Clinical Study and Review of Articles (Korean) about Retrorectal Developmental Cysts in Adults

PURPOSE: A retrorectal developmental cyst (tailgut cyst, epidermoid cyst, dermoid cyst, teratoma, and duplication) is very rare disease, and the symptoms are not characteristic so that sometimes this disease is still misdiagnosed as a supralevator abscess or a complex anal fistula. We would like to present a clinical approach to this disease. METHODS: We retrospectively examined the charts of 15 patients who were treated for retrorectal cysts from January 2001 to November 2009. RESULTS: All 15 patients were female. The average age was 41 years (range, 21 to 60 years). Fourteen patients (93.3%) were symptomatic, and the most common symptom was anal pain or discomfort. Nine patients (60%) had more than one previous operation (range, 1 to 9 times) for a supralevator abscess, an anal fistula, etc. In 12 patients (80%), the diagnosis could be made by using the medical history and physical examination. Thirteen cysts (80%) were excised completely through the posterior approach. The average diameter of the cysts was 4.8 cm (range, 2 to 10 cm). Pathologic diagnoses were 8 tailgut cysts (53.3%), 5 epidermoid cysts (33.3%) and 2 dermoid cysts (13.3%). The average follow-up period was 18.3 months (range, 1 to 64 months). CONCLUSION: In our experience, high suspicion and physical examination are the most important diagnostic methods. If a female patient has a history of multiple perianal operations, a retrorectal bulging soft mass, a posterior anal dimple, and no conventional creamy foul odorous pus in drainage, the possibility of a retrorectal developmental cyst must be considered.

Four Cases of Postoperative Sclerosing Mesenteritis

Mesenteric panniculitis is an extremely rare inflammatory condition of the adipose tissue of unknown etiology. It is characterized by extensive, progressive fibrosis of the mesenteric fat tissue, leading to tumor formation. Clinical manifestations vary according to the process involving the structures. Abdominal pain accompanied by nausea, malaise, pyrexia, and weight loss and a poorly defined mass are common presentations. Major pathologic changes include (1) degeneration of mesenteric fat, (2) an inflammatory reaction, and (3) fibrosis of the adipose tissue. We present four patients with an aggressive form of mesenteric pannicultis with characteristic histopathologic features. We discuss the relationship between the histopathologic features and the surgical intervention in these cases.

Current Trend of Inflammatory Bowel Disease

PURPOSE: Inflammatory bowel disease (IBD) has steadily increased, according to westernized life style, popular use of colonoscopy, and development of pathology and diagnostic radiology. However, there is no avaliable data about epidemiology of IBD in Korea. Even though our data is not a standard of IBD patients in Korea, it is possible to understand the trend of IBD. METHODS: From Jan. 1995 to Dec. 2000, cases of ulcerative colitis (UC), Crohn's disease (CD), and indeterminate colitis (ID) were evaluated retrospectively. Annual incidence of IBD at our hospital was calculated with using new IBD patients/new out-patients. To compare the incidence of CD with that of intestinal tuberculosis (TB), intestinal TB cases from Jan. 1997 to Dec. 2000 were evaluated. RESULTS: Total number of IBD patients was 651: UC (480, 73.7%), CD (149, 22.9%) and ID (22, 3.4%) in order of frequency. Male was more prevalent than female (1.2:1), especially in CD (2.5:1). However, there was no difference of sex in UC. Mean age was 37.9 ( 14.1) years old, ranging from 11 to 79. CD patients (25.1 9.4) were younger than UC (41.9 13.0). Incidence of IBD out of new out-patients increased annually:0.30% (53 cases) in 1995, 0.31% (67 cases) in 1996, 0.37% (99 cases) in 1997, 0.38% (100 cases) in 1998, 0.54% (158 cases) in 1999 and 0.58% (174 cases) in 2000. The most common types of UC and CD were proctitis (52.3%) and ileocolic type (59.7%), respectively. Incidence of CD was more prevalent than that of intestinal TB (2.5:1). CONCLUSION: About 0.5% of new out-patients had IBD and the number of patients of IBD increased annually. CD patients were younger than those of UC and male was predominant. The number of patients with CD exceeded that of intestinal TB patients.

