Journal of the Korean Society of Coloproctology

Recently developed BMS TM (Zassi Bowel Mana

Dae-Ho Shon

Sang Hun Jung

Min-Chul Shim

Jae-Hwang Kim

Application of BMS™ Avoids a Defunctioning Colostomy in the Treatment of Fournier's Gangrene

BMS™ 在治疗Fournier坏疽中避免造口的应用

Purpose:The detection of synchronous and metachronous colon cancer is important for the surgical treatment.The aim of this study is to review the clinicopathological characteristics of multiple colon cancers.Methods: A retrospective analysis was performed with 43 patients with multiple colon cancers who underwent surgical treatment from June 1996 to May 2008.Patients with familial adenomatous polyposis and cancer from inflammatory bowel disease were excluded.Results: There were 43 cases of multiple colon cancers.Synchronous colon cancers were present in 30 patients and metachronous colon cancers were present in 18 patients.The mean age was 61.33±11.44,and the male-to-female ratio was 23:20.The index cancer and the second cancers in synchronous colon cancers, as well as the first colon cancer in metachronous colon cancers showed, significantly more distal tumor locations.However, the second cancers in metachronous colon cancers showed no significant differences in tumor location.As for stage, a more advanced stage was noted in the index cancer than in the second cancers in synchronous cancer.However, an early stage was noted for the first colon cancer in metachronous cancers.Seventeen patients with synchronous cancer and 14 patients with metachronous colon cancer underwent a total or a subtotal colectomy.Conclusion: Detection of synchronous colon cancer was important for deciding the extent of surgical resection.Patients with colon cancer should be considered for frequent colonoscopy follow-up for early detection of metachronous colon cancer.

Ok Joo Paek

Seung Yeop Oh

Kwang Wook Suh

Treatment of Multiple Colorectal Cancers

多发性结直肠癌的治疗

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.

Nak Song Sung

In Seok Choi

Won Jun Choi

POSSUM, P-POSSUM, and Cr-POSSUM Scoring Systems as Predictors of Postoperative Morbidity and Mortality in Elderly Colorectal Cancer Patients

POSSUM、P-POSSUM和Cr-POSSUM评分系统作为老年结直肠癌患者术后发病率和死亡率的预测指标

See Article on Page 140-144

Post-operative results are variable. Some rectoceles might be caused by a paradoxical puborectalis contraction leading to an outlet obstruction and to disappointing surgical results [1]. Thus, an anorectal physiologic study including anal sponge (anal plug) electromyography should be performed for excluding non-relaxing puborectalis syndrome [2]. In that case, biofeedback therapy should be applied first. A vital point for a good post-operative result is the tightness (strength) of the reconstructed rectovaginal septum even though long-term post-operative results aredisappointing [3]. A larger decrease in the rectocele diameter means greater strength of the rectovaginal septum.

Yong Hee Hwang

Journal of the Korean society of coloproctology

Good Post-operative Results Depend on Strict Patient Selection and Strict Operative Procedure

良好的术后效果取决于严格的病人选择和严格的手术程序

See Article on Page 241-246

A parastomal hernia at the site of a permanent end colostomy is a common and troublesome complication, and its incidence is estimated to be up to 48.1% [1]. The aim of this study was to analyze the incidence of and the risk factors for a parastomal hernia. In this study, the plausible risk factors for a parastomal hernia were as follows: female gender, age over 60 years, body mass index more than 25 kg/m2, and hypertension. Other risk factors from other studies were obesity and waist circumference greater than 100 cm. Although the prophylactic use of mesh may be an option for those patients requiring a permanent [2], the efficacy of using prophylactic mesh for patients with a permanent is a subject of debate due to mesh-associated complications [3, 4]. In this study, the parastomal hernias were assessed by using computed tomography scans. No objective grading-system was used, and no subject symptoms were noted. Also, no descriptions of the stoma-creation techniques used by the authