Annals of Coloproctology

Volume 22(5); October 2006

Original Articles

Analysis and Measures for Anal Stricture following a Hemorrhoidectomy.: Lim, Seok Won; J Korean Soc Coloproctol. 2006;22(5):293-297.

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Abstract PDF: PURPOSE
The most common cause of anal stricture following a hemorrhoidectomy is excision of too much hemorrhoidal tissue. However, the extent of excision of the hemorrhoid and other factors that can lead to an anal stricture are not yet well known. Thus, the author analyzed cases of anal stricture in order to find a method to prevent anal stricture.
METHODS
The author analyzed 14 patients who had anal stricture following a hemorrhoidectomy among 750 hemorrhoidectomy patients at Hang clinic from Jan. 2003 through Dec. 2003. The author analyzed the relation between the incidence of anal stricture and factors such as the number of hemorrhoids removed, the depth of the ligation, and the preoperative anal tension. The author also analyzed the treatment method for postoperative anal stricture.
RESULTS
1) The male-to-female ratio for these 14 cases was 3 : 11, and the most prevalent age group was the 4th decade, followed by the 5th decade. 2) The incidences of postoperative anal stricture for patients with one to six piles removed were 0%, 0.5%, 0.9%, 4.6%, 6.5%, and 14%, respectively. 3) In analysis of anal stricture according to the depth of ligation, the patient who had two removed hemorrhoids had two high ligations without low ligation (1 case). The patients who had three removed hemorrhoids had three high ligations without low ligation (2 cases). The patients who had four removed hemorrhoids had three high ligations with one low ligaton (3 cases) and four high ligations without low ligation (3 cases). The patients who had 5 removed hemorrhoids had three high ligations with two low ligations (2 cases) and four high ligations with one low ligation (1 case). The patients who had six removed hemorrhoids had three high ligations with three low ligations (2 cases). 4) There were 5 cases (7.6%) of anal stricture for high preoperative anal tension and 9 cases (1.3%) for low preoperative anal tension. 5) The treatment methods for postoperative anal stricture were bougination (10 cases), a sphincterotomy (2 cases), and a sliding skin graft (2 cases).
CONCLUSIONS
For the prevention of postoperative anal stricture, removal of three or fewer hemorrhoids seems ideal. Low ligation may be better than high ligation in preventing anal stricture, and the hemorrhoidectomy should be performed more cautiously in cases of high preoperative anal tension. In conclusion, the number, the width, and the length of the removed hemorrhoid, as well as the preoperative anal tension, should be considered to prevent postoperative anal stricture.

Is Barium Enema Prior to Ileostomy Closure Necessary?.: Lee, Min Ro , Lee, Min Joo , Kim, Jong Hun , Hwang, Yong; J Korean Soc Coloproctol. 2006;22(5):298-300.

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Abstract PDF: PURPOSE
A barium enema is frequently performed to check for healing prior to ileostomy closure, but there have been reports that ileostomy closure without a contrast study is safe in selected patients. The aim of this study was to assess the necessity of a routine barium enema prior to ileostomy closure.
METHODS
Between January 1994 and June 2005, 51 patients with a temporary loop ileostomy who had a barium enema prior to ileostomy closure at Chonbuk National University Hospital were retrospectively reviewed. These patients were divided into 2 groups, the protective ileostomy group and the ileostomy-after-leakage group. To examine the necessity of a routine barium enema prior to ileostomy closure, we assessed whether the barium enema results changed management and whether there were pelvic sepsis and obstructive symptoms following ileostomy closure.
RESULTS
In the protective ileostomy group (n=39), the barium enema was performed after a mean of 59 days (range: 27~151 days). There were no abnormal findings at the barium enema, no schedule changes, no pelvic sepsis, and no obstructive symptoms following ileostomy closure. In the ileostomy-after-leakage group (n=12), the barium enema was performed after a mean of 54 days (range: 30~82 days). In 2 patients, with barium enemas at 33 days and 36 days, an anastomotic leakage was found, and ileostomy closure was delayed.
CONCLUSIONS
In patients with a protective ileostomy, a barium enema prior to ileostomy closure is unnecessary, but in patients with an ileostomy after leakage, barium enema should be considered.