Clinical Significance of Depressed-Type Colorectal Neoplasms Based on Growth and Development

A route of colorectal cancer development other than the adenoma-carcinoma sequence has recently become an issue due to the discovery of depressed-type early colorectal cancers. Moreover, the fact that some polyp-like cancers actually originate from depressed-type lesions has become obvious. Despite the protruding shapes of depressed-type early colorectal cancers, they probably have biological characteristics, which are different from those of the usual polyp lesions. We undertook this study to evaluate the clinical significance of depressed-type colorectal neoplasms. The authors recently experienced 87 cases of depressed-type colorectal neoplasms. Using Kudo's classification, we classified these 87 cases into three types based on their growth patterns, type IIc, type IIa + IIc, and type Is + IIc, and then analyzed these types on the basis of size, type, and submucosal invasion rate. The submucosal invasion rate of cancers of type IIa + IIc was significantly higher than that of type IIc (p < 0.05), and the rate for cancers of types IIa + IIc and Is + IIc together was significantly higher than that of type IIc (p < 0.05). However, no significant difference was found between the rates of types IIa + IIc and Is + IIc. In conclusion, the IIa + IIc and Is + IIc sub-types of depressed-type colorectal neoplasms, individually and together, have higher rates of submucosal invasion than type IIc lesions. Accordingly, type IIa + IIc and type Is + IIc must be differentiated from the usual polyps and should be managed cautiously, despite their protruding shapes.

Duplication of the Transverse Colon: A Case Report

Duplications of the alimentary tract are rare congenital malformations and accurate diagnosis is difficult. Duplications can occur at any level in the gastrointestinal tract. Ileal duplications are the most common while colonic duplications are rare. Duplications are usually single, vary widely in size, are more often spherical than tubular and are lined by alimentary tract mucosa. They usually share a common smooth muscle wall and blood supply with the adjacent bowel, with which they may be communicated. Some duplications are asymptomatic but more than 80% of cases present before age of 2 years. Recently, we have experienced a case of duplication of the transverse colon in 9-year old female patient without any other combined anomaly. The chief complaint were palpable abdominal mass, defecational difficulty and intermittent cramping pain of abdomen. The duplication of the transverse colon was diagnosed at operation. A left hemicolectomy was performed with complete resection of duplicated bowel. We report a case of colonic duplication and review the literature.

The Clinical Features and Charateristics of anal Cancer Arising from Chronic Fistula-in-ano

PURPOSE: The incidence of unhealed chronic fistula is about 7% and the cancer can occur in the longstanding unhealed fistula. The most of the cancer is mucinous adenocarcinoma. The report is diverse about treatment, adjuvant chemotherapy and prognosis. The purpose of this study is review of the clinical characteristics and survival of the anal cancer arising from chronic fistula-in-ano. METHODS: The number of patients was 10. The diagnosis is made under pathological examination at the Kanbuk Samsung Hospital from 1983 to 2000. The retrograde study was done with patients' records and telephone questionnaire. The survival rate was calculated with Kaplan-Meier method. RESULTS: All patients were male. The patients had symptoms of anal discharge and anal swelling suggesting the anal fistula. The patients had history of anal surgery. The external openings were multiple. Seven patients had mucinous adenocarcinoma. The prognosis was poor. Among 8 patients' follow-up data, except one patient, 7 patients died within 43 months. CONCLUSIONS: The anal cancer can occur in longstanding unhealed fistula. In our series, all patients were male, and they had multiple opening fistula. The patient who had small size tumor have only survived. Through meticulous exploring and deep biopsy of the fistula, early detection is best method to treat the anal cancer arising from chronic fistula-in-ano.

