups (P<0.05). In cases with difficulty in evacuation, the frequency of bowel movements was significantly higher postoperatively and the duration of bowel movements was significantly shorter (P<0.05). The symptom of difficulty in evacuation disappeared in 21 of the as patients experiencing such a symptom, and was improved in the remaining of patients (P<0.05). Following the hemorrhoidectomy for the patients with difficulty in evacuation in the mean and the maximum resting pressure, and the maximum squeeze pressure decreased significantly (P<0.05).
CONCLUSIONS
An adjunctive internal sphincterotomy was not necessary for patients who had hemorrhoids with difficulty in evacuation because following the hemorrhoidectomy, the resting pressure was significantly decreased, and the difficulty in evacuation had nearly subsided.

A Pilot Study as the Biochip Based Gene Expression Profiling in Patients with Hyperplastic Colonic Polyp.: Park, Ung Chae , Kim, Kyong Rae , Seong, Moo Kyung , Wang, Joon Ho , Lee, Jae Dong , Kim, Sang Yoon , Park, Seung Hwa , Choi, Dong Kug , Kim, Chan Gil; J Korean Soc Coloproctol. 2006;22(4):241-249.

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Abstract PDF: PURPOSE
A microarray-based gene expression analysis may offer a rapid and efficient means for assessing. However, the molecular genetic change in nonneoplastic colonic polyp is still poorly understood. To elucidate the molecular genetic basis, We now report the results of our initial microarray data to analyze the genom pattern in patients with hyperplastic polyps of colon.
METHODS
36 samples (18 pairs of colonic polyps and normal colonic mucosa were) harvested from colonoscopic biopsy. 3 of 18 colonic polyps were pathologically identified as the serrated type of hyperplastic polyp. We used the oligonucleotide microarray technique for analysis of the expression profiles of serrated polyps and normal mucosa. For the identification of differentially expressed genes, SAM (Significance Analysis of Microarray) package method was used. The result was analysed by using global normalization, intensity dependent normalization and block-wise normalization.
RESULTS
Polypectomy specimens microscopically showed the pathologically characteristic serration with a saw-teeth like luminal border (branching of the crypts). 8 genes including RHEB (Ras homolog enriched in brain), WASF2 (WAS protein family, member 2), TYRP1 (Tyrosinase-related protein 1), VSX1 (Visual system homeobox 1 homolog), ROS1 (V-ros UR2 sarcoma virus oncogene homolog 1), WEE1 (WEE1 homolog), TEC (Tec protein tyrosine kinase), TNFRSF10A (Tumor necrosis factor receptor superfamily, member 10a) in serrated polyp were up-regulated by more than 10 times as compared with normal colonic mucosa. On the other hand, 6 genes including SIAT7D (Sialyltransferase 7D), DRD1 (Dopamine receptor D1), SIAT1 (Sialyltransferase 1), ITSN1 (Intersectin 1), TNFSF12 (Tumor necrosis factor superfamily, member 12), CHES1 (Checkpoint suppressor 1) were down-regulated by less than a tenth of the expression as compared with normal colonic mucosa.
CONCLUSIONS
Serrated polyps as a subset of hyperplastic colonic polyps were analyzed with the oligonucleotide microarray technique. We authors could identify 14 genes (8 up-regulated and 6 down-regulated genes) that showed the significant change of expression as compared with normal colonic mucosa. Specifically, we believe that current study will serve as a fundamental base to offer a bioinformative characteristics of the serrated colonic polyp in future clinical applications.

Laparoscopic Splenic Flexure Mobilization Using a Medial Approach.: Kim, Hyoung Ran , Lee, Yoon Suk , Lee, In Kyu , Kim, Jin Jo , Lee, Keun Ho , Oh, Se Jung , Park, Seung Man , Oh, Seung Taek , Kim, Jun Gi , Kim, Young Ha; J Korean Soc Coloproctol. 2006;22(4):250-254.

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Abstract PDF: PURPOSE
Splenic flexure mobilization in an anterior resection is a subject of controversy, but a tension-free anastomosis is needed in case of a low anterior resection or a coloanal anastomosis. Classical splenic flexure mobilization by means of the lesser sac opening is technically difficult in the laparoscopic era.
METHODS
This study retrospectively analyzed the medical records and operation videos of 16 patients who underwent laparoscopic splenic flexure mobilization in Our Lady of Mercy Hospital, The Catholic University of Korea by using a medial approach. The operation procedure is as follows: Under general anesthesia, the patient was placed in the Trendelenburg position, after making pneumoperitoneum, the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV) were ligated and divided. A medial-to-lateral mesocolon dissection was done, and the pancreas was dissected from the mesocolon of the transverse colon; then, the greater omentum was dissected.
RESULTS
The mean age was 60 years old, and the male- to-female sex ratio was 9:7. The mean operation time was 293 minutes. The mean distal margin was 5.3 cm, and the mean number of harvested lymph nodes was 15. An anterior resection was done in 2 cases, a low anterior resection is 10 cases, and a coloanal anastomosis in 4 cases. The mean time from ligation of the IMA to splenic flexure mobilization was 45 minutes. There was no mortality or morbidity.
CONCLUSIONS
Laparoscopic medial splenic flexure mobilization is a technically feasible and safe method.