Prognostic Factors Associated with Surgical Mortality Conferred by Emergency Operation in Colorectal Cancer.: Lee, Ho Jin , Oh, Jae Hwan , Lee, Jung Nam , Baek, Jeong Heum , Chung, Min , Lee, Woon Kee , Kim, Keon Kuk , Park, Heung Kyu , Min, Seung Kee , Lee, Young Don , Lee, Tae Hun; J Korean Soc Coloproctol. 2006;22(5):301-307.

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Abstract PDF: PURPOSE
Compared with elective surgery, emergency surgery for colorectal cancer has been reported to be associated with high mortality, though little is known about the prognostic factors associated with surgical mortality. Above all, a distinction between patients with high and low mortalities might be helpful for perioperative management. The purpose of this study was to identify prognostic factors associated with surgical mortality due to an emergency operation.
METHODS
Ninety-five cases of emergency surgery for colorectal cancer were performed from 1998 through 2005. The genders and the ages of the patients, the duration of symptoms, the APACHE score, the cancer location, the presence of perforation, the operative type, and the disease stage were determined as prognostic factors. The patients were examined retrospectively to establish any relationships between the prognostic factors and surgical mortality.
RESULTS
In the univariate analysis, significantly higher surgical mortality rates were found in patients who were more than 75 years old, who had an APACHE II score above 10, and who had a perforation (P<0.05). Gender, duration of symptoms, cancer location, operation type, and disease stage were, however, not associated with a significantly higher surgical mortality (P>0.05). Multivariate analysis showed that age and APACHE II score were related to surgical mortality. The surgical mortality rate for colorectal cancer in an emergency situation was 8.4%.
CONCLUSIONS
Prognostic factors of significance associated with surgical mortality due to an emergency operation were age (> or = 75) and APACHE II score (>10). Careful attention is needed for appropriate perioperative management of patients with these risk factors.

The Significance of Peritoneal Effusion in Colorectal Cancer.: Lee, In Kyu , Yi, Jeong Min , Lee, Yoon Suk , Kim, Hyung Jin , Park, Jong Kyung , Oh, Seong Taek , Kim, Jun Gi , Jeon, Hae Myung , Chang, Suk Kyun; J Korean Soc Coloproctol. 2006;22(5):308-313.

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Abstract PDF: PURPOSE
It has been reported that in colorectal cancer, the positive rate of the cytological examination of ascites is low and that the cytologically positive result of the cancer cell influences its prognosis; nonetheless, not many studies on the correlation of the formation of peritoneal effusion and cancer have been done yet. Thus, this study on the correlation of clinico-pathological findings with peritoneal effusion was initiated.
METHODS
The study population, includes a total of 191 patients who underwent an operation for colon cancer and rectal cancer from May 1, 2004, to December 31, 2005. Peritoneal effusion considered to be present in cases with more than 10 cc of body fluid retained in the Douglas pouch, and a cytological test was performed on patients whose retained fluid was more than 50 cc. In all patients, the correlation of the clinico-pathological findings with peritoneal effusion was analyzed, and the volume of effusion and the positive result of peritoneal cytology were compared.
RESULTS
Among the 191 patients, patients without peritoneal effusion numbered 133 (69.6%) and patients with peritoneal effusion numbered 58 (30.4%). Between the two groups, the presence of intestinal obstruction due to cancer (P<0.001), perineural involvement (P=0.025), lymph node metastasis (P=0.004), lymph-node stage (P=0.001), distal metastasis (P=0.012), macroscopic peritoneal dissemination, and stage (P=0.017) were statistically significantly different. In the multivariate analysis, only the presence of intestinal obstruction and lymph-node disease stage correlated statistically significantly to the formation of peritoneal effusion (P=0.009, 0.004). Twenty patients (34.5%) had peritoneal effusion of more than 50 cc, and among them, malignant cells were detected in 3 patients (15%). Based on 50-cc peritoneal effusion, more or less effusion and the detection of malignant cells by peritoneal cytology did not correlate with the clinico- pathological outcomes (P>0.05).
CONCLUSIONS
For colorectal cancer patients with peritoneal effusion, but without co-morbid medical diseases inducing such peritoneal effusion, by regarding peritoneal effusion itself as meaningful, the range of lymphadenectomies, adjuvant chemotherapy, and other additional therapy should be considered.

