Annals of Coloproctology

Volume 25(6); December 2009

Review

Surgery in an Intersphincteric Fistula.: Lim, Seok Won; J Korean Soc Coloproctol. 2009;25(6):365-371.; DOI: https://doi.org/10.3393/jksc.2009.25.6.365

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An intersphincteric fistula is the most common type of fistula, about 70% of all fistulas, and is often encountered by the surgeon during anal surgery. The operative procedures include a simple fistulotomy, a fistulectomy, a cutting seton technique, and a sphincter-saving technique. Most posterior-located intersphincteric fistulas can be successfully treated by using the lay-open technique, but using that technique in cases of lateral- or anterior-located fistulas may result in incontinence or anal deformity. In this respect, a sphincter-saving technique has more advantage in sparing anal function than other procedures in cases of lateral or anterior fistulas, but the recurrence rate is high. The delayed open method with seton techniques have a low recurrence rate, but do not preserve anal function well. As mentioned above, the operative method for treating intersphincteric fistulas should be suitable for keeping sphincter tone and should have a low recurrence rate. This article discusses the rationale for and the estimated effectiveness of many operative methods for treating intersphincteric fistulas.

Citations

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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

Original Articles

Histological Differences between Vascular and Mucosal Hemorrhoids.: Lim, Cheong Ho , Lee, Hun Kyung , Shin, Hyeon Keun , Lee, Young Chan , Choi, Dong Hyun , Hwang, Jae Kwan , Chang, Han Jeong , Ko, Yong Taek , Jeong, Seung Kyu , Yang, Hyung Kyu; J Korean Soc Coloproctol. 2009;25(6):372-379.; DOI: https://doi.org/10.3393/jksc.2009.25.6.372

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Abstract PDF: PURPOSE
The aim of this study is to compare and analyze the histological differences between vascular and mucosal hemorrhoids, two structurally different types of hemorrhoids. METHODS: Internal hemorrhoidal tissue samples were fixed in 10% Formalin solution, and coronal sections included 10-mm proximal and 5-mm distal of the dentate line. Routine Masson-Trichrome and H&E were performed to evaluate the thickness of the mucosa and changes in the structure and the densities of submucosal vessels, connective tissue, and muscle. RESULTS: Compared with the corresponding tissues of mucosal hemorrhoids, the submucosal connective tissue and perivascular connective tissue of vascular hemorrhoids showed a loosened density, severe fragmentation, and an irregular arrangement. The submucosal vascular dilatation was more frequent and more severe in vascular hemorrhoids, but the number of vessels between both types of hemorrhoids did not show much difference. Hypertrophy and regular arrangement of the submucosal muscles were observed more frequently in the mucosal than in the vascular hemorrhoids.
CONCLUSION
Compared to mucosal hemorrhoids, vascular hemorrhoids showed augmented damage in submucosal connective tissue and intense dilatation of vessels with a thinner mucosa. On the other hand, compared to vascular hemorrhoids, mucosal hemorrhoids showed hypertrophy of submucosal muscle and relatively minor alterations in vessels with a thicker mucosa. These histological differences may provide the basis for different etiologies between vascular and mucosal hemorrhoids.

A Comparison of Standard Laparoscopic Surgery and Hand-Assisted Laparoscopic Surgery in Patients with Diverticular Diseases of the Large and the Small Bowel.: Jung, Jae Hak , Kim, Chang Nam , Park, Jin Seok , Kim, Jong Yup , Cho, Byung Sun , Lee, Min Koo , Choi, Young Jin , Kang, Yoon Jung , Park, Joo Seung; J Korean Soc Coloproctol. 2009;25(6):380-386.; DOI: https://doi.org/10.3393/jksc.2009.25.6.380

