Annals of Coloproctology

Volume 23(6); December 2007

Original Articles

Transgastric Gastroscopic Intra-abdominal Exploration in a Female Dog Model: NOTES (Natural Orifice Transluminal Endoscopic Surgery).: Kim, Young Ill , Park, Jong Heon , Lee, Sang Ill , Jeong, Seong Mok , Kim, Ji Yeon; J Korean Soc Coloproctol. 2007;23(6):397-402.; DOI: https://doi.org/10.3393/jksc.2007.23.6.397

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PURPOSE
Natural orifice transluminal endoscopic surgery (NOTES) is a new surgical option using endoscopic advancement to the peritoneal cavity through the stomach, colon, vagina, or urinary bladder without an abdominal wall scar (incision). The aim of this study was to assess the feasibility of transgastric gastroscopic intra-abdominal exploration with gastric incision and closure before the NOTES would be done.
METHODS
Under general anesthesia of a female dog, one-channel gastroscope was advanced to the stomach and the lumen was irrigated with anti-bacterial solution. The anterior wall of the antrum was incised by about 1 cm with a needle knife; then, the gastroscope was advanced into the peritoneal cavity. An exploration of the entire intra-abdominal cavity was performed.
RESULTS
We were able to evaluate the stomach, the greater omentum, the diaphragm, the peritoneum, the urinary bladder, the bowel, the spleen, the liver, the gallbladder, the uterine horn, the uterine body, and the vagina, but could not evaluate the ovary, the kidney, and the pancreas. The observation of the abdominal cavity was followed by the gastric wall closure with a 135o endoclip. The dog was recovered after confirmation of secure closure of the incision site.
CONCLUSIONS
Transgastric incision, closure, and abdominal exploration are feasible without an abdominal wall scar, and the NOTES can be one option for future abdominal operations in humans and needs to be further investigated.

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Transvaginal Endoscopic Appendectomy
Eung Jin Shin, Gui Ae Jeong, Jun Chul Jung, Gyu Seok Cho, Chul Wan Lim, Hyung Chul Kim, Ok Pyung Song
Journal of the Korean Society of Coloproctology.2010; 26(6): 429. CrossRef
Endoscopic Cecectomy with Hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Canine Models
Young-Ill Kim, Chi-Woo Park, Seong-Mok Jeong, Sang-Il Lee, Jin-Soo Kim, Ji-Yeon Kim
Journal of the Korean Surgical Society.2010; 79(5): 362. CrossRef

Retrospective Analysis of a Fistula-in-ano: Focus on an Anal-sphincter-preserving Procedure.: Han, Ki Su , Cho, Hyeon Min , Kim, Do Hyoung , Kim, Jun Gi; J Korean Soc Coloproctol. 2007;23(6):403-409.; DOI: https://doi.org/10.3393/jksc.2007.23.6.403

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PURPOSE
The results of anal fistula treatments have improved with the development of the anal fistula operative technique. However, there are still complications, such as recurrence and anal incontinence. To this end, the authors classified anal fistulas by using Sumikoshi's classification and performed an anal-sphincter-preserving procedure.
METHODS
We experienced 98 anal fistula cases involving 86 patients who underwent anal fistula operations at The Catholic University of Korea, St. Vincent's Hospital from January 2001 to December 2006. This study was done retrospectively by chart review and telephone questioning. The follow-up period was from 2 to 72 months (mean 29.5, SD: 19.1).
RESULTS
The study showed 0 cases of Type I (0.0%), 49 cases of Type II (50.0%), 46 cases of Type III (46.9%), and 3 cases of Type IV (3.1%) fistulas. Among the 98 fistula-in-ano operations were 27 (27.6%) of fistulotomies and 71 (72.4%) sphincter-preserving procedures (2 cases of coring-out+muscle filling+rectal mucosal advancement flap, 31 cases of coring-out+ muscle closure+rectal mucosal advancement flap, 28 cases of coring-out+cutting seton, and 10 cases of loose seton). After the sphincter-preserving operation, there were 4 cases (4/71, 5.6%) of recurrence. There were no major disorders of the anal sphincter. However, minor disorders of the anal sphincter (6/71, 8.5%, soiling) were found.
CONCLUSIONS
The anal-sphincter-preserving procedure is very effective in preventing recurrence and anal incontinence, but these results are from a retrospective study with a small number of patients and the follow-up period was short. If further cases are collected and continuous follow-up is done, better results can be expected.

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New Techniques for Treating an Anal Fistula
Kee Ho Song
Journal of the Korean Society of Coloproctology.2012; 28(1): 7. CrossRef

Diagnosis of Non-relaxing Puborectalis Syndrome by using the Manometric Defecation Index.: Kim, Tae Won , Seong, Moo Kyung , Yoo, Young Bum; J Korean Soc Coloproctol. 2007;23(6):410-415.; DOI: https://doi.org/10.3393/jksc.2007.23.6.410

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Abstract PDF: PURPOSE
Currently, various tools are used for the diagnosis of nonrelaxing puborectalis syndrome (NRPRS), one of major causes of chronic constipation. Defecography, electromyography (EMG), balloon expulsion test, and a colon transit time study one examples of such tools, but none can be said to be the most accurate and effective one. A diagnosis is only made when two or more examinations show positive findings simultaneously. The aim of this study is to assess the correlation between EMG and the manometric defecation index (DI), which is a relatively new parameter, for the diagnosis of NRPRS.
METHODS
Forty-two chronically cornstipated patients without any history of anal or abdominal surgery underwent both anorectal manometric and EMG tests. The manometric defecation index (DI) was defined as the ratio between the peak rectal pressure and the peak anal pressure when the pressures were measured simultaneously during push by the catheter with longitudinally arranged side holes. The ratio of EMG activity was defined as the ratio between the peak amplitude during push and the peak amplitude during rest when EMG activities were measured by using an anal plug electrode. The two variables were compared prospectively, and their correlation was analyzed.
RESULTS
The manometric DI and the ratio of EMG activit in 42 patients were 0.80+/-0.75 and 1.50+/-0.65, respectively. The correlation coefficient between the two variables was -0.50 (P= 0.001).
CONCLUSIONS
The manometric DI and the ratio of EMG activit were correlated significantly. Therefore, it can be said that the anorectal manometric test can replace the EMG test for diagnosis of NRPRS, which has less convenient access for most colorectal surgeons.

Adult Intussusception: Diagnosis and Treatment.: Yang, Jae Do , Lee, Min Ro , Kim, Jong Hun; J Korean Soc Coloproctol. 2007;23(6):416-419.; DOI: https://doi.org/10.3393/jksc.2007.23.6.416

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Abstract PDF

PURPOSE
Adult intussusception occurs infrequently and differs greatly from childhood intussusception in etiology. Proper diagnostic of and surgical therapeutic methods for adult intussusception remain controversial. The aim of this study was to determine useful diagnostic modalities and proper surgical interventions in adult intussusception.
METHODS
A retrospective analysis performed at Chonbuk National University Hospital identified 38 patients, aged 15 and older, with a diagnosis of intussusception from January 1991 to January 2007.
RESULTS
There were 19 males and 19 females. The median age of the group was 44 years with a range of 20 to 80 years. The mean follow-up period was 82 months. Abdominal pain was the most common presenting complaint (89%). There were 30 small bowel intussusceptions and 8 colonic intussusceptions. A pathologic cause was identified in 79% of the patients, with 5 of 30 (17%) small bowel and 4 of 8 (50%) large bowel lesions being malignant. A preoperative diagnosis was made accurately in 25 of 38 (66%) patients. The diagnostic rates of pre-operative radiological methods were 77%, 60%, 79%, and 100% for barium enema, ultrasonography, abdominal computerized tomography, and both ultrasonography and abdominal computerized tomography, respectively. Operative treatment consisted of manual reduction only in 6 small bowel (20%) and 1 large bowel intussusception (12%), bowel resection after manual reduction in 8 small bowel (27%) and 2 large bowel intussusceptions (24%), and resection alone in 16 small bowel (53%) and 5 large bowel intussusceptions (64%).
CONCLUSIONS
Both ultrasonography and abdominal computerized tomography are the most useful diagnostic modalities. Colonic intussusception should be treated with en-bloc resection without reduction due to the high incidence of malignancy. However, manual reduction only, bowel resection after reduction, and bowel resection alone can be chosen selectively in cases of small bowel intussusception.