Comparative Evaluation of Immune Responses after Laparoscopic and Open Surgery in Patients with Colorectal Cancer.: Lee, In Taek , Choi, Gyu Seog , Weidong, Liu , Won, Dong Il , Jo, Min Jung , Jun, Soo Han; J Korean Soc Coloproctol. 2006;22(5):314-321.

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Abstract PDF: PURPOSE
The laparoscopic approach is thought to reduce postoperative immunologic and metabolic effects after surgery compared to the open approach. This study was designed to compare the systemic immune and metabolic responses after laparoscopic and open surgery in patients with colorectal cancer.
METHODS
Forty-four patients with colorectal cancer were prospectively assigned to undergo either a laparoscopic (n=22) or open (n=22) approach. The postoperative immune and metabolic responses were assessed by measuring the serum level of the relative proportion of lymphocytes, the T-cell count, the natural killer cell (NK-cell) count, the human leukocyte antigen-DR (HLA-DR) expression on monocytes, the interleukin-6 (IL-6), and the C-reactive protein (CRP) at specific time intervals.
RESULTS
Both approaches resulted in a significant decrease in lymphocyte count, T-cell count, NK-cell count, and HLA-DR expression on monocytes at 2, 24, and 72 hours postoperatively. However, the decrease in HLA-DR expression on monocytes was more significant in open surgery at 2 hour postoperatively (mean level, laparoscopic: 90.9% vs. open: 83.1%, P<0.001). Significant rises in IL-6 and CRP were demonstrated within 72 hour postoperatively in both groups. However, no significant difference between the two groups was seen.
CONCLUSIONS
Although both laparoscopic and open surgery in patients with colorectal cancer evoked an alteration of the systemic inflammatory and immune response, our data showed that a HLA-DR expression on monocytes may be less compromised after laparoscopic approach for an immediate postoperative period. However, clearer evidence from large-scaled prospective randomized trials are needed.

Clinical Significance of Lateral Resection Margin Involvement for Colon Cancer.: Lee, Nan Joo , Ha, Tae Geun , Shin, Jin Yong , Jeong, Su Jin , Hong, Kwan Hee; J Korean Soc Coloproctol. 2006;22(5):322-329.

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Abstract PDF: PURPOSE
The clinical significance of the lateral resection margin for rectal cancer has been widely investigated. The ascending and the descending colon do not have a peritoneal covering posteriorly. Therefore, colon cancers located on their posterior side can penetrate the entire bowel wall, which is similar to mesorectal invasion in rectal cancer. However, the prognostic significance of the retroperitoneal resection margin involvement is unknown. The aim of this study is to evaluate the prognostic significance of the lateral resection margin in ascending and descending colon cancer.
METHODS
A retrospective study was performed and involved 92 patients who had undergone a curative resection for right or left colon cancer with TNM stage II and III. The patients were assigned to either a lateral margin negative group (LMNG, n=73) or a lateral margin positive group (LMPG, n=19) according to the presence of a tumor or a metastatic lymph node within 1 mm of the lateral resection margin. The oncological outcomes of the LMPG were compared with those of the LMNG.
RESULTS
The LMPG was younger and had higher incidences of tumors positive vascular or neural invasion and advanced T and N stages. The overall recurrence rate of the LMPG was higher than that of the LMNG (36.8% versus 16.4%) and the cumulative survival rate of the LMPG was significantly lower than that of the LMNG (35.0% versus 76.2%). High preoperative CEA, lymphatic invasion, lateral margin involvement of the tumor, N2 in nodal status were significant factors in the univariate analysis for evaluation of the prognosis, but lateral margin involvement was not a significant factor in the multivariate analysis. In the lymph-node-positive group and the CEA non-elevation group, lateral margin involvement of the tumor was revealed as a prognostic factor.
CONCLUSIONS
Lateral margin involvement of ascending and descending colon cancer affects tumor recurrence and overall survival, but it is not a significant prognostic factor.