Analysis of Factors Affecting the Degree of Difficulty in Total Mesorectal Excision for Rectal Cancer: Investigation of the Factors Affecting Incomplete Resection and the Resection Time.: Baik, Seung Hyuk , Kim, Nam Kyu , Lee, Young Chan , Sohn, Seung Kook , Cho, Chang Hwan; J Korean Soc Coloproctol. 2006;22(4):255-263.

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Abstract PDF: PURPOSE
The aim of this study was to estimate the degree of difficulty in total mesorectal excisions (TMEs) for rectal cancer by using statistical methods after analysis of factors affecting the resection time and incomplete resection.
METHODS
A total of 63 patients who underwent a total mesorectal excision for rectal cancer were evaluated. MRI pelvimetry data {(transverse diameter (TD), obstetric conjugate (OC), interspinous distance (ID), sacrum length (SL), sacrum depth (SD)}, tumor size (TS), T stage, and body mass index (BMI) were prospectively analyzed. A stepwise multiple regression analysis was performed to determine the operating time prediction equation by using these variables, and the differences in the mean operating time hased on gross evaluations of each specimen were analyzed.
RESULTS
A stepwise multiple regression with the operating time as a dependent variable led to the following equation: Operation time (min)=35.726-2.162xTD (cm)-2.324 x OC (cm) + 2.671 x SL (cm) + 1.274 x TS (cm), with r2=0.533 and SEE=5.438. The mean operating time according to a gross evaluation of the TME specimen was 20.0 +/- 7.3 min in complete TME cases (n=42) and 27.9 +/- 7.2 min in incomplete TME cases (n=21) (P<0.001).
CONCLUSIONS
MRI pelvimetry data (TD, OC, SL) and tumor size were factors affecting the operation time in TMEs for rectal cancer, and the operating time could be predicted by using the equation of the present study. Also, the mean operating time in incomplete TME cases was longer than that in complete TME cases. Thus, the degree of difficulty of an operation for rectal cancer can be predicted by using these factors.

The Risk Factors of Lymph Node Metastasis in Submucosal Invasive Colorectal Cancer.: Choi, Pyong Wha , Yu, Chang Sik , Jang, Se Jin , Kim, Mi Jung , Han, Kyong Rok , Jung, Sang Hun , Yoon, Yong Sik , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(4):264-270.

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Abstract PDF: PURPOSE
Recent studies have shown a 7~15% lymph node (LN) metastasis rate in submucosal invasive colorectal cancer (SICC). Identification of risk factors for LN metastasis is crucial in the choice of therapeutic modalities for SICC. The present study was performed to assess the possibility of LN metastasis and to determine the risk factors of LN metastasis in SICC.
METHODS
A retrospective study of 168 patients with SICC who underwent a curative resection between June 1989 and December 2004 at Asan Medical Center was conducted. The level of submucosal invasion was classified into upper third (sm1), middle third (sm2), and lower third (sm3) according to the submucosal depth of invasion. The following carcinoma-related variables were assessed: tumor size, tumor location, level of submucosal invasion, cell differentiation, lymphovascular invasion, neural invasion, and tumor cell dissociation (TCD).
RESULTS
The overall LN metastasis rate was 14.3%. According to the level of submucosal invasion, LN metastasis was seen as follows: sm1, n=4 (4.2%), sm2, n= 10 (21.3%), and sm3, n=10 (38.5%) (P=0.039). According to cell differentiation, LN metastasis was observed as follows: well-differentiated, n=4 (4.9%), moderately differentiated, n=19 (22.9%), and poorly differentiated, n=1 (25.0%) (P=0.028). Nineteen of the 66 cases (28.8%) with TCD had significantly higher risk of LN metastasis as did 5 of the 102 cases (4.9%) without TCD (P=0.045). No statistical difference was observed in the risk of LN metastasis with regard to tumor location, tumor size, neural invasion, or lymphovascular invasion.
CONCLUSIONS
Submucosal invasion, cell differentiation, and tumor cell dissociation were significant pathologic predictors of LN metastasis in SICC. As SICC has considerable risk of LN metastasis, local excision should be reserved to highly selective sm1 cancers.