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Citations to this article as recorded by

Adult intussusceptions: preoperative predictive factors for malignant lead point
Kil Hwan Kim, Hwan Namgung, Dong Guk Park
Annals of Surgical Treatment and Research.2014; 86(5): 244. CrossRef
A Case of Small Bowel Intussusception Caused by Jejunal Hamartoma Confused as Hepatitis A in an Adult
Joon Hur, Gu-Min Cho, Young Ook Eum, Ji Young Park, Mi Sung Kim, Byung Seong Ko, Hyang Mi Shin, Seung-Myoung Son
Yeungnam University Journal of Medicine.2012; 29(2): 110. CrossRef

Anastomosis Protection with Mallecot in Low Rectal Anastomosis.: Jang, Young Soo , Lim, Kyoung Hoon , Kang, Byung Mo , Choi, Gyu Seog , Jun, Soo Han; J Korean Soc Coloproctol. 2007;23(6):420-423.; DOI: https://doi.org/10.3393/jksc.2007.23.6.420

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PURPOSE
Anastomotic leakage following surgery is one of the most significant causes of morbidity and mortality. Therefore, prevention of anastomotic leakage is crucial for safe rectal surgery. The aim of this study is to determine the effect of Mallecot(R) insertion on the prevention of anastomotic leakage after low rectal anastomosis.
METHODS
From January 2002 to December 2006, 264 rectal cancer surgeries were performed in one center and by one surgeon. Among them, 110 cases whose anastomosis was located below 6 cm from the anal verge were collected and reviewed retrospectively. We made a diverting stoma on 6 out of 20 patients with high risk of anastomotic leakage, and inserted Mallecot(R) on the remaining 14 patients transanally. Removal of Mallecot(R) was done at the 7th postoperative day after a digital rectal examination to identify the completeness of anastomosis had been performed.
RESULTS
Totally, anastomotic leakage occurred in 8 of 110 patients (73%). Among the 90 patients without any preventive measures, 7 incidents of anastomotic leakage were observed; on the other hand, 1 of 14 patients with Mallecot(R) insertion suffered anastomotic leakage. In two of the patients with leakage, including 1 in the Mallecot(R) group, the leakage was resolved via percutaneous drainage; in the other 6 patients were reoperated.
CONCLUSIONS
The importance of preventing an anastomotic leakage after low rectal surgery cannot be overemphasized to reduce morbidity and to improve the prognosis. In addition, Mallecot(R) insertion may be an alternative method for diverting stoma formation.

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Transanal tube placement for prevention of anastomotic leakage following low anterior resection for rectal cancer: a systematic review and meta-analysis
Gi Won Ha, Hyun Jung Kim, Min Ro Lee
Annals of Surgical Treatment and Research.2015; 89(6): 313. CrossRef

Crohn's Anal Fistula and Perianal Abscess: Results of Surgical Treatment.: Lee, In Seob , Choe, Eun Kyung , Park, Sung Chan , Park, Kyu Joo; J Korean Soc Coloproctol. 2007;23(6):424-430.; DOI: https://doi.org/10.3393/jksc.2007.23.6.424

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PURPOSE
In this paper, we intend to review the postoperative course of patients with a Crohn's anal fistula and/or perianal abscess and determine the relationship between the healing time and Crohn's Disease Acitivity Index (CDAI), the extent of intestinal unflammation, and the types of medical treatment.
METHODS
We performed a clinical analysis of the records of 25 Crohn's anal fistula patients (35 operation cases). All patients had undergone operations involving one surgeon at the same hospital between August 1998 and October 2006. We divided the patients into 2 groups (simple vs. complex fistula) and investigated the treatment and clinical course of each group.
RESULTS
The mean age of the patients was 27 years old; the numbers of simple and complex fistulas were 5 (14.3%) and 30 (85.7%), respectively. All simple-group patients healed without recurrence. Moreover, there was no difference in healing time compared with the non-Crohn's patients in the simple-type group (50.4 vs. 45.6 days, P=0.976). However, in the complex group, only 23 cases healed, and the healing time was prolonged significantly compared with that for the non-Crohn's patients in the complex-type group (213 vs. 80 days, P=0.036). The mean healing time was 185.4 days, the number of operations was 1.64, the recurrence rate 32%, and the time to recurrence was about 900 days. Neither CDAI value (mean: 141.6) nor the extent of intestinal inflammation (including rectal inflammation) had any relationship with the healing time (P=0.392, P= 0.911). All patients used azathioprine during treatment, and neither infliximab nor prednisolone medication had any statistically significant effect on the healing time (P=0.73, 0.59).
CONCLUSIONS
The postoperative course of patients in the simple-type group was the same as that for patients with a non-Crohn's anal fistula. On the other hands in the complex-type group, there was frequent recurrence and slow recovery, regardless of the type of operation or medical treatment.

