Rectal Involvement of Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder and is essentially a disorder of capillary, venous, and lymphatic malformations. Hematochezia is the most common symptom associated with intestinal hemangiomatosis and remains one of the life-threatening emergencies in KTS. We reported one patient of KTS presented with rectal bleeding and severe anemia who was successfully managed by sphincter-saving operation.

The Clinical Characteristics and Outcomes of Biofeedback Treatment for Patients with Nonrelaxing Puborectalis Syndrome

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

The Colorectal Cancer Risk of Meat Intake, Smoking, and CYP2E1 Polymorphisms: The Comparison of Colorectal Cancer Patients with Controls

PURPOSE: Genetic susceptibility for colorectal cancer is explained by polymorphisms of the drug-metabolizing enzymes. CYP2E1 activate the procarcinogens and they are involved in carcinogenesis. We analyzed the polymorphisms of CYP2E1 in colorectal cancer patients and the controls, and we examined the interaction between meat intake, smoking and CYP2E1 polymorphisms in colorectal cancer. METHODS: Polymerase chain reaction was performed for 96- bp insertion polymorphisms in 113 colorectal cancer patients and 110 controls. 80 cancer patients and 75 controls were interviewed for determining their meat intake and smoking behavior. We analyzed the clinical characteristics and the combined effect of meat intake, smoking and CYP2E1 polymorphisms on the susceptibility to colorectal cancer. RESULTS: The insert 0, insert 1 and insert 2 subtypes for the 96-bp insertion polymorphism were seen in 75 (66.4%), 35 (31.0%) and 3 (2.7%) cases, respectively, and in 82 (74.5%), 26 (23.6%) and 2 (1.8%), respectively. CYP2E1 polymorphisms didn't increase the colorectal cancer risk (OR: 1.5, 95% CI 0.3~10.1) in the insert 1 group and the insert 2 group. The combined effects of CYP2E1 polymorphisms, meat intake and smoking were not significant, (OR: 1.6, 95% CI: 0.4~4.7) in the low-meat intake group, the high-meat intake group, (OR: 0.4, 95% CI: 0.1~2.5) and in the smokers and ex-smokers (OR: 0.8, 95% CI: 0.3~2.3). CONCLUSION: The CYP2E1 polymorphisms, alone or combined with meat intake or smoking, did not increase the risk of colorectal cancer. Further well designed large scaled studies will be needed to determine the effects of CYP2E1 polymorphisms on colorectal cancer.

Distribution and Characteristics of Colorectal Polyps at Colonoscopy

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.

The Clinical and Physiologic Characteristics of Patients with Pelvic Outlet Obstructive Disease

PURPOSE: With recent anorectal physiologic studies, functional etiologies of pelvic outlet obstructive disease were evaluated in detail. The current study was designed to assess the clinical and the physiologic characteristics of patients with pelvic outlet obstructive disease. METHODS: one hundred two (102) patients with pelvic outlet obstructive disease were evaluated with anorectal physiologic studies, including the colonic transit time (n=66), anorectal manometry (n=88), defecography (n=102), anal sphincter EMG (n=50), and colonoscopy or barium enema (n=77). The patients were categorized as group I (nonrelaxing puborectalis syndrome), group II (rectocele), group III (sigmoidocele), and group IV (rectoanal intussusception). The clinical and the physiologic characteristics were compared between the groups. RESULTS: The mean age was 51.9 years, and the sex ratio was 1:1.9. the populations of the groups were group I 45.1% (n=46), group II 36.3% (n=37), group III 5.9% (n=6), and group IV 9.8% (n=10). In group II and group III, co-existing etiologies were more, and the incidences of female patients was higher (P<0.05). Delayed colonic transit time was noted in 11 patients (17%). Diverticula was observed in 6 patients (8%), polyps in 12 patients (16%), and melanosis coli in 14 patients (18%). On anorectal manometry, group I showed higher maximal voluntary contraction and mean squeezing pressure than the other groups (P<0.05). On defecography, group I had a shorter perineal descent at rest and a smaller anorectal angle at push (P<0.05). CONCLUSIONS: The current study showed the clinical and the physiologic characteristics of the each functional etiology in patients with pelvic outlet obstructive disease. These results provide fundamental data for diagnosis of and tailored therapy for pelvic outlet obstructive disease.

Safety of a One-stage Operation for an Obstructed Left Colon Carcinoma

PURPOSE: For a left-sided colonic obstruction, the traditional method of a staged defunctioning colostomy and resection has been performed. Recently, there has been a trend towards a one-stage primary resection and anastomosis. The aim of this study was to assess the safety and the efficacy of a one-stage resection and anastomosis for obstructed left colon cancer. METHODS: We retrospectively reviewed the records of 29 patients who had been diagnosed as having an obstructed left-sided colon cancer during the period from January 1995 to December 2003 at Ewha Womans University Hospital. We compared two techniques, a one-stage operation (10 cases) and a staged operation (13 cases). RESULTS: The mean age of the one-stage group was 58.5+/-16.1, and that of the staged operation group was 65.0+/-13.4. Both groups had similar co-morbidities, TNM stages, and tumor locations. In the one-stage operation group, a subtotal colectomy (n=3), a resection and anastomosis with intraoperative lavage (n=5), and a resection and anastomosis following stent insertion (n=2) had been performed. Patients who had undergone a colostomy as the first operation, resection and anastomosis (n=3), and a resection and anastomosis following a defunctioning colostomy (n=10) were included in the staged operation group. The mean postoperative hospital stay showed no significant differences between the two groups. One patient who had undergone a one-stage operation presented with an intestinal partial obstruction five months later. There were no anastomotic leakages, intraabdominal absceses, and wound infections, nor were there any mortalities. CONCLUSIONS: A one-stage resection and primary anastomosis for obstructed left-sided colon cancer can be done safely without significant morbidity.

Diffuse Colonic Infarction due to Multiple Mesenteric Embolism

Acute mesenteric ischemia and infarction is emergent situation associated with high mortality, arising from sudden loss of blood supply to mesenteric vessels. Most of all, the patients has cardiovascular insufficiency such as arrhythmia, recent myocardial infarction or valvular heart diseases. Acute abdominal pain is a main symptom and abdominal distension, rigidity, nausea and/or vomiting, and diarrhea are frequently observed. Delayed diagnosis and management are usually due to the nonspecific symptom and sign and lack of accurate diagnostic modality. A patient with acute abdominal pain having a history of cardiovascular disorders should be meticulously evaluated considering to exclude mesenteric vascular emergency. This dismal disease is mostly segmental ischemia of small bowel or colon due to occlusion of one mesenteric vessel, but occasionally multiple occlusions is are possible. We report a 67 years old female patient with diffuse colonic infarction due to multiple mesenteric embolism with review of literatures.

Relationship between Microsatellite Instability and Dihydropyrimidine Dehydrogenase Expression as a Predictor of Response to 5-Fluorouracil Chemotherapy for Colorectal Cancer

PURPOSE: Dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in 5-FU catabolism, so the enzymatic activity of DPD reflects the 5-FU response. Moreover, recent studies have revealed that microsatellite instability (MSI) status correlates well with the prognosis and the 5-FU chemosensitivity in colorectal cancer (CRC). This study aimed to determine whether DPD mRNA expression is related with the MSI status of primary CRC as a prognostic predictor. METHODS: Tumor samples and adjacent normal colonic mucosal tissues were collected from 59 patients. DPD mRNA expression was calculated by using the real-time RT-PCR method. The MSI status was examined by using multiplex fluorescent PCR with five reference markers. The results of DPD mRNA expression and MSI status were compared with the clinicopathologic variables and with each other. RESULTS: The mean age of the 59 patients was 59 (range: 36~81) years. In 55 patients (93.2%), the colorectal cancers were histologically well or moderately differentiated. Forty-nine of the tumors (49, 83.1%) were located distal to the splenic flexure, and 46 patients (78%) had TNM stage II (n=17) or stage III (n=29) cancer. The DPD mRNA expression level was informative in all 59 cases. The median expression level was 2.5 (range: 0~67.33). There was no correlation between the DPD mRNA expression level and age, gender, location, or TNM stage. MSI status was informative in 43 cases (72.9%). Thirty-six cases (36, 83.7%) were microsatellite-stable (MSS), 4 cases (9.3%) showed low-level microsatellite instability (MSI-L), and 3 cases (7.0%) showed high-level microsatellite instability (MSI-H). Proximal CRC showed a higher proportion of MSI-H than distal CRC (25% vs. 2.9%, P=0.03). We could not find any correlation between the DPD mRNA expression level and the MSI status in tumor tissues (r=0.29, P=0.09). CONCLUSIONS: The expression level of DPD mRNA raried among the tumors studied. The relatively low frequency of MSI in distal CRC prohibits the use of MSI status as a predictor of 5-FU chemosensitivity. We suggest that a well-designed large-scale study would be helpful to confirm the relation between DPD mRNA expression and MSI status as a predictor of 5-FU chemosensitivity in CRC patients.

Current Status of Stoma Researches in Korea

Stoma operations are one of the most frequently performed operation by the colorectal surgeons. And the consequences of the stoma operation of the patients are well known. However, most colorectal surgeons who performed stoma operation were not aware of the problems that are part of the rehabilitation of the ostomates. In order to elucidate the current status of the stoma studies in Korea, literature reviews were performed by using the Korean medical literature database. Most of the Korean literatures written by the colorectal surgeons are related with the postoperative complications of stoma surgeries. Very few papers are concerned with rehabilitation issues including postoperative adaptation of ostomates, quality of life, and stoma nursing care. Recently, more and more papers concerning the stoma rehabilitation issues were published and the interests in the patient's adjustment to a change in body function are growing. Stoma rehabilitation program should be the part of the nations' welfare program which would be successful with the active participation of the colorectal surgeons, enterostomal therapists and ostomates. We, colorectal surgeons, and the Korean Society of Coloproctology should do the major role in stoma-related researches and cooperate with the enterostomal therapists and ostomates organizations in order to establish and develop the stoma rehabilitation program in Korea.

Terlipressin Effect of Portal Pressure Control on Liver Regeneration in 90% Hepatectomized Rats

PURPOSE: Liver regeneration is crucial following major liver resection or partial liver transplantation. The inhibition mechanism of regeneration is portal hypertension caused by excessive portal flow to the small liver. Portal hypertension can be controlled with terlipressin, an effective splanchnic vasoconstrictor. The purpose of this study was to investigate the effect of terlipressin on the portal pressure and liver regeneration in 90% hepatectomized rats. METHODS: Forty-eight male Sprague-Dawley (250 gm) rats were divided into three groups; Group N (n=16) underwent Sham operation, Group C (n=16) was injected with 0.1 mL saline after 90% hepatectomy, and Group T (n=16) was injected with 50microgram/kg terlipressin after 90% hepatectomy. To assess the liver regeneration response, the changes in proliferating cell nuclear antigen (PCNA) and tumor necrosis factor-alpha (TNFalpha) were monitored for 48 hours. RESULTS: The baseline portal pressures in Groups N, C, and T were 4.9, 12.4, and 14.1 mmHg (P<0.05). In Group T, the injection of terlipressin induced a significant reduction of the portal pressure (-30.2%, P<0.05). There was no difference in PCNA between Groups C and T. However, serum TNFalpha levels were significantly higher in Group T (248.4 pg/ mL) than Group C (52.3 pg/mL) 48 hours postoperatively (P<0.05). CONCLUSION: The control of portal pressure with the use of terlipressin was correlated with serum TNFalpha. These data provide evidence that the administration of terlipressin during the early postoperative period following major liver resection may have an attenuating effect on portal hypertension, which may also stimulate the initiation of the regenerative process.

Local Resection for Treatment of Early Colorectal Cancer

PURPOSE: Early colorectal cancer is defined as invasive tumor, limited to the mucosa or submucosa. The incidence of early colorectal cancer detection has been increased due to well designed screening technology and development of colonoscopy. The novel treatment of early colorectal cancer is still not settled despite of this advancement. We performed retrospective study about outcomes of colorectal cancer after radical resection or local resection. METHODS: Sixty two patients, diagnosed as early colorectal cancers by pathology, were selected for this case study. The hospital records were reviewed retrospectively and the following was found: Twenty four patients received local resection such as colonoscopic polypectomy or local resection of colon. Remaining thirty-eight patients received radical resection. The clinicopathologic features of two groups were analyzed statically and survival rate was compared. RESULTS: The clinical features were similar between two groups including sex, age, stage, tumor size and differentiation. The median follow-up duration was 47.3 months (range: 2~152 months). Survival rate was not different according to resection type. Recurrent cases were one patient from each group. They were all submucosal tumors. CONCLUSIONS: The local resection is safe treatment modality for early colorectal cancer. However, case selection for local resection should be cautious because submucosal cases have more recurrent potential. Longterm follow-up will be needed to achieve safety of early colorectal cancer.

Accuracy of Preoperative Staging of Rectal Cancer: Comparative Study of Transrectal Ultrasonography and Computerized Tomography

PURPOSE: Preoperative assessment of the depth of invasion in the rectal wall and of lymph node metastases is very important in determining the treatment modality in rectal cancer. The purposes of study were to evaluate the accuracy of transrectal ultrasonography (TRUS) in preoperative staging of rectal cancer and to compare that accuracy with the accuracy for computed tomography (CT). METHODS: We reviewed 59 patients who were diagnosed as having rectal cancer and who had been staged by using TRUS and CT preoperatively. Ultrasonographic tumor (uT) and nodal (uN) stage and computerized tomographic tumor (cT) and nodal (cN) stage were entered into the database prospectively. The accuracy of each staging was compared with the pathologic staging. The accuracy, the sensitivity, the specificity, the positive predictive value, and the negative predictive value of each diagnostic test were calculated. Chi- square tests were conducted to identify the factors influencing the accuracy. RESULTS: The accuracies of TRUS and CT in assessing the depth of invasion were 66.1% and 62.5%, respectively. The accuracies of TRUS and CT in assessing the nodal involvement in patients treated with radical surgery were 70.4% and 63.6%, respectively. For detection of fat infiltration, the sensitivities were 97.4% for TRUS and 76.3% for CT. The specificities were 45.0% for TRUS and 55.6% for CT. The sensitivities for detection of lymph node involvement were 59.3% for TRUS and 42.9% for CT. The specificities were 81.5% for TRUS and 85.2% for CT. The gross appearance of the tumor had a significant influence on the assessment of the depth of invasion (P=0.015). In 9 out of 77 patients (11.7%) could not be performed the TRUS examination due to obstruction or the location of the tumor. CONCLUSIONS: In spite of some limitations, TRUS is considered a very useful tool in the preoperative assessment of the depth of invasion and of the lymph node involvement in rectal cancer. However, CT examination is mandatory to overcome the limitations of TRUS in the preoperative diagnosis of rectal cancers.

Impact of the Number of Nodes Examined on the Prognosis of Dukes B Colorectal Cancer

PURPOSE: Metastasis to the regional lymph nodes is the most important prognostic indicator in patients with colorectal cancer (CRC). The number of lymph nodes examined for adequate staging is still controversial. The aim of this study was to determine if the number of lymph nodes after curative surgery is associated with long-term outcome in patents with Dukes B CRC. METHODS: A retrospective analysis was performed in 174 consecutive patients with Dukes B CRC who underwent curative resection from 1990 to 1999. Patients were stratified according to the number of nodes examined as group A (less than 12 nodes) and group B (12 or more nodes). End-points were local and systemic recurrence and relapse-free survival. Comparisons between the groups were performed by Kaplan-Meier methods and chi-square test as appropriate. RESULTS: There were 115 men (66%). The mean number of nodes examined was 13.4 with the median of 11. No significant difference was found in the number of nodes examined between colon and rectum (16+/-10.6 vs. 13+/-10.0, P=0.675). However, the number of lymph nodes examined tends to be more in recent period of study and if the specimens were examined in the fresh status. With the median follow-up of 44 months, there were 5 local recurrences (2.9%), 22 systemic recurrences (12.6%), and 2 combined local and systemic recurrences (1.1%). Most of the recurrences were observed in group A (79%). The difference of 5-year relapse-free survival rates between the groups was also statistically significant (group A: 73.5%, group B: 91.7%, log-rank test, P=0.0114). The pT stage and number of lymph nodes examined were the independent variables associated with relapse-free survival in multivariate analysis. CONCLUSIONS: The number of lymph nodes examined has prognostic value in patients undergoing curative resection for CRC. Based on our analysis, we recommended at least 12 lymph nodes should be analyzed for accurate staging of CRC.

Association between Helicobacter pylori and Colorectal Neoplasm

PURPOSE: Helicobacter pylori infection has been reported as a major factor of chronic gastritis, peptic ulcer, gastric lymphoma, and stomach cancer. In some uncontrolled studies, a high seroprevalence of H. pylori infection unexpectedly has been found in patients with colorectal cancer. The purpose of this study was to investigate the prevalence of H. pylori infection in patients with colorectal neoplasm. METHODS: 93 colonic tissue samples were collected during the colonoscopic biopsy. The specimens included polyp, cancer, and normal colonic mucosa. The CLO testTM kit (Delta West Ltd., Bentley, Western Australia) was used for detection of H. pylori. The SAS program (USA) was used for the Fisher's exact test. RESULTS: H. pylori infection was detected 11 (11.8%) of total 93 specimens, 7 (25.7%) of 27 in cancers and 3 (6.9%) of 43 in polyps. Significantly higher H. pylori infection was detected in the colorectal cancers than non-cancer lesions (p=0.012) and polyps (p=0.038). CONCLUSIONS: These results suggest a statistically significant association between H. pylori and colorectal neoplasm. The mechanism underlying this association needs to be investigated.

Clinical Significance of Cyclooxygenase-2 Expression in Colorectal Adenoma and Carcinoma

PURPOSE: Interest is mounting in developing prevention strategies for patients at high risk of developing colorectal cancer. Recent epidemiological investigations indicate an inverse relationship between the intake of NSAIDs and colorectal cancer risk. Cyclooxygenase (COX) enzyme may be involved in the initiation and/or the promotion of carcinogenesis. A major action of NSAIDs is the inhibition of COX. We have studied the clinical significance of COX-2 expression in colorectal adenoma and carcinoma. METHODS: We studied 19 patients with colorectal adenomas (15 males and 4 females: ages 30~73 years) and 20 patients with colorectal carcinoma (12 males and 8 females: ages 35~80 years). COX-2 status were determined by immunohistochemical methods using the mouse monocolnal antibody for COX-2 (Transduction Lab, USA) on paraffin sections. RESULTS: Immunoreactive COX-2 were expressed in 9 patients (47%) of colorectal adenoma and 9 patients (45%) of colorectal carcinoma. 57% of villous adenoma and 42% of tubular adenoma were positive for COX-2 in colorectal adenoma (p=0.650). COX-2 were expressed in 12.5% of stage B and 73% of stage C of colorectal cancer (p=0.006). COX-2 expression did not relate with the size of adenoma and carcinoma. CONCLUSIONS: The data suggest that COX-2 may be more expressed in villous adenoma and advanced carcinoma. Therefore, enhanced expression of COX-2 may play a role in the carcinogenesis of colorectal cancer.

Sufficiency of Preoperative CT Staging of Colorectal Cancer?

PURPOSE: Establishing the preoperative stage of colorectal cancer is of primary importance in determining the management and the operative procedure. A comparative study of preoperative evaluation of colorectal cancer is necessary for proper management. METHODS: This study reports a 7 years' experience using another two species of CT for preoperative staging. One species of CT (1989, Delta 2060, Technicare, USA) was used from January 1990 to December 1992; the other species of CT (1992, Highlight Advantage, General Electric Company, USA) was used from January 1993 to December 1997. This study included retrospective analysis of 237 cases of colorectal cancer from January 1990 to December 1997. In first group, the preoperative stage evaluation was done with a much older species of CT from January 1990 to December 1992; in the other group, the preoperative stage evaluation was done with a newer species of CT from January 1993 to December 1997. RESULT: The accuracy & sensitivity of preoperative staging between the two groups showed no significant differences. CONCLUSION: CT is recommended in the preoperative staging of rectal cancer and as an aid in choosing the appropriate therapy. In addition to CT, transrectal ultrasonography and MRI are recommend for improving the accuracy of preoperative staging in assessing local invasion by cancer.

Comparative Study of Anatomic and Physiologic Measurement of the Anal Sphincter in Adult Women

PURPOSE: This study has carried out to clarify the relationship between changes in the anal sphincter muscle thickness and pressure. Also, this study shows the effect of vaginal delivery and benign anal disease on the function and structure of the anal sphincter. METHODS: Women (n=42; mean age: 33.2 +/- 9.6 years old) without defecation problems or history of anal surgery, who came to Ewha Womans University Hospital between July 1999 and October 1999, were chosen. We measured the resting and the squeezing pressure with anal manometry and the thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) by endoanal sonography. RESULTS: The mean squeezing and resting pressures were 98.3 +/- 38.2 and 53.9 +/-17.4 cmH2O, and the mean EAS and IAS thicknesses were 4.9+/-0.9 and 1.9+/-0.3 mm, respectively. The thickness of the EAS and squeezing pressure did not correlate. Neither did the IAS thickness and the resting pressure. In cases with a history of vaginal delivery (n=15), the squeezing and the resting pressures were 94.0+/-43.0 and 57.1+/-22.2 cmH2O, and the thicknesses of the EAS and the IAS, 4.6+/-0.9 and 2.0+/-0.4 mm, respectively. The number of deliveries had no correlation with the thickness or the pressure of the anal sphincter. In patients with benign anal lesions (n=11), the squeezing and the resting pressure was 113.0+/-42.9 and 57.0+/-14.0 cmH2O, and the thicknesses of the EAS and the IAS were 5.0+/-1.3 and 2.1+/-0.4 mm, respectively. CONCLUSION: Our data suggest that the function and the structure of the anal sphincter are independent. In adult women, the thickness of the anal sphincter, the history of vaginal delivery, and the existence of benign anal lesions had no effect on anal sphincter function.

Management of Complicated Diverticular Disease of the Colon

BACKGROUND: Colon diverticular disease is known to be prevalent in the western population and rare in the oriental population. Nowadays, the incidence in Korea is steadily increasing, so appropriate management has become clinically important. We must decide whether the patient needs surgical management and bowel preparation, or not. We must decide when and how to do it. METHODS: We retrospectively reviewed the medical records of 53 patients who were admitted with colon diverticular disease to Ewha Womans University Hospital from September 1993 to January 1999. RESULTS: They were 35 men and 18 women. The mean age was 47 years. The patients were divide into two groups: the conservatively managed group (Group C, n=28) and the operatively managed group (Group O, n=25). The lesions were located in the right colon in 23 cases of Group C (82%) and 17 cases of Group O (62%). The barium enema was the most commonly used diagnostic tool (Group C: 78.8%; Group O: 56%). However, an abdomino-pelvic CT was a more effective diagnostic tool in emergency cases (66.7%). Recurrence (n=12) was the most common indication for an operation. Bowels were not prepared in some elective (n=5) and all emergency cases (n=6). One-stage operations were performed in 19 cases of elective operations and in three cases of emergency operations. Two-stage operations were performed in the other three cases of emergency operations. Postoperative complications were noted in six cases of elective operation, four with bowel preparation (28.5%) and two without preparation (40.0%) and in five cases of emergency operations (83%). Also we had one mortality. CONCLUSIONS: The barium enema was the most accurate and commonly used diagnostic tool. However, in emergency cases, an abdomino-pelvic CT was effective for deciding on the treatment. It seems better to do an elective operation with bowel preparation than to do an emergency operation without bowel preparation for colon diverticulitis, provided the patient's condition permits.

Chemoembolization in the Treatment of Multiple or Unresectable Hepatic Metastases from Colorectal Cancer

BACKGROUND: Hepatic artery chemoembolization represents an alternative treatment for patients of metastasis or primary hepatic malignant lesions. The aims of this study was confirm the usefulness, the complications and the survival benefits of chemoembolization for patients with colorectal carcinoma metastasis to the liver. METHODS: During 3 years, 23 patients with multiple or bulky unresectable liver metastasis from colorectal cancer were treated with chemoembolization using adriamycin, cisplatin or mitomycin with lipiodol . Repeated treatments were perform at 6- to 8-week intervals. RESULTS: Hepatic metastases were detected at the initial diagnosis of colorectal cancer in 15 patients. The metastatic lesions included 7 cases of a single bulky lesion and 16 cases of multiple lesions. A decrease of at least 25% of the baseline CEA level occurred transiently in 43% of the cases. The median survival for all 23 patients was 10 months after initiation of chemoembolization, and the 1-year survival rate was 36%. Complications were liver abscesses with cholecystitis, thrombocytopenia, and ascites. CONCLUSION: Chemoembolization is feasible treatment modality for patients with multiple or un resectable hepatic metastases from colorectal cancer.

An Angiography Study of the Colon Artery from the Superior Mesenteric Artery

Incorporation of laparoscopic techniques into the gastrointestinal surgeon's armamentarium has led to a renewal of interest in the anatomy of mesenteric arteries because hemorrhagic complications can be a major cause of conversion and/or morbidity during laparoscopic intestinal surgery. BACKGROUND: Since a colonic resection with laparoscopic techniques has become a common procedure, the limited exposure currently provided in laparoscopic intestinal resection demands a precise knowledge of mesenteric vascular anatomy to avoid such complications and to expedite the procedure. Historically, It was thought that the arterial supply to the right colon consisted of three arterial branches (middle colic artery, right colic artery, ileocolic artery) arising independently from the superior mesenteric artery (SMA). However, on recent reports and clinical observations, two colonic arteries only arising independently from the SMA are more common than three colonic arteries. METHODS: We reviewed 40 cases of angiography which focused on the SMA and it's branches. RESULTS: We found the ileocolic artery in 39 of 40 cases, the middle colic artery in 39 of 40, and the right colic artery in 19 of 40. Based on the existence of the right colic artery in our review, about half (47.5%) of the cases had a right colic artery directly arising from this SMA. CONCLUSION: This knowledge may help lower the risk of vascular complications during laparoscopic intestinal surgery.