Case Reports

A Case of Adult Duplication Cyst Presenting with Lower Gastrointestinal Bleeding.: Park, Min Su , Lee, Kil Yeon , Lee, Suk Hwan , Kim, Youn Wha; J Korean Soc Coloproctol. 2006;22(4):271-275.

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Abstract PDF: Congenital cystic duplications of the alimentary tract are rare, but can occur anywhere along the GI tract. Ileal duplication cysts account for the majority of diagnosed cases. Symptoms generally develop during infancy or childhood, with diverse presentations. Common manifestations include abdominal pain, an abdominal mass, vomiting, occasional intussusception, perforation, bleeding, and obstructive symptoms. In this report, we present the case of a 20-year-old man with an ileal duplication cyst with obscure lower gastrointestinal bleeding. The patient underwent cyst excision with a primary end to end anastomosis. The patient was discharged on the postoperative 7th day without any complications.

Fournier's Gangrene after Excision of a Thrombosed Hemorrhoid.: Lee, Min Ro , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 2006;22(4):276-278.

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Abstract PDF: Fournier's gangrene is a life-threatening disorder characterized by necrotizing fasciitis of the perineal region. Because delay in diagnosis and treatment of this condition can be fatal, it is important not to overlook the symptoms. We present an unusual case of Fournier's gangrene after excision of a thrombosed hemorrhoid. A previously healthy 74-year-old female patient developed Fournier's gangrene after a hemorrhoidectomy. In spite of aggressive treatment, she eventually died. Here, we emphasize early recognition and prompt treatment of this condition, reporting an unexpected disastrous complication of a hemorrhoidectomy.

A Case of Inflammatory Malignant Fibrous Histiocytoma of the Colon.: Namgung, Hwan; J Korean Soc Coloproctol. 2006;22(4):279-282.

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Abstract PDF: A malignant fibrous histiocytoma (MFH) is one of the most common types of soft-tissue sarcomas. It tends to develop in elderly people and is mainly localized in skeletal muscles, the dermis, the subcutis, and the retroperitoneum. A MFH of the intestine is an exceedingly rare neoplasm. We experienced a primary inflammatory malignant fibrous histiocytoma of the colon in a 51-year-old male. A right hemicolectomy and gastro-jejunostomy were performed. Microscopically, the tumor consisted of atypical fibroblast like spindle cells, arranged in a storiform or fascicular pattern and accompanied by infiltration of acute inflammatory cells.

Note

Submucosal Hemorrhoidal Artery Ligation Technique and Shortening Suture Technique for a Hemorrhoidectomy.: Lim, Seok Won; J Korean Soc Coloproctol. 2006;22(4):283-284.

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Abstract PDF: There are many techniques for performing a hemorrhoidectomy. The author introduces the submucosal hemorrhoidal artery ligation technique and the shortening suture technique. In the author's expericence, the submucosal hemorrhoidal artery ligation technique reduces not only the secondary bleeding rate but also the hemorrhoid recurrence rate after a hemorrhoidectomy. The shortening suture technique reduces the postoperative anal stricture rate by folding skin into the anal canal and prevents a skin tag after a hemorrhoidectomy.

Review

Treatment of Peritoneal Carcinomatosis from Colorectal Cancer.: Kim, Hyung Jin , Oh, Seong Taek; J Korean Soc Coloproctol. 2006;22(4):285-290.

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Abstract PDF: Intraperitoneal carcinomatosis accounts for 25~35% of recurrences of colorectal cancer, and peritoneal carcinomatosis from colorectal cancer has been regarded as a lethal condition. However, a combination of aggressive cytoreductive surgery and intraperitoneal chemotherapy has been tried and appears to be beneficial in selected patients. The primary goal of cytoreductive surgery is to remove all visible tumor within the peritoneal cavity. The goal of intraperitoneal chemotherapy is to eradicate the microscopic residual tumor and to prevent its recurrence. There are various ways to perform intraperitoneal chemotherapy. One is postoperative intraperitoneal chemotherapy, and another is intraoperative hyperthermic chemotherapy during surgery. Hyperthermia increases the penetration of chemotherapy into tissues and the level of chemotherapy cytotoxicity. The timing of surgery in cases of intraperitoneal chemotherapy and the optimal dosage of drugs must be evaluated in further studies. In colorectal cancer, the peritoneum should be regarded as an intra-abdominal organ, like the liver. Therefore, intraperitoneal carcinomatosis must be treated by using a combination of aggressive surgical treatment and intraperitoneal chemotherapy. Eventually, the long-term overall survival will be increased.

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