Long-term Oncological Outcomes of T1 Rectal Cancer according to the Therapeutic Modalities.: Choi, Pyong Wha , Yu, Chang Sik , Jung, Sang Hun , Kim, Dae Dong , Hong, Dong Hyun , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2006;22(5):330-336.

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Abstract PDF: PURPOSE
Recent studies have showed a 7~15% lymph node metastasis rate in T1 rectal cancer. Surgical options for T1 rectal cancer are radical resections, local excisions, and local excisions with adjuvant radiotherapy. Outcomes according to the type of surgery are variable. The present study was performed to assess outcomes of T1 rectal cancer according to therapeutic modalities and to provide guidelines for appropriate treatment of T1 rectal cancer.
METHODS
A retrospective study of 117 patients with T1 rectal cancer who underwent surgery between June 1989 and December 2002 at Asan Medical Center was conducted. Radical resections, local excisions, and local excisions with adjuvant radiotherapy were performed as therapeutic modalities. Adjuvant radiotherapy after local excision was performed in patients with sm2 or sm3 cancers, lympho-vascular invasion (+), poorly differentiated cancer, and resection margin (+) or because of a patient's refusal to undergo a radical resection.
RESULTS
Twenty-five (21.3%) patients were treated by local excision, 14 (12.0%) by adjuvant radiotherapy after local excision, and 78 (66.7%) by radical resection. The distance from the anal verge was significantly longer in the radical resection group than in the local excision group (7.8+/-3.4 vs. 4.9+/-2.1 cm; P<0.001). There was no significant difference by age, sex, or pathologic findings between the three groups. There was one local recurrence in the local excision group, one distant metastasis in the local excision with adjuvant radiotherapy group, and two distant metastases in the radical resection group. The 5-year cancer-specific survival and disease-free survival rates were as follows; local excision group, 94.1 and 95.8%, respectively; local excision with adjuvant radiotherapy group, 100 and 92.8%, respectively; radical resection group, 98.3 and 98.6%, respectively. There were no significant differences in survival between the groups.
CONCLUSIONS
Oncological outcomes of T1 rectal cancer patients were comparable among the surgical options. Adjuvant radiotherapy is recommended after local excision in patients with risk factors, such as sm2 or sm3 cancer, poorly differentiated cancer, and positive lympho-vascular invasion.

Case Reports

Idiopathic Granulomatous Appendicitis: A case report.: Park, In Hyung , Kim, Woo Jin , Han, Min Suk , Kim, Soo Hang , Sun, Jae Hyung , Park, Jin Suk , Park, Jae Hong , Lee, Soong , Lee, Woong , Kim, Sun Phil; J Korean Soc Coloproctol. 2006;22(5):337-340.

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Abstract PDF: Crohn's disease is a chronic condition characterized by a non-specific granulomatous necrosis involving potentially any location in the alimentary tract, but a primary lesion confined to the appendix alone is very rare. It is difficult to discriminate Crohn's appendicitis from acute appendicitis preoperatively because of their clinical similarities. Because Crohn's disease confined to the appendix has a more favorable prognosis than typical Crohn's disease, it is considered a separate disease from Crohn's disease. Recently, the term idiopathic granulomatous appendicitis has gained wide acceptance as a distinct disease entity. We experienced a case of Crohn's disease giving rise to appendicitis or idiopathic granulomatous appendicitis and report a case with a review of the literature.