Outcome and Preoperative Predictive Factor after Complete Anatomical Repair in Perineal Obstetric Injury

PURPOSE: To assess the outcome of complete anatomical repair (sphincteroplasty, rectal wall plication, rectovaginal septum plication, perineal body repair, levatoroplasty) and to identify the preoperative factors influencing the outcome for the perineal obstetric injury. METHODS: Eighteen, consecutive female patients who had undergone complete anatomical repair with chronic fecal incontinence due to perineal injury during 13 months were evaluated. Mean age was 48.9+/-10.1 years, mean duration of symptom was 18.9 (range: 1-33) years, mean delivery numbers were 2.8 +/-1.2 times, and mean follow up was 11.9 +/- 4.7 months. The predictive factors were age, manometry, PNTML (pudendal nerve terminal motor latency), rectal sensation, RAIR (rectoanal inhibitory reflex), duration of symptom, angle of sphincter defect, vaginal delivery numbers, hospital stay, follow-up period, wound healing period, and Wexner's incontinence score. RESULTS: The anatomical success rate via endoanal ultrasonography was 100%, complication rate was 5.5%, and functional success rate (Wexners' score < or =5) was 88.9%. The patients showed lower maximal resting pressure, maximal squeezing pressure, maximal voluntary contraction, mean resting pressure, mean squeezing pressure, and maximal tolerable volume than the normal control group (p<0.05). The median incontinence score was significantly decreased after surgery (pre op=12.2 vs post op=2.9) (p<0.05). Among the preoperative predictive factors, the incontinence score correlated significantly with postoperative functional success (r=0.552, P=0.017). CONCLUSIONS: Complete anatomical repair showed an excellent anatomical result and a good functional outcome. Patient with high preoperative incontinence score had a tendency for postoperative residual incontinence.

Difference between Genders in Patients with Obstructive Defecation: Analysis of 1,513 Defecograms

PURPOSE: The aims of this study were to find the difference in frequency between genders and to determine the correlation between age-related disease and other diseases in obstructive defecation. METHODS: A consecutive series of 1,513 patients (343 males, 1,170 females) with obstructive defecation who undertook defecography and/or cinedefecography during 1 year period was analyzed. RESULTS: The causes of obstructive defecation in males showed as spastic pelvic floor syndrome (SPFS) (48.3%), rectal prolapse (RP) (31.4%), descending perineum syndrome (DPS) (25.9%), enterocele or sigmoidocele (7.6%), and rectocele (7%). However, in females, the causes were rectocele (83.8%), DPS (49.2%), RP (37.6%), SPFS (32.5 %), and enterocele or sigmoidocele (11.2%). The SPFS was negatively correlated with enterocele or sigmoidocele, DPS, RP in both genders, but SPFS had no statistical correlation with rectocele. DPS was correlated with RP in both genders and with enterocele or sigmoidocele in females, but no statistical correlation was seen in males. The size of the rectocele showed a slight correlation with age in females (r=0.102, P=0.01). Age was correlated with rectal prolapse in females; however, it showed a negative correlation with SPFS in females. CONCLUSIONS: The frequency of diseases causing obstructive defecation is different between genders. Age may not play a role in aggrevating the diseases causing obstructive defecation. Further pathophysiologic study of gender differences in patients with obstructive defecation is needed.

Laparoscopic Suture Rectopexy for Rectal Prolapse

PURPOSE: This study was undertaken to eveluate the early results of the laparoscopic suture rectopexy in the treatment of rectal prolapse. METHODS: From May 1999 to July 2001, laparoscopic suture rectopexy (LSR) was successfully performed in 26 patients and the results were compared to those of 5 patients with open suture rectopexy (OSR) and 6 patients with open resection rectopexy (ORR). Preoperative and postoperative functional assessment included Wexner's incontinence score, constipation score, and anorectal manometry. RESULTS: Immediate postoperative morbidity was minimal in all groups. Bowel function was resumed significantly sooner (P=0.001), the numbers of the analgesics injection were significantly fewer (P<0.001) and postoperative hospital stay was significantly shorter (P<0.001) in the LSR than in the open groups. Postoperatively, the anal resting and squeezing pressures increased slightly and Wexner's incontinence score decreased significantly in all groups of patients. Constipation score decreased slightly in all groups of patients after surgery. There was one mucosal prolapse recurrence after surgery in the LSR. CONCLUSIONS: Laparoscopic suture rectopexy for rectal prolapse can be performed safely. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Functional results are obtained similarly with both approaches.