Citations

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Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy
Min Young Park, Yong Sik Yoon, Hyoung Eun Kim, Jong Lyul Lee, In Ja Park, Seok-Byung Lim, Chang Sik Yu, Jin Cheon Kim
Asian Journal of Surgery.2021; 44(11): 1383. CrossRef
Risk of Repeat Surgery for Perianal Crohn Disease
Doo Han Lee
Annals of Coloproctology.2015; 31(5): 169. CrossRef

Clinical Experience with a Circular Stapled Hemorrhoidopexy without Circular Anal Dilator (CAD).: Yun, Kyung Jin , Cho, Hae Chang; J Korean Soc Coloproctol. 2007;23(6):431-436.; DOI: https://doi.org/10.3393/jksc.2007.23.6.431

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PURPOSE
The circular stapled hemorrhoidopexy (SH) reduces mucosal prolapse and interrupts the end branches of the upper hemorrhoidal artery through a suitable instrument, Procedure for Prolapse and Hemorrhoids (PPH). However, there are some technical difficulties in routine use of the circular anal dilator (CAD). The goal of this study was to evaluate the efficacy and the safety of a CSH without use of a CAD.
METHODS
Between April 2005 and November 2006, 250 patients with Grade III and IV prolapsed hemorrhoids who had undergone CSH with PPH without using a CAD were retrospectively analyzed. The sex and age, the operation time, the type of anesthesia, the number of excised hemorrhoid piles, the degree of hemorrhoids and postoperative pain (consumed analgesics), the hospital stay, the postoperative complications, and the number of follow-up examinations at the outpatient clinic were analyzed.
RESULTS
The operation time was 17.76 minutes (10~35 minutes). Most patients (89%) experienced spinal anesthesia. The degrees of hemorrhoids were Grade III (45%) and Grade IV (55%). The numbers of excised piles were 3 (44%), 4 (43%), and more than 5 (13%). The number of consumed postoperative analgesics was 0.97 times (mean). The mean hospital stay was 2.83 days. The postoperative complications were pain, bleeding, and urinary retention.
CONCLUSIONS
A CSH without use of a CAD was an effective and safe surgical modality compared with other procedures for treating hemorrhoids. This procedure is feasible and convenient. The procedure is a new alternative in the treatment of severe hemorrhoids.

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Partial Stapled Hemorrhoidopexy Versus Circular Stapled Hemorrhoidopexy
Jin Sub Kim
Annals of Coloproctology.2017; 33(1): 7. CrossRef
Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III–IV Prolapsing Hemorrhoids
Hyeonseok Jeong, Sunghwan Hwang, Kil O Ryu, Jiyong Lim, Hyun Tae Kim, Hye Mi Yu, Jihoon Yoon, Ju-Young Lee, Hyoung Rae Kim, Young Gil Choi
Annals of Coloproctology.2017; 33(1): 28. CrossRef

Pelvic Actinomycosis: Is It Possible to Diagnose Preoperatively?.: Hwang, Hong Pil , Lee, Min Ro , Kim, Jong Hun; J Korean Soc Coloproctol. 2007;23(6):437-440.; DOI: https://doi.org/10.3393/jksc.2007.23.6.437

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PURPOSE
Pelvic actinomycosis is a rare infection which presents difficulty in establishing a correct preoperative diagnosis. The aim of this study is to find diagnostic clues for pelvic actinomycosis preoperatively.
METHODS
A retrospective analysis performed at Chonbuk National University Hospital identified 9 patients with a diagnosis of pelvic actinomycosis from 1998 to 2006.
RESULTS
All patients were women with a history of intrauterine device (IUD) use. Abdominal pain (7 cases), palpable mass (3 cases), defecation difficulty (3 cases) and leucorrhea (2 cases) were the main presenting complaints. The median duration of presenting symptoms was 78 days (range: 10~365 days). The median duration of using an IUD unchanged was 11 years (range: 4~30 years). A correct diagnosis was made in 3 patients (33%) without exploration. All patients were treated with antibiotics after pathologic diagnosis. There was no recurrence.
CONCLUSIONS
It is very difficult to diagnose pelvic actinomycosis preoperatively. Howere, if a mass or a pelvic abscess is found in women with an IUD that has been unchanged for a long time, pelvic actinomycosis should be suspected to avoid unnecessary exploration.

Citations

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A Case of Actinomycotic Thyroiditis in an Adult with Piriform Sinus Fistula
Hyun Ju Choi, Bo Won Kim, Min Ji Shin, Bo Kwang Choi, Ji Hyun Kang, Yun Kyung Jeon, Sang Soo Kim, Bo Hyun Kim, In Ju Kim, Yong Ki Kim
Endocrinology and Metabolism.2012; 27(3): 222. CrossRef
Actinomycosis of the Appendix: A Case Report
Sung Bae Jee, Ki Seok Jang, Sung Ho Kim, Chul Joong Kim
Journal of the Korean Society of Coloproctology.2010; 26(3): 233. CrossRef
A Case of Adrenal Actinomycosis that Mimicked a Huge Adrenal Tumor
Eui Joo Kim, Hyon Seung Yi, Inku Yo, Sanghui Park, Kyoung Min Kim, Yoon Soo Park, Sihoon Lee, Yeun Sun Kim, Ie Byung Park
Endocrinology and Metabolism.2010; 25(2): 147. CrossRef
Preoperative Diagnosis and Medical Treatment of Pelvic Actinomycosis
Hong Jue Lee, Su Jin Lee, Young Jae Kim, Sung Hee Kim, Jung Han Lee, Seung Ryoung Kim, Sam Hyun Cho
Journal of Bacteriology and Virology.2008; 38(2): 89. CrossRef

Clinical Analysis of Appendicitis in the Elderly Over 60 Years of Age.: Kim, Il Gun , Heo, Tae Gil , Lee, Jung Min , Choi, Pyong Wha , Park, Je Hoon , Lee, Myung Soo , Kim, Chul Nam , Chang, Surk Hyo; J Korean Soc Coloproctol. 2007;23(6):441-447.; DOI: https://doi.org/10.3393/jksc.2007.23.6.441

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PURPOSE
As average life expectancies are prolonged, the elderly population is steadily increasing. The increasing number of elderly persons has been accompanied by cases of acute appendicitis in the elderly. In order to understand the clinical significance and to improve the treatment of elderly patients with appendicitis. we analyzed patients over 60 years of age with appendicitis.
METHODS
We retrospectively reviewed the medical records of 268 patients over 60 years of age who were pathologically diagnosed with appendicitis. We analyzed the patients' clinicopathologic factors and outcomes, dividing them into 3 age groups: 60~69, 70~79, 80 and over.
RESULTS
Of the 268 patients, there were 109 male and 159 female. The sex ratio was 1:1.46. The numbers of patients in each group were 169 (63.1%) in the 60-69 group, 73 (27.2%) in the 70~79 group, and 26 (9.7%) in the over 80 group. There was no difference in the leukocyte count and the time delay in surgical treatment between the groups. In the older groups, compared to the younger groups, there were more frequent paramedian and median incisions in the operation (P=0.02), a longer duration of postoperative admission (P=0.001) and starvation after the operation (P<0.001). In the pathologic findings, the gangrenous and abscess stages of appendicitis were more frequent in the older groups than in the younger groups (P<0.001).
CONCLUSIONS
Early aggressive diagnostic intervention, such as ultrasound and CT, is essential in managing appendicitis in elderly patients who complain of vague abdominal pain.

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Ultrasonography of Appendicitis
Dae Hyun Kim
Clinical Ultrasound.2016; 1(1): 19. CrossRef

Complications, Mortality and Functional Outcome following a Total Colectomy and Ileo-rectal Anastomosis.: Kim, Do Yoon , Oh, Seung Yeop , Lee, Jae Man , Suh, Kwang Wook; J Korean Soc Coloproctol. 2007;23(6):448-453.; DOI: https://doi.org/10.3393/jksc.2007.23.6.448

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PURPOSE
This study reviews the feasibility of a total colectomy with ileo-rectal anastomosis (TCIRA) and the functional outcome following the operation.
METHODS
The cases of a total of 50 patients (31 men and 19 women) with a median age of 61 who underwent a TCIRA were reviewed retrospectively. The median follow-up time was 28 months (4~72). The clinical records were reviewed to analyze the postoperative complications and bowel function. The clinical outcomes were examined directly from patients' scoring.
RESULTS
The indications of TCIRA were metachronous or synchronous colorectal cancer (34 percent), multiple polypoid lesions (22 percent), malignant colon obstruction (24 percent), ischemic colitis (2 percent), Crohn's disease (6 percent), and tuberculosis colitis (2 percent). The overall mortality and morbidity rates were 0 and 31 percent, respectively. The morbidity included postoperative bleeding, obstruction, intra-abdominal abscess formation, pneumonia, and wound complications. We used the CCIS index to evaluate postoperative functional bowel habit change. The CCIS index evaluation revealed perfect continence in 57 percent of the patients with short-term follow up (<6 months) and in 83 percent of the patients who had undergone a TCIRA more than 2 years ago.
CONCLUSIONS
Most patients were satisfied with their bowel function on long-term follow up, and we think the TCIRA is a safe operation, and the clinical outcomes are relatively satisfactory.

Citations

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Treatment of Multiple Colorectal Cancers
Ok Joo Paek, Seung Yeop Oh, Kwang Wook Suh
Journal of the Korean Society of Coloproctology.2009; 25(1): 34. CrossRef

Is a Short Distal Resection Margin of Less than One Centimeter in a Sphincter-saving Resection for Rectal Cancer Oncologically Safe?.: Cho, Min Jeong , Yu, Chang Sik , Park, In Ja , Jeong, Sang Hoon , Chae, Pheung Ha , Hong, Dong Heun , Kim, Dea Dong , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2007;23(6):454-459.; DOI: https://doi.org/10.3393/jksc.2007.23.6.454

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Abstract PDF: PURPOSE
Sphincter preservation is one of the main goals in the treatment of rectal cancer. The aim of this study was to evaluate the oncologic safety of a sphincter-saving resection with a distal resection margin of less than 1 cm.
METHODS
Two hundred forty-eight patients who underwent a sphincter-saving resection between June 1989 and December 2002 and who had a confirmed distal resection margin of less than 1 cm on pathologic examination were included. All patients were evaluated for local and systemic recurrences.
RESULTS
The median follow-up period was 45 (6~144) months. The mean length of distal resection margin was 0.79+/-0.26 cm. Lower rectalcancer was most common (56.5%). Forty patients (16.1%) experienced recurrence. The local recurrence rate was 3.6%, systemic recurrence rate was 11.7%, and the combined local and systemic recurrence rate was 0.4%. In systemic recurrence, the liver was the most common site, followed by the lung. Among stage II & III groups, patients who underwent adjuvant chemoradiotherapy experienced significantly lower local recurrence compared to patients in the chemotherapy-only or the no-adjuvant group (2.6%, 12.9%, 8.7%, P=0.05). The length of distal resection margin, the total mesorectal excision, the location of tumor, sex, histology, and stage were not associated with local recurrence.
CONCLUSIONS
A distal resection margin of less than 1 cm in a sphincter-saving resection showed acceptableoncologic outcomes. Adjuvant chemoradiotherapy were beneficial to reduce local recurrence in the stage II and the stage III groups.

The Prognostic Significance of Tumor Budding, Tumor Nodules, and Lymph Node Extracapsular Extension in Stage III Colorectal Cancer Patients.: Kim, Seong Ah , Shin, Ok Ran , Kim, Hyong Ran , Cho, Hang Ju , Seo, Hak Jun , Kim, Kee Hwan , Kim, Ji Il , An, Chang Hyeok , Oh, Seung Tack , Kim, Jeong Soo; J Korean Soc Coloproctol. 2007;23(6):460-476.; DOI: https://doi.org/10.3393/jksc.2007.23.6.460

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PURPOSE
The prognosis of advanced colorectal cancer patients may be different even for the same TNM staging. The characteristic features of tumors, such as tumor budding, tumor nodules, and extracapsular extension (ECE) of lymph nodes, can influence the disease progression and the outcome for patients. Tumor budding occurs what at the invasion front of colorectal adenocarcinomas, tumor cells, singly or in small aggregates, become detached from the neoplastic glands, and it can be divided it into two groups, low grade (0~16 foci in a field) and high grade (17 or more foci in a field). A tumor nodule is histologically identified within the fatty tissue or the detached fatty tissue around the dissected lymph nodes, or is a place picked up as lymph nodes from resected specimens which contain no lymph node components. ECE is defined as a tumor extension beyond the node capsule. The aims of this study were to evaluate the clinical significance of tumor budding, tumor nodules, and ECE of lymph nodes as prognostic factors in Stage III colorectal cancer patients.
METHODS
We analyzed the disease-free and overall 5-year survival rates and recurrence rates in 94 Stage-III colorectal cancer patients according to tumor the budding intensity, the tumor nodules, and the lymph node ECE status.
RESULTS
Of the entire group, the 5-year disease-free and overall survival rates were 49%, and 50%, respectively. The 5-year disease-free and overall survival rates were higher in the low-grade tumor budding group than in the high-grade group (58% vs 33%, P=0.045, 61% vs 39%, P=0.003). The 5-year disease-free and overall survival rates in patients with tumor nodules were lower than those in patients without one (44% vs 69%, P=0.086, 47% vs 77%, P=0.018). The recurrence rate was also higher in the group with tumor nodules than without one (80% vs 52%, P=0.045). The 5-year disease-free and overall survival rates were higher in the ECE negative group than in the positive one (68% vs 37%, P=0.018, 75% vs 42%, P=0.001). The recurrence rate was also higher in the ECE positive group than in the negative group (78% vs 46%, P=0.008). The existence of ECE and tumor nodule were strongly related to systemic recurrence (P=0.006, P=0.033), but not to the local recurrence (P=0.777, P=0.611). Considering the analysis of the recurrence pattern by N stage classification, there is no statistical difference in the N2 patient group, but there was in the existence of ECE and tumor nodule were strongly related to the systemic recurrence in N1 group (P=0.019, P=0.028). These three factors were scored according to the existence, and the score range was divided into two prognostic groups, high risk group (> or =2) and low risk group (<2). The high risk group was significantly associated with systemic recurrence (P= 0.004) rather than recurrence (P=0.865), and these score value were only significant in the N1 patient group (P=0.007) rather than in the N2 group (P=0.927). The high risk group also showed poor overall survival rate compared with the low risk one in only the N1 group (P=0.002), but nof in the N2 group (P=0.193). On multivariate analysis, UICC stage and ECE were two significant factors for tumor recurrence and the 5-year disease-free survival rate.
CONCLUSIONS
These data showed that even if similar lymph node metastasis existed in advanced colorectal cancer patients, there was a different 5-year disease-free survival rate and overall survival rate according to the tumor budding, tumor nodule, and ECE status. On multivariate analysis, UICC stage and ECE were two significant factors for the tumor recurrence and the 5-year disease-free survival rate. Our results suggest that tumor budding, tumor nodule, and ECE of lymph node are excellent parameters to provide a confident prediction of clinical outcome.

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Tumor Budding and Survival After Potentially Curative Resection of Node-Positive Colon Cancer
Joanne Sy, Caroline L.-S. Fung, Owen F. Dent, Pierre H. Chapuis, Les Bokey, Charles Chan
Diseases of the Colon & Rectum.2010; 53(3): 301. CrossRef
The Relatioships Between Tumor-related Gene Expression and Tumor Budding, Tumor Nodule and Lymph Node Extracapsular Extension in Colorectal Cancer
Hyun Jong Kang, Hang Joo Cho, Gi Chang Kang, Kee Hwan Kim, Won Kyung Kang, Ji Il Kim, Jong Kyung Park, Seungtack Oh, Jeong Soo Kim, Chang Hyeok An
Journal of the Korean Society of Coloproctology.2009; 25(1): 1. CrossRef

A Comparative Study of Operated and Non-operated Groups in Patients with Hepatic Metastasis from Colorectal Cancer.: Yun, Sang Chul , Kim, Hyung Chul , Chu, Chong Woo , Shin, Eung Jin , Baek, Moo Jun , Cho, Gyu Seok , Choi, Nam Kyu , Jung, Jun Chul , Song, Ok Pyung , Kim, Hyun Jung , Kim, Chan Gyoo , Lee, Joon Hyoek , Park, Seong Jin , Cho, Jun Hee , Lee, Hae Kyung , Kim, Hee Kyung , Koh, Eun Suk; J Korean Soc Coloproctol. 2007;23(6):477-482.; DOI: https://doi.org/10.3393/jksc.2007.23.6.477

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Abstract PDF: PURPOSE
The prognosis for patients with liver metastases (LM) from colorectal cancer is significantly influenced by the clinician's decision. Recently, there have been remarkable advances in treatment of LM, so there can be some changes in therapeutic modalities. We performed a comparative study between operated and non-operated groups of patients with LM to analyze the clinical outcome.
METHODS
From Feb. 2001 to Feb. 2006, 27 patients with LM underwent a hepatectomy, and 113 patients received non-surgical therapy. thirteen hepatectomized cases among the 27 patients had multiple LM. The outcomes of those 13 patients (Group A) were retrospectively compared to those of the non-operated group (Group B, n=21), which had had potentially resectable LM at the initial diagnosis or after chemotherapy, but didn't undergo hepatic resection.
RESULTS
After a median follow-up duration of 31.3 months, the estimated 3-years overall survival (OS) rates were 76.9% and 14.3% in group A and B, respectively (P=0.0001). In the stepwise Cox multivariate regression analysis, factors such as the absence of hepatic resection and a greater diameter of the liver mass independently influenced the poor survival (P=0.005 and P=0.012 respectively). Additionally, two radiologists evaluated the intraoperative ultrasonographic (IOUS) results. IOUS detected new metastatic lesions in 4/13 (30%) patients. There were sub-centimeter metastatic lesions (5~7 mm) and had not been detected in SPIO-enhanced MRI.
CONCLUSIONS
Our results compared to palliative chemotherapy suggest that aggressive surgical resection should be performed to increase the survival rate in patients with LM. Additionally, the treatment plan for LM patients should be discussed with the gastroenterololgist, the radiologist, the oncologist, and the surgeon.