Obstructive Colitis Associated with Upper Rectal Cancer.: Lee, Jung Won , Namgung, Hwan , Park, Dong Guk; J Korean Soc Coloproctol. 2006;22(5):341-345.

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Abstract PDF: Obstructive colitis refers to ulceroinflammatory lesions that occur in the colon proximal to an obstructing lesion. The pathogenesis is unclear, but raised intraluminal pressure, distension, and bacterial stasis are thought to play a role in the development of ischemia. The normal appearance at surgery may lead to involved segments of colon being used for anastomoses with consequent complications, so an awareness of the clinical, radiological, and endoscopic features of obstructive colitis is mandatory to prevent anastomotic complications. We experienced a case of obstructive colitis associated with a partially obstructing upper rectal cancer in a 67-year-old male. Obstructive colitis was diagnosed by using colonoscopy preoperatively, and an extended resection involving both the tumor and the colitis segment was performed without complications.

Sigmoid Colon Cancer with Isolated Metastasis to the Left Kidney.: Kim, Hyung Jin , Choi, Ho Joong , Kang, Won Kyung , Oh, Soon Nam , Jung, Chan Kwon , Oh, Seong Taek; J Korean Soc Coloproctol. 2006;22(5):346-349.

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Abstract PDF: We report the case of a 63-year-old female with sigmoid colon cancer and isolated metastasis to the left kidney at the time of initial diagnosis. An anterior resection of the sigmoid colon and a left nephrectomy were performed. Three cycles of adjuvant chemotherapy consisting of oxaliplatin, 5-fluorouracil, and leucovorin were given, but two months after the surgery, multiple metastases of the liver were detected on a CT scan. The patient refused further treatment and died 5 months after the discovery of an isolated metastasis. An isolated metastasis to the kidney is very rare in clinical practice. A nephrectomy for kidney metastasis has no effect on survival and quality of life, and a nephrectomy may also compromise the choice of chemotherapy agents that require renal clearance; thus, a careful evaluation of renal function is necessary before a nephrectomy. At present, kidney metastasis should be regarded as an advanced metastatic disease, and aggressive chemotherapy, including target therapy, should prolong survival and improve the quality of life. However, when a synchronous or a metachronous renal tumor is suspected, a nephrectomy should be performed for accurate diagnosis and treatment.

Review

Artificial Bowel Sphincter for Fecal Incontinence.: Lee, Kil Yeon; J Korean Soc Coloproctol. 2006;22(5):350-355.

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Abstract PDF: Fecal incontinence is a common disorder, affecting all ages and both sexes. It is a devastating condition and has a major impact on quality of life. The level of treatment must be appropriate for the severity of symptoms. Nonsurgical techniques are appropriate for patients with minor degrees of incontinence. Patients with sphincter disruption or rectal prolapse can benefit from the appropriate surgical therapy. Patients with intractable, clinically significant fecal incontinence, caused by trauma or the failure of surgical therapy, need salvage options. In the past if a patient was not amenable to a tissue repair or failed a tissue repair, a colostomy was his or her only surgical option. However, new innovations can give patients more options to regain continence. The artificial bowel sphincter (ABS) is one of those newer options. It is an implantable device used to treat the patients with severe fecal incontinence, who have failed, or are not candidates for less invasive forms of restorative therapy. It is intended to mimic the natural process of bowel control. This device is reserved for patients with severe fecal incontinence that is not amenable to lesser forms of therapy. Because it is an artificial device, ABS is unfortunately associated with high morbidity and low success rate. With experience, however, the infection rate has declined due to new standardized prophylactic antibiotics regimen. Therefore, the ABS has become a good option for patients with severe fecal incontinence. The results are quite impressive with a significant number of patients obtaining complete continence. This review presents the technique of ABS implantation and the current status of ABS.

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