Perineal Rectosigmoidectomy with Levatoroplasty for Rectal Prolapse Early functional outcome

PURPOSE: This study was designed to analyze the short-term clinical and functional outcomes of perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. METHODS: The data were prospectively collected and consisted of the clinical data, the functional status before and after surgery, the operation record, and the postoperative course. The functional status was evaluated by using Wexner's constipation score (0-30), Wexner's incontinence score (0-20), anorectal manometry, and pudendal nerve terminal motor latency. Follow-up was performed at 3-6 months after the operation by using both a standardized questionnaire completed in the outpatient clinic or telephone interview (n=23) and an anorectal physiology test (n=7). RESULTS: During a one-year period, 23 patients (male=10) underwent perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. The median duration of the operations was 88 minutes. The median length of postoperative hospital stay was 6 days. There was one urinary tract infection and no mortalities. The constipation score was significantly decreased after the operation (9.8 vs 3.8; P<0.001), and constipation was improved in 90 percent (19/21) of the cases. The incontinence score was significantly decreased after surgery (mean preop.=11.6, postop.=3.7; P<0.001) and incontinence was improved in 17 of 21 patients with impaired continence (81 percent). Anal sphincter function was not improved but rectal reservoir capacity was significantly decreased after surgery (rectal urgent volume (45.7 cc vs 37.1 cc; P=0.045), maximal tolerable volume (120 cc vs 85.7; P=0.011). Most patients (83 percent) felt that the operation had improved their symptoms. The major reasons for dissatisfaction after surgery were frequent defecation, fecal soiling, persistent or aggravated fecal incontinence, and recurrence. One patient had a complete recurrence (4.3 percent), and another patient had a mucosal prolapse which was treated. CONCLUSIONS: Perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse is a safe technique with acceptable short-term functional results; however, it is not recommended for rectal prolapse patients with diarrhea-predominant irritable bowel syndrome.

Rectal Carcinoid: Effectiveness of Endoscopic Resection

PURPOSE: Small-sized carcinoids, less than 1 cm, are easily detected using flexible sigmoidoscopy or total colonoscopy and can be treated by local excision. Recently, there has been many advances in the technique of endoscopic resection. The aim of this study was to determine the endoscopic findings of a rectal carcinoid and to evaluate the effectiveness of endoscopic resection. METHODS: We experienced 22 rectal carcinoids in 21 patients who were treated by endoscopic resection from June 1996 to February 1999. Nineteen cases were followed for an average of 21 months. Follow-up studies consisted of chest P-A, hepatic ultrasonography, and total colonoscopy. RESULTS: The male-to-female ratio was 1.6 to 1. The most common age group was the 4th decade. The tumor was located at the lower rectum in 10 patients, at the upper rectum in 10 patients, and at the rectosigmoid junction in 2 patients. The tumor sizes ranged from 3 to 12 mm in diameter and were smaller than 10 mm in 20 cases (90.1%). Endoscopic finding revealed that the tumors were covered by a normally appearing mucosa in 12 cases, were yellow-discolored polyps in 17 cases, and were sessile-type tumors in 19 cases. The method of treatment was an endoscopic mucosal resection (EMR, 14 cases) or a snare polypectomy (8 cases). Microscopically positive margins were noticed in four cases, two cases of EMR (2/14, 14%) and two cases of snare polypectomy (2/8, 25%). All the patients were alive and clinically free of disease; however, the duration of the follow-up is short. CONCLUSIONS: Endoscopic resection for rectal carcinoid tumors smaller than 1 cm in diameter is a safe, functional, time-saving, and effective treatment. If the tumor suggests a carcinoid, EMR is advised rather than a polypectomy even though the tumor is small. Microscopically positive margins are not absolute indications for further surgery in the treatment of carcinoids smaller than 1 cm in diameter. It is much more important for an endoscopist to be confident that the endoscopic resection is done completely. It is necessary to identify the factors influencing the malignancy potential and to have a longer follow-up.

Topical Glyceryl Trinitrate (GTN) Versus Conservative Treatment (CT) in Chronic Anal Fissure: Prospective and Randomized Study

PURPOSE: This study was designed to compare the effect of treatment using glyceryl trinitrate (GTN) ointment with that of conservative treatment (CT) on chronic anal fissure. METHODS: As a preliminary study, maximal resting pressures of the anal canal were checked in 13 patients having chronic anal fissure before and 10 minutes after application of 0.2% GTN ointment. As the study groups, 59 patients having chronic anal fissure were randomly allocated to the GTN and the placebo groups. All the patients in both groups were given oral analgesics, sedatives, and bulk-forming agents. They had applied 0.2% GTN ointment or a placebo ointment three times a day to their perianal skin. Maximal resting pressures of the anal canal were checked at the beginning and at the endpoint of the treatment period which continued for 6 weeks. If there was complete healing of the fissure in the middle of the treatment, the treatment was stopped. Sixteen patients were lost during the study. RESULTS: Among the rest, 22 and 21 patients were included in the GTN group and the placebo group, respectively. The maximal resting pressure decreased significantly in all groups (p0.05). CONCLUSION: The effect of GTN on the symptomatic relief and results of treatment in patients having chronic anal fissure is not superior to that of conservative treatment.

Delayed Bleeding in a Colonoscopic Polypectomy: An experience with 5,236 polypectomies

PURPOSE: Delayed hemorrhage rarely happens after a colonoscopic polypectomy, ranging from 0.2 to 1.8% in frequency. Although its occurrence is unpredictable and it may be serious in some cases, scanty data on its causes, characteristics, and effective management exist in Korea. This study was conducted to provide such data, especially data on the characteristics of delayed hemorrhage and its effective management. METHODS: From 1997 to 1999, one endoscopist at Song-Do Colorectal Hospital performed 5236 polypectomies on 2511 patients. Delayed hemorrhage occurred after 9 of those polypectomies, for a bleeding incidence rate of 0.17% (9/5236). The authors reviewed those 9 incidence of delayed hemorrhage, which involved 9 patients and 9 lesions, with emphasis on the characteristics of the bleeding and the treatment. RESULTS: The mean age of the 9 patients was 50 years, and the male-to-female ratio was 8: 1. The sigmoid colon was involved in 4 of those patients (44.4%), and the right-sided colon was involved in another 4 of those patients. Lesions smaller than 11 mm were either sessile or flat-elevated and accounted for 6 of the 9 lesions (66.7%). The remaning lesions, which were larger than 10 mm, were either pedunculated or semipedunculated. Three (3) of the 9 patients (33.3%) experienced bleeding on day 1, the most common bleeding day. Another 5 patients (55.6%) experienced bleeding during the next 4 days (days 2 to 5). The last patient experienced bleeding on day 9, the latest bleeding day. A snare polypectomy had been performed on 7 of the 9 patients (77.8%), and a hot biopsy had been performed on the other 2 (22.2%). All delayed bleeding was treated by using hemoclips; additional epinephrine injection was used in 55.6% of the cases and an additional detachable snare in 22.2%. Rebleeding was noticed the day following the initial treatment of bleeding in one case and was managed by using hemoclips. CONCLUSIONS: The first 5 days after a colonoscopic polypectomy are crucial, and caution is required during the next 5 days. Thorough knowledge about preventing and managing bleeding is essential.

Clinical Application and Limit of Magnifying Colonoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Magnifying colonoscopy was developed for detailed examination of the surface of colorectal neoplastic lesions. While magnifying colonoscopy is useful for differentiating neoplastic lesions from nonneoplastic ones, for evaluating early colorectal cancers, it still has limits in practice. This study was designed to clarify the usefulness and the limits of magnifying colonoscopy. METHODS: Three hundred and fifty-two lesions, which were observed using magnifying colonoscopy from July to August 1999 and whose histologies were proven, were analyzed according to their pit patterns. The pit patterns are I, normal round pits; II, large starry-shaped pits; IIIs, small round pits; IIIL, large round or rod-shaped pits; IV, branched or gyrus-like pits; and V, irregularly shaped or nonstructural pits. In cases where a pit pattern was hard to read, the pattern was classified as 'D'. RESULTS: The dominant pit pattern for protruded lesions was IIIL, accounting for 44.6%. In diminutive lesions (< or =5 mm), II and IIIL were equally common, 40% of the total for those lesions, respectively. In medium-sized lesions (from 6 to 10 mm), IIIL was the major pit pattern, 45.6% of the total for that type of lesion. In lesions larger than 10 mm, IIIL and IV were the most common pit patterns, each accounting for 26.7% of the total. The overall accuracy ratio of pit pattern diagnoses was 79.5%. The frequency of difficult pit patterns to read was 6.3%. Among them, 77.3% were due to difficulty in interpreting the pit patterns, and 22.7% were due to an inability to clarify the pit pattern because of poor staining. Ninety-one percent of the difficult cases to read involved diminutive lesions, and 86% of those difficult cases involved tubular adenomas. CONCLUSIONS: The 80% accuracy rate for pit pattern diagnosis suggests that magnifying colonoscopy is probably useful, but problems, such as poor staining due to mucus and difficulty with interpretation, still exist.

Diagnosis and Treatment of Depressed Colorectal Neoplastic Lesion

PURPOSE: Depressed colorectal cancer is a newly recognized colorectal cancer. It has the characteristics of rapid growth and early invasion of the submucosa. Accordingly, recognition of that lesion is important. However, it is still rarely detected in Korea. This study was designed to evaluate the characteristics of depressed colorectal neoplastic lesions. METHODS: We experienced 22 cases of depressed neoplastic lesions from January 1997 to December 1998. All of them were detected by performing colonoscopy. Among them, 6 were early colorectal cancers. The twenty-two cases accounted for 1.3% of all neoplastic lesions but advanced colorectal cancers encountered during the same period, and the six accounted for 6.6% of all early colorectal cancers during that period. We reviewed and analyzed those 22 lesions with respect to their clinicopathologic characteristics, especially size and histology. RESULTS: The most common age group was the 6th decade. The male-to-female ratio was 2.7 to 1. The predilection of sites were the descending colon, the transverse colon, and the sigmoid colon in that order. The most common size was 3~4 mm, 9 lesions (40.9%) and the next was 5~6 mm, 7 lesions (31.8%). Twenty lesions (90.9%) were 8 mm or smaller in size. The overall malignancy rate was 27.3% (6/22), comprising 9.1% (2/22) for mucosal cancers, and 18.2% (4/22) for submucosal ones. The two lesions which were larger than 10 mm were submucosal cancers. Endoscopic mucosal resection (EMR) was the most common type of treatment, accounting for 59.1%. Two submucosal cancers and one mucosal cancer were operated on without any endoscopic treatment. That one mucosal cancer had initially been suspected of being a submucosal one upon endoscopic examination. There were neither complications nor recurrences during the average 10-month follow-up. CONCLUSIONS: The target for detecting and treating depressed colorectal cancer should be lesions below 10 mm in size, and the treatment of choice should be EMR.

Availability of Flexible Sigmoidoscopy for Outpatients, Inpatients,and Mass Screening at a Proctologic Clinic

PURPOSE: The clinical guidelines and rationale published by the American Gastroenterological Association in 1997 recommended that it is not necessary to screen patients in the average risk group who are below the age of 50. The purpose of this study was to evaluate both the effectiveness of flexible sigmoidoscopy (FS) as a diagnostic and screening tool and the utility of screening at an age earlier than 50 years. METHODS: From Jan. to Dec. 1997, FS was used in 8964 cases. These cases were divided into three groups: Group A, 1336 outpatients; Group B, 5308 cases involving a hemorrhoidal operation; and Group C, 2320 cases of mass screening. RESULTS: The mean age was lower in Group B (42.4 11.5) than in Group A (47.0 14.5) and Group C (46.1 10.7). The incidences of cancer, inflammatory bowel disease (IBD), and nonspecific proctocolitis in Group A were significantly higher than they were in Groups B and C, and the FS findings in Groups B and C were similiar. The locations of the polyps, cancer, IBD, and nonspecific proctocolitis were below the left colon in 91.9% cases involving an abnormal finding. Also, the locations of polyps and IBD determined by using FS and by using colonoscopy (CS) were not very different. About two-thirds of the carcinomas found by using FS in all three groups were located in the upper rectum and the sigmoid. In Group B, the FS findings did not depend on whether or not an enema had been administered. Also, the total incidence of cancer in patients less than forty years of age was nearly the same as the incidence of cancer in Group B and the incidence of cancer in Group C. CONCLUSIONS:The risk of cancer for patients in the average risk group who are under 50 years of age should not be underestimated. FS is effective not only for the diagnosis of colorectal disease but also as an initial screening technique for patients below forty years of age.

Clinical Analysis of Ulcerative Colitis

Ulcerative colitis is increasing now in Korea, and the diagnosis has become relatively easy because sigmoidoscopy and colonoscopy are frequently used. However, the result of treatment is not satisfactory because the relapse rate is very high. Hence, the aim of treatment is to put this disease into remission as soon as possible and to keep it in remission. The authors reviewed 80 confirmed ulcerative colitis cases which were treated from Feb. 1997 to Sep. 1997 at Song Do Colorectal Hospital. The results are as follows: 1) The male to female ratio for these 80 cases was 41:39, and the most prevalent age group was the 4th decade. 2) The most common clinical symptoms were anal bleeding in 77 cases(96%), diarrhea in 68 cases(85%), and abdominal pain in 21 cases(26%). 3) The extension of the disease were the proctitis in 47 cases(59%), the left - side colitis in 28 cases(35%), the total colitis in 4 cases(5%), and the atypical colitis in 1 case(1.3%). 4) The duration of the disease was below 6 month in 30 cases, 6 months to 1 year in 35 cases, and 1~5 years in 11 cases, and over 5 years in 4 cases. 5) Clinical types were the one-attack-only type(18 cases), the relapsing-remitting type(60 cases), the chronic continuous type(1 case), and the acute fulminating type(1 case). 6) In the 28 cases of left side colitis, the average time to remission depended on the medication was 18 days for a 5-ASA 5-ASA suppository, 14.5 days for a 5-ASA oral steroid, and 8.3 days for a 5-ASA budesonide enema. Thus, a budesonide enema is the most effective medication for obtaining remission. 7) The most commonly suspected predisposing factors for relapse were cessation of medication(58 cases), mental stress(18 cases), physical stress(15 cases), and inadequate diet(8 cases). As indicated above, ulcerative colitis is increasing now in Korea, and the rectum is the most commonly involved site for this disease. Relapsing-remitting ulcerative colitis is the most frequently occurring type. Almost all cases were easily put into remission within 4 weeks, but relapse frequently occurred. Suspected predisposing factors, such as mental stress, physical stress, and inadequate diet, should be avoided in order to prevent relapse, and medication, such as 5-aminosalicylic acid, should be continued to maintain remission.

Intraoperative Muscular Injection of Tarasyn(R) for Postoperative Hemorrhoidectomy Pain Management

The pain after a hemorrhoidectomy is widely feared by many patients who are mostly still treated with oral/intramuscular narcotics to control their pain postoperatively. In an effort to decrease posthemorrhoidectomy pain by applying newer methods of analgesia, a prospective trial was conducted to investigate the postoperative analgesic effect of Tarasyn(R) (ketorolac tromethamine) injected into the internal sphincter muscle at the time of the hemorrhoidectomy. Tarasyn(R) is a nonsteroidal anti-inflammatory drug introduced for intramuscular injection to control postoperative pain. It's action is peripheral. Therefore, it seems appropriate to inject it directly into the anal sphincter muscles when these are exposed during anorectal procedures. A total loading dose of 60 mg(2 cc, 30 mg/ml) of ketorolac was used intraoperatively. It was injected intramuscularly locally after completion of hemorrhoidectomy. Postoperative pain after a hemorrhoidectomy can be safely controlled in a patient by using newer methods of pain control, including supplemental use of the nonsteroidal analgesic ketorolac, which allows early release of the patient, the day of surgery by diminishing the postoperative pain in our study group. Another important advantage of a local injection of ketorolac was the elimination of urinary retention.

Tubulovillous and Villous Adenomas of the Colon and Rectum - Endoscopic Characteristics and Management / 대한소화기내시경학회지

BACKGROUND/AIMS: A villous tumor, histologically villous or tubulovillous adenoma, is a clinical challenge because of its higher potential for malignancy and higher recurrence rate. However, information and experience with these tumors in the Korean people is still lacking. For that reason, we designed this study to review and analyze the colonoscopic features, the potential for malignancy, and the treatiment with respect to the confirmation of guidelines for the accurate diagnosis and reasonable management of such tumors in the Korean population. MATERIALS AND METHODS: We performed 753 polypectomies, including 4 transanal excisions and several bowel resections, from January 1996 to May 1997 at Song-Do Colorectal Hospital in Seoul, Among them, 447 cases (59.4%) were adenomas, comprising 405 (53.8%) tubular adenomas, 31 (4.1%) tubulovillous adenomas, and 11 (1.5%) villous adenomas. We analyzed the 42 (5.6%) tubulovillous and villous adenomas.