Significance of Subclassification of Depressed-Type Early Colorectal Cancer Based on Growth and Development

PURPOSE:Recently it became obvious that some early cancers which appeared to be polyp lesions had actually originated from depressed-type lesions. The aim of this study was to clarify both the characteristics of depressed- type early colorectal cancers compared with protruded- or flat-type ones and the significance of a subclassification of depressed-type early cancers. METHODS:The authors experienced 248 early colorectal cancers from 1996 to 2000. We classified those cancers into protruded, flat, and depressed types based on growth and development. Further, we used Kudo's classification to subclassify the depressed-type cancers into three sub-types, IIc, IIa+IIc, and Is+IIc. We analyzed the 248 cases with emphasis on size, type, sub-type, and submucosal cancer (sm) rate. RESULTS:The sm rate of the depressed cancers was 81.8% (18/22) and was significantly higher than those of the protruded (30.5%) or the flat (38.5%) types (P<0.05). The sm rate of the depressed lesions not larger than 10 mm was 70% (7/10) and that of the lesions from 11 mm to 20 mm was 91.7% (11/12); there were no depressed cancers larger than 20 mm in diameter. The sm rate of the type IIa+IIc plus type Is+IIc lesions was higher than that of type IIc lesions (93.3%, 14/15 vs. 57.1%, 4/7). Endoscopic resection was done in 74.2% of all early colorectal cancers. CONCLUSIONS:The sm rate of depressed-type early colorectal cancers was 82%, and no depressed cancers were larger than 20 mm in diameter, suggesting that by the time a depressed-type cancers had become larger than 20 mm in size, it had already progressed into an advanced cancer. Thus, it is very important to detect depressed-type cancers in an early stage. Moreover, it is imperative to differentiate type IIa+IIc and type Is+IIc from polyp lesions and to manage them cautiously because their sm rate is higher than that for type IIc lesions.

A Case of Granular Cell Tumor in the Perianal Region

Since granular cell tumor was first described by Abrikossoff in 1926, it has been known as a rare disease. The histogenesis of this tumor is still controversial, but the origin is thought to be from a Schwann cell. About one third of the tumors occur in the tongue, and uncommonly in the perianal region. We report a case of granular cell tumor that developed in the perianal region. The tumor grew slowly for 5 years and was removed by a local excision. This tumor showed positive staining with neuron-specific enolase (NSE).

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.

Factors Influencing Fecal Incontinence in Complete Rectal Prolapse: A Prospective Analysis

PURPOSE: This study was undertaken to identify factors influencing fecal incontinence in rectal prolapse. METHODS: The clinical and anorectal physiologic data (anal manometry, rectal sensitivity test, pudendal nerve terminal motor latency (PNTML)) of 42 complete rectal prolapse patients were collected in a prospective database and were analyzed according to Wexner's incontinence score (0-20). RESULTS: The mean Wexner's incontinence score was 10.6. Females (n=24) were more prone to be incontinent than males (n=18)(incontinence score 14.8 vs 5.1, p<0.001). A linear regression analysis showed that increased age (r= 0.497, p=0.001), decreased maximum resting pressure (MRP) (r= 0.686, p<0.001), decreased maximum squeezing pressure (MSP)(r= 0.789, p<0.001), decreased maximal rectal tolerable volume (MTV) (r= 0.386, p=0.012) influenced the incontinence score. An absent rectoanal inhibitory reflex (RAIR) was not related to incontinence, but was related to significantly low resting anal pressure. Delayed PNTML did not influence incontinence or the MSP. In a multiple regression analysis, decreased MRP (beta= 0.383; p=0.002), decreased MSP (beta= 0.345; p =0.007) and female gender (beta=0.343; p=0.006) influenced incontinence significantly. CONCLUSIONS: Major factors influencing fecal incontinence in complete rectal prolapse were decreased MRP and MSP. Female patients were more prone to fecal incontinence than males. RAIR and MTV were not significant factors. PNTML did not show any relation to incontinence score or the anal pressure.