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Abstract PDF

PURPOSE
In complicated diverticular disease, hand-assisted laparoscopic surgery (HALS) has been considered as a useful alternative treatment to standard laparoscopic surgery (SLS) and open surgery. As compared with standard laparoscopic surgery, HALS offers advantages such as tactile sense, better exposure, and shorter learning curve. Minimally invasive surgery is another advantage of HALS. The aim of this study was to compare SLS to HALS in patients with diverticular diseases of the small bowel and the colon.
METHODS
We retrospectively reviewed the records of 32 patients who had undergone SLS and HALS for diverticular disease between February 2002 and March 2009. RESULTS: Of the 32 patients, 20 patients (62.5%) were in the SLS group, and 12 patients (37.5%) were in the HALS group. The mean maximal incision length was longer in the HALS group (SLS group vs. HALS group, 4.5 vs. 7.4 cm, P<0.001). However, the mean operating time, the time to flatus, the time to diet, the mean duration of narcotic analgesia, the length of hospital stay, and the postoperative complications were similar. There was no mortality in either group. CONCLUSION: The longest incision length for the HALS group was longer than that for the SLS group, but HALS could reduce the conversion rate and has the many advantages of minimally invasive surgery. For complicated diverticular disease, HALS may be considered as a useful alternative treatment.

Citations

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Emergent Colorectal Surgery: What Should Be Considered?
Chang-Nam Kim
Annals of Coloproctology.2016; 32(4): 124. CrossRef

Anal Diseases from Ingested Foreign Bodies.: Kim, Hansuk , Ryoo, Seungbum , Choe, Eun Kyung , Kim, Dosun , Lee, Doohan , Park, Kyu Joo; J Korean Soc Coloproctol. 2009;25(6):387-392.; DOI: https://doi.org/10.3393/jksc.2009.25.6.387

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Abstract PDF

PURPOSE
Anal problems due to ingested foreign bodies are rare and usually present as acute anal pain. However, various clinical presentations are possible. This study was performed to identify the diverse manifestations of and the outcomes of treatments for anal diseases caused by ingested foreign bodies. METHODS: Between September 1995 and June 2003, seven patients were treated for anal diseases due to the impaction of ingested foreign bodies in Seoul National University Hospital and Daehang Hospital. We retrospectively reviewed the medical records of those unusual patients.
RESULTS
All patients were males, and their mean age was 49.4 yr (range, 37 to 74 yr). The detected foreign bodies were fish bones (n=3), fish fins (n=2), a chicken bone (n=1), and a toothpick (n=1). Four patients had acute anal pain as the primary symptom while two patients presented anal pus discharge, and one patient presented anal bleeding. In the four patients with acute anal pain, the foreign bodies were easily found on digital rectal examination and inspection with anoscopy. Those patients underwent simple removal of the foreign body at the outpatient clinic. In three patients, the foreign bodies were found during surgery for hemorrhoids or fistulas. The two fistulas detected were complex types and needed seton placement. CONCLUSION: Anal problems caused by ingested foreign bodies usually involve acute anal pain, but our results indicate that, in some cases, the anal foreign bodies are also the cause or an aggravating factor in chronic anal disease.

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Operative Treatment with a Laparotomy for Anorectal Problems Arising from a Self-Inserted Foreign Body
Seung-Bum Ryoo, Heung-Kwon Oh, Heon-Kyun Ha, Eun Kyung Choe, Sang Hui Moon, Kyu Joo Park
Journal of the Korean Society of Coloproctology.2012; 28(1): 56. CrossRef

Immunohistochemical Studies of Fascin, MMP-9 Overexpression, and Proliferating Index as Prognostic Factors in Cases of a Colon Adenocarcinoma.: Kim, Beom Gyu , Ha, Kyung Won , Park, Jun Suk , Yoo, Jae Hyung; J Korean Soc Coloproctol. 2009;25(6):393-400.; DOI: https://doi.org/10.3393/jksc.2009.25.6.393

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Abstract PDF

PURPOSE
The malignant conversion of epithelial cells involves alterations in the expression and the function of cell-matrix and cell-cell adhesive systems that enable a switch to a migratory phenotype in tumor invasion and metastasis. Here, the author studies the prevalence and the potential clinical significance of fascin and Matrix metalloproteinase-9 (MMP-9) expression in relation to the progression of colon adenocarcinoma and of tumor cell proliferation as measured by using the topoisomerase II-alpha (Topo II-alpha) index. METHODS: Relatively well-preserved paraffin-embedded tissues of 120 cases of colon adenocarcinomas were immunohistochemically stained for fascin, MMP-9, and Topo II-alpha expression. A reaction was determined as being positive when more than 10% of the cells were positive for fascin, and/or MMP-9. The Topo II-alpha index is defined as the positive number of tumor cells divided by the total number of tumor cells counted times 100. At least 1,000 cells were counted for this analysis. A chi-square test, by using Epi info 2000, for Fascin and/or MMP-9 and a two-sided test for the Topo II-alpha index were employed with a significance of P<0.05. RESULTS: Positive reactions for fascin and MMP-9 in colon adenocarcinomas were 44.2% and 56.7%, respectively. In clinically annotated tumors, fascin immunoreactivity was more common in tumors located in the right colon (P=0.014) and was associated with older age (>65 yr, P=0.028), tumor grading (P=0.009), and lymph node metastases (P=0.005). However, MMP-9 immunoreactivity was not statistically associated with age, gender, tumor stage, or lymph node metastases. Fascin expression was statistically associated with MMP-9 expression, especially for left colon adenocarcinomas (P=0.0032). Although the topo II-alpha proliferating index was associated with lymph node metastasis (P<0.01), this result was not statistically associated with Fascin or MMP-9 expression. CONCLUSION: Fascin expression may be closely linked with tumor grading and lymph node metastasis of more aggressive colon adenocarcinomas and partly associated with MMP-9 expression in tumor invasion. However, further studies of fascin expression as an independent prognostic factor are required for the determination of significant relationships with other clinicopathologic indices.

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Association of fascin-1 with mortality, disease progression and metastasis in carcinomas: a systematic review and meta-analysis
Vanessa Y Tan, Sarah J Lewis, Josephine C Adams, Richard M Martin
BMC Medicine.2013;[Epub] CrossRef

The Influence of Age on Survival and Recurrence after a Curative Surgical Resection for Colon Cancer Patients.: Lee, Cho Rok , Kim, Young Wan , Kim, Nam Kyu , Hur, Hyuk , Min, Byung Soh , Lee, Kang Young , Sohn, Seung Kook , Cho, Chang Hwan; J Korean Soc Coloproctol. 2009;25(6):401-409.; DOI: https://doi.org/10.3393/jksc.2009.25.6.401

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Abstract PDF

PURPOSE
This study was performed to evaluate whether age was a factor associated with oncological outcome for colon cancer patients who underwent a curative surgical resection.
METHODS
A retrospective study of 2,125 colon cancer patients who underwent surgery between January 1989 to December 2004 was conducted. RESULTS: Of the 2,125 patients, 1,724 patients underwent a curative resection (R0). The patients with R0 were classified into three groups: group I (n=142) under 40 yr of age, group II (n=1,462) between 40 and 75 yr of age, and group III (n=120) over 75 yr of age. There were no significant differences in gender, tumor diameter, or postoperative complications among the groups. A history of hereditary colon cancer, advanced TNM stage (III, IV), and poorly- differentiated histology were more commonly found in group I. Adjuvant chemotherapy was administered less frequently in group III. In the survival analysis, the cancer-specific survival (CSS) and the disease-free survival (DFS) rates were not different between groups I and II. The CSS and the DFS rates of group III were significantly unfavorable compared with those of groups I and II. On the multivariate analysis, old age (group III), TNM stage, and preoperative CEA level were independent risk factors for CSS and DFS. CONCLUSION: In colon cancer patients, tailored approaches according to age, such as early screening in young adults with family history and proper patients selection for adjuvant treatment in old patients, could be needed.

Citations

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Overweight is Associated with a Favorable Survival in Patients with Colorectal Cancer: A Prospective Cohort Study in an Asian Population
Yang Won Min, Su-A Kim, Jun Hee Lee, Jin Young Kim, Dong Kyung Chang, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee, Young-Ho Kim
Annals of Surgical Oncology.2012; 19(11): 3460. CrossRef
Analysis of the Prognostic Effectiveness of a Multivisceral Resection for Locally Advanced Colorectal Cancer
Sejin Park, Yun Sik Lee
Journal of the Korean Society of Coloproctology.2011; 27(1): 21. CrossRef

Risk Factors for Conversion in Laparoscopic Surgery for Colorectal Cancer.: Lee, Seung Hwan , Lee, Kil Yeon , Park, Soon Do , Park, Sun Jin , Lee, Suk Hwan; J Korean Soc Coloproctol. 2009;25(6):410-416.; DOI: https://doi.org/10.3393/jksc.2009.25.6.410

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Abstract PDF: PURPOSE
Recently, laparoscopic surgery has been performed with increasing frequency in cases of various diseases, including colorectal cancer. However, in some cases, laparoscopic surgery should be converted to open procedures because of several factors. In this study, we tried to find the causes of and the risk factors for conversion to open procedures during colorectal cancer surgery. METHODS: From June 2002 to May 2008, laparoscopic surgery in 324 patients who were diagnosed as having colorectal cancer was performed by two surgeons. Patients were divided into two groups, non-conversion and conversion groups. We investigated the differences in age, sex, presence of preoperative colonic obstruction, tumor invasion (pT stage), and so on between the two groups. RESULTS: Of the 324 patients, 20 patients experienced an open conversion: 5 of 28 patients who had a colonic obstruction and 15 of 296 patients who had no obstruction (P=0.021). The causes of conversion during the surgery were tumor invasion, peritoneal adhesion, hemorrhage, and cancer perforation. There were 8 conversions out of 92 patients from June 2002 to May 2005 and 12 out of 232 from June 2005 to May 2008 (P=0.231). In regards to the degree of tumor invasion, 9 of 32 who were stage pT4 experienced a conversion to an open procedure (P<0.001). In multivariate analysis, the presence of a colonic obstruction and pT4 stage were meaningful risk factors for conversion to an open procedure. CONCLUSION: From this study, we can predict a higher rate of conversion to an open procedure in patients with locally advanced colon cancer, especially when a colonic obstruction is present. Therefore, a careful laparoscopic approach is needed in such patients.

Short-Term Outcome of Curative One-Stage Laparoscopic Resection for Obstructive Left-Sided Colon Cancers Followed by Stent Insertion: Comparative Study with Non-Obstructive Left-Sided Colon Cancers.: Kim, Hyun Sil , Kim, Sung Geun , Ahn, Chang Hyuk , Kang, Won Kyung , Lee, Yun Seok , Lee, In Kyu , Kim, Hyung Jin , Lee, Sang Cheol , Cho, Hyeon Min , Park, Jong Kyung , Oh, Seong Taek , Kim, Jun Gi; J Korean Soc Coloproctol. 2009;25(6):417-422.; DOI: https://doi.org/10.3393/jksc.2009.25.6.417

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Abstract PDF: PURPOSE
Laparoscopic surgery has been considered to be contraindicated for treating malignant colorectal obstruction. Stent insertion for obstructive colorectal cancer has recently allowed laparoscopic surgery to be performed by means of preoperative bowel decompression and bowel preparation. The aim of this study is to evaluate the safety and the feasibility of a one-stage laparoscopic resection for obstructive left-sided colon cancer after stent insertion by comparing the results to those for non-obstructive left-sided colon cancer. METHODS: Between May 2006 and January 2009, a laparoscopic colorectal operation was performed on 18 consecutive patients with obstructive left-sided colon cancer after placement of a self-expandable stent by one colorectal surgeon, and the results were compared retrospectively to those for 43 patients with non-obstructive left-sided colon cancer who had undergone a laparoscopic procedure with the same surgeon. The collected data were the clinicopathologic characteristics, the perioperative complications, the oncologic outcomes, the postoperative recovery results, and the survival rate. RESULTS: The obstructive left-sided colon cancer group had significant benefits in retrieved lymph nodes (18.8+/-5.3 vs. 14.0+/-8.7, P=0.036), and distal resection margin (5.5+/-3.0 cm vs. 3.6+/-2.4 cm, P=0.011). There were no significant differences in other clinicopathological characteristics and oncologic outcomes, including the overall 3-yr survival rate, between the two groups. CONCLUSION: Preoperative stent decompression followed by a laparoscopic colorectal resection is a safe and feasible option for treating obstructive left-sided colon cancer. A further large-scale prospective study should be performed to evaluate the long-term outcome of a one-stage laparoscopic resection using stent insertion in cases of obstructive left-sided colon cancer.

POSSUM, P-POSSUM, and Cr-POSSUM Scoring Systems as Predictors of Postoperative Morbidity and Mortality in Elderly Colorectal Cancer Patients.: Sung, Nak Song , Choi, In Seok , Choi, Won Jun; J Korean Soc Coloproctol. 2009;25(6):423-428.; DOI: https://doi.org/10.3393/jksc.2009.25.6.423

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Abstract PDF: PURPOSE
The Physiological and Operative Severity Score for the enumeration of Morbidity and Mortality (POSSUM), the Portsmouth-POSSUM (P-POSSUM), and the colorectal-POSSUM (Cr-POSSUM) are relative scoring systems for the prediction of postoperative morbidity and mortality. This study is designed to evaluate the usefulness of each scoring system in elderly colorectal cancer patients undergoing major colorectal surgery. METHODS: From January 2000 to May 2008, the authors retrospectively analyzed the medical records of 251 elderly colorectal cancer patients who had undergone surgery. Collected data were analyzed using the Mann-Whitney U-test, a risk stratification analysis, and a receiver-operator characteristic (ROC) curve to evaluate the usefulness and the accuracy of each scoring system. RESULTS: All the predicted morbidity and mortality rates calculated by using the three POSSUM systems were higher than the observed morbidity and mortality rates. A risk stratification analysis showed a considerable correlation in risk prediction between the observed data and the calculated data. The ROC curves showed that all three POSSUM scoring systems had quite high accuracies as predictors of postoperative morbidity and mortality. POSSUM and P-POSSUM were more accurate than Cr-POSSUM. CONCLUSION: All three scoring systems have a tendency for overestimation. The accuracies of POSSUM, P-POSSUM, and Cr-POSSUM as predictors are acceptance, and POSSUM and P-POSSUM are more accurate than Cr-POSSUM for prediting postoperative morbidity and mortality.

Safety of Early Chemotherapy after a Laparoscopic Colorectal Cancer Resection: A Case-Control Study.: Shin, Seung Ho , Lee, Sun Il , Choi, Dong Jin , Woo, Si Uk , Kim, Jin , Min, Byung Wook , Moon, Hong Young , Kim, Seon Hahn; J Korean Soc Coloproctol. 2009;25(6):429-436.; DOI: https://doi.org/10.3393/jksc.2009.25.6.429

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Abstract PDF: PURPOSE
Since micrometastasis is generally inhibited by primary cancer, surgical ablation of the tumor may stimulate the growth of residual cancer cells, if they exist. This supports the importance of early administration of postoperative chemotherapy. METHODS: We reviewed the cases of patients who underwent a laparoscopic resection and then received chemotherapy (5 fluorouracil+leucovorin or FOLFOX4) between September 2006 and May 2008. The chemotherapy was scheduled on the 7th or the 8th postoperative day, but was postponed when a final pathologic report was delayed or patients were discharged early. The safety of chemotherapy was evaluated in two ways. Early safety, such as the presence of surgical complications and medical toxicity, was prospectively assessed just before the beginning of the second cycle of chemotherapy. Late safety, such as medical toxicity, was retrospectively estimated from the 2nd to the last cycle. These safeties were compared between the two groups: the early chemotherapy group (n=50) for which chemotherapy started on the 7th or 8th postoperative day as scheduled and the delayed chemotherapy group (n=31) for which chemotherapy started after the 14th postoperative day.
RESULTS
Patient demographics were not different between the two groups. With regards to early safety, no differences in surgical complications existed between the two groups. In medical toxicities, there were no differences, except for a higher rate of nausea in the early chemotherapy group (20 percent vs. 10 percent, P=0.01). With regards to late safety, the two groups were not different in the development of medical toxicities. CONCLUSION: Because nausea is an easily controllable toxicity, we conclude that chemotherapy is safely started on the 7th or the 8th day after a laparoscopic colorectal cancer resection.

Case Reports

Perineal Reconstructive Surgery of a Cloaca-Like Perineal Defect: A Case Report.: Jung, Hae Il , Bae, Sang Ho , Baek, Moo Jun , Kim, Chang Ho , Ahn, Hyung Sik; J Korean Soc Coloproctol. 2009;25(6):437-440.; DOI: https://doi.org/10.3393/jksc.2009.25.6.437

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Abstract PDF: The perineal defect in female genitalia results from multiple etiologies, including obstetric injury, sexual assaults, and perineal trauma. Untreated defects may lead to significant physical, functional, and esthetic complaints. Numerous reconstruction methods are used for a perineal defect, but various complications, such as fecal impaction, fecal incontinence, and wound disruption, are introduced. We report a case of a 40-yr-old woman with a cloaca-like perineal defect, who was treated with reconstructive surgery of the perineal defect and recovered with a good anatomical and functional outcome.

Perineal Reconstructive Surgery of a Cloaca-Like Perineal Defect: A Case Report.: Kye, Bong Hyeon , Kim, Hyung Jin , Lee, In Kyu , Kim, Do Hyoung , Won, Dae Youn , Kang, Won Kyung , Oh, Seong Taek; J Korean Soc Coloproctol. 2009;25(6):441-444.; DOI: https://doi.org/10.3393/jksc.2009.25.6.441

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Abstract PDF

Retrorectal or presacral tumors are rare, with incidences of approximately 0.01%. Generally, these tumors have no specific symptoms and are likely to be found incidentally on CT or MRI scans. Most of them are benign masses, but malignant masses are reported on occasion. The modality of treatment is a resection in cases of a benign mass, but chemotherapy or radiation therapy can be done in cases of malignancy. Like our case, a matured cystic teratoma in the retrorectal area is very rare. In addition, no laparoscopic resection of a retrorecal teratoma was reported until 2008. Thus, we report the case of a 31-yr-old female patient who underwent a total laparoscopic excision for a matured cystic teratoma in the retrorectal space.

Citations

Citations to this article as recorded by

Laparoscopic Approach to Type IV Sacrococcygeal Teratoma in an Adult
Mehul V. Sukhadiya, Ushashree Das
Indian Journal of Surgery.2015; 77(S1): 62. CrossRef
Clinicopathological features of retrorectal tumors in adults: 9 years of experience in a single institution
Bong-Hyeon Kye, Hyung-Jin Kim, Hyeon-Min Cho, Hyung-Min Chin, Jun-Gi Kim
Journal of the Korean Surgical Society.2011; 81(2): 122. CrossRef
Multiple Presacral Teratomas in an 18-year-old Girl: A Case Report
Young Jin Park
Journal of the Korean Society of Coloproctology.2011; 27(2): 90. CrossRef

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