A Prospective Study on the Significance of Peritoneal Washing Cytology as a Diagnostic Modality in Colorectal Cancer.: Park, Jeong Mi , Yun, Min Young , Choi, Yoon Mee , Choi, Sun Keun , Hur, Yoon Suk , Lee, Kun Young , Kim, Sei Joong , Cho, Young Up , Ahn, Seung Ik , Hong, Kee Chun , Shin, Suk Hwan , Kim, Kyung Rae , Woo, Ze Hong; J Korean Soc Coloproctol. 2007;23(6):483-489.; DOI: https://doi.org/10.3393/jksc.2007.23.6.483

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Abstract PDF: PURPOSE
Free intraperitoneal cancer cells exfoliated from a tumor are considered to be responsible for peritoneal dissemination. Therefore, microscopic evaluation of cells washed from the peritoneal cavity during surgery for various intraabdominal malignancies has been used to detect subclinical intraperitoneal metastases from these tumors. The purposes of this study were to detect intraperitoneal free cancer cells at the time of surgery by using peritoneal washing cytology in colorectal cancer and to evaluate their diagnostic significance.
METHODS
During the 29-month period from January 2000 through May 2002, 149 randomly selected patients with primary colorectal cancer without evidence of gross peritoneal metastasis underwent peritoneal washing cytologic analysis before surgical manipulation of the tumor. Peritoneal washing cytology was compared with the pre-existing prognostic factors.
RESULTS
Positive peritoneal washing for free cancer cells was found in 19 of 149 patients (12.8%). This positivity was significantly correlated with histologic grade (P=0.002), serosal invasion (P=0.025), lymph node metastasis (P=0.034), Astler-Coller classification (P=0.008), recurrence (P<0.001), and 5-year survival (P<0.001). Cancer-specific survival was significantly associated with histologic grade (P=0.025), peritoneal washing cytology (P<0.001), lymph node metastasis (P<0.001), recurrence (P<0.001), and stage (P= 0.010) in the multivariate analysis.
CONCLUSIONS
The presence of free cancer cells was predictive of survival and was an independent prognostic factor. This information may be useful in stratifying patients with colorectal cancer for therapeutic trials, such as intraperitoneal chemotherapy.

The Characteristics of Colorectal Cancer in Patients Older than 80 Years.: Lee, Jae Myeong , Kim, Hee Cheol , Park, In Ja , Kim, Dae Dong , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2007;23(6):490-496.; DOI: https://doi.org/10.3393/jksc.2007.23.6.490

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PURPOSE
The frequency of surgery for elderly Koreans with colorectal cancer has increased because of the current life expectancy rates. The purpose of this study is to identify the characteristics of colorectal cancer in very elderly patients, to determine the optimal treatment decision, and to evaluate the patients prognosis.
METHODS
Between 1989~2005, 181 patients (96 men and 85 women, median age 82) over the age of 80 with colorectal cancer underwent surgery at OO hospital, Korea. Medical records with these patients' co-morbidities, symptoms, clinico-pathologic characteristics, complications, survival, and other relevant data were obtained and analyzed retrospectively.
RESULTS
The principal clinical symptoms were bleeding (45.3%) and bowel habit change (40.9%). Of these patients, 126 had at least one preoperative co-morbidity, and hypertension (29.3%), and cardiac disease (16.0%) were common. Curative surgery was performed in 82.9% (n=150). Emergency surgery was performed in 6.1% (n=11), and the principal cause was obstruction. The most common location of the colorectal cancer was the rectum (39.8%). There were postoperative complications in 36.4% of the patients, including voiding difficulty (12.2%) and wound infection (9.9%). The thirty-day mortality rate was 0.6% (n=1). A preoperative, low PaO2 level significantly increased the incidence of postoperative complications (P=0.036). The five-year survival rate of the curative resection group was higher than that in the remaining patients (44.3% vs. 38.8%, P<0.001).
CONCLUSIONS
Although the preoperative morbidity was high in these very elderly patients, it could be lowered with strict patient management. In addition, these patients showed a relatively good survival rate. Therefore, we believe that major, curative, colorectal surgery should be performed in selected very elderly patients.

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