Clinical Aspects and Surgical Methods in Perianal Hidradenitis Suppurativa

PURPOSE: Hidradenitis suppurativa is a chronic suppurative and cicatricial inflammatory disease involving apocrine gland- bearing areas including the axilla, groin, and anogenital regions. Recurrence after surgery is not rare, and there is much debate about operative methods. This study analyzed the clinical characteristics and the relationship between different surgical methods and recurrences of perianal hidradenitis suppurativa. METHODS: A retrospective study of 20 patients with perianal hidradenitis suppurativa was done. The clinical characteristics were examined. The patients were divided into several groups (acute, chronic regional, chronic extensive) according to lesion status; then, different operative methods and recurrence rates were compared. RESULTS: All of the patients were male smokers. The mean age of onset was 28.4 years. The mean duration of disease was 10 years. The total number of operations, including incision and drainage, was 29 cases. Only 4 patients were overweight or obese. The most common symptom was pus discharge (52%). The recurrence rate after final surgery was 30.0%. After incision and drainage in the acute group, 7 of 8 cases (87.5%) recurred. In the chronic regional group, 5 of 9 cases (55.6%) experienced recurrence after excision and primary repair. After excision and healing by secondary intention, 1 of 7 cases (14.3%) had recurrence. In the case of one unroofing and marsupialization, there was no recurrence. In the chronic extensive group, 1 recurrence was noted in 4 unroofings and marsupializations. CONCLUSIONS: In the case of abscess, proper incision and drainage is needed, but further definitive surgery must be done. In the case of chronic disease, if the lesions are regional, excision and healing by secondary intention is more ideal for decreasing the recurrence rate. If the lesions are extensive, unroofing and marsupialization is recom-mended.

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.

Clinical and Physiologic Characteristics of Rectal Prolapse in Males

This study compares the sexual differences among rectal prolapse patients regarding the clinical and the physiologic characteristics with emphasis on males. METHODS: The clinical data, functional status and operative records of 43 patients, who had completed both clinical and functional evaluations were collected in a prospective database and were analyzed according to sex. The functional status of the patients was evaluated by Wexner's constipation score (0~30), Wexner's incontinence score (0~20), anorectal manometry, and pudendal nerve terminal motor latency (PNTML). RESULTS: The incidences of rectal prolapse in males (n=22) and in females (n=21) were similar. The age of onset for males was lower (mean standard deviation, 19.6 19.59 (50% in childhood) vs 52.0 20.75 years; p=0.001) and the duration of symptoms was longer (31.5+/-19.87 vs 12.5+/-14.31 years; p<0.001). Surgery in males was most commonly performed during the sexually active years (51.2+/-16.34 vs 64.5+/-13.19; p=0.006). The incidence of mucosal prolapse in males was higher (10/22 vs 4/17; p=0.065). The incidences and the severities of defecation difficulty in males and females were similar (n=12, mean Wexner score=8.4 vs n=12, mean Wexner score=9.9; p=NS) but, the incidences and the severities of fecal incontinence were lower in males (n=4, mean Wexner score=4.3 vs n=17, mean Wexner score= 14.2; p<0.001). The maximum resting pressure was higher in males (39.2+/-21.46 vs 26.3+/-19.98 mmHg; p=0.049), and the maximum squeezing pressure was better preserved (131.2+/-62.63 vs 67.5+/-37.99 mmHg; p<0.001). No significant difference existed in the PNTML. Female patients underwent abdominal resection rectopexy (n=6), perineal rectosigmoidectomy with lavatoroplasty (n=11), and Delorme's procedure (n=4), but all male patients preferred the perineal approach (rectosigmoidectomy with lavatoroplasty (n=8), Delorme's procedure (n=14)) for fear of sexual dysfunction after the abdominal approach. CONCLUSIONS: These findings suggest that the mechanism for developing rectal prolapse in male and female may be different and that surgical treatment should be tailored to the patient.

Investigation of Skip Lesion at the Appendiceal Orifice in Ulcerative Colitis

BACKGROUND: Generally ulcerative colitis has a character that has a continuous pathological lesion from the rectum toward the cecum. Ulcerative appendicitis with a skipped appendiceal orifice lesion, which is unusual in ulcerative colitis, has been infrequently reported, and its clinical characteristics have not been identified. PURPOSE: This study was carried out to evaluate the incidence rate and the clinical characteristics of ulcerative appendicitis. METHODS: One hundred consecutive patients with ulcerative colitis who had been treated from Jan. 1997 to Aug. 1998 at Song-Do Colorectal Hospital were used for the study. Data evaluated included age, sex, involved site, clinical type, clinical severity of the disease, and endoscopic severity of the disease. RESULTS: Nineteen (19%) of the 100 patients had skipped lesions around the appendiceal orifice; the other 81 did not. There were no significant differences between these two groups with respect to the age and the sex distributions, the involved site, the clinical type, and the clinical severity. There was a correlation between the endoscopic grades, based on the Riley classification, of the lesions at the rectum and at the appendiceal orifice. Seven patients (36.8%) of the 19 patients with appendiceal orifice lesions showed an extended lesion from the appendiceal orifice to the cecum. CONCLUSIONS: We suggest that appendiceal lesions in ulcerative colitis are not infrequent. Even though no significant differences in the clinical characteristics of ulcerative colitis with ulcerative appendicitis, compared with those of ulcerative colitis without ulcerative appendicitis, were found, we suggest that more profound study of ulcerative appendicitis probably contribute to understand the pathophysiology of ulcerative colitis.

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.

Colorectal Cancer in Young Adults

Colorectal cancer(CRC) is the most common gastrointestinal malignancy in the Western world. The total number of CRC cases in Korea is increasing probably due to western-style diets. CRC is relatively uncommon in the young adult group. Nevertheless, these cases warrant special attention because they are often diagnosed in an advanced stage and are more likely to involve a family history of CRC. Controversies still exist over the determination of the age range and over the true value of age factor in the prognosis for the young adults. The aim of this study is to calculate the incidence, to evaluate the clinicopathologic characteristics and the outcome of management of young adult with CRC. A retrospective review of 864 patients with an adenocarcinoma of the colon or rectum, who were surgically treated and followed-up in our Department of the Kang Buk Samsung Hospital, Sung Kwun Kwan University College of Medicine, Seoul, Korea, between January 1970 and December 1995 was performed. Among these patients, 138 were in the young adult group, aged less than 40. All cases accompanied by familial adenomatous polyposis coli and ulcerative colitis were excluded. Young adults accounted for 16.0% of all patients with CRC, showing no significant sex difference compared with the control group. The rectum and sigmoid colon were the most frequent sites of the lesion (80.4%). The incidences of Dukes' stage C and poorly differenciated adenocarcinoma cases were significantly higher in the young adult group (p<0.05). The curative resection rate of tumors in young patients was 93.4%. Despite of the more advanced stage and poorly differenciation, the stage-related and overall 5-year survival rate was not significantly different between old and young patients (57.9% and 59.4% in young and old patients, respectively). CRC in young adults in Korea is increasing in number, but its proportion is decreasing. The results of our study indicate that the prognosis and the stage-related survival for CRC in young adults are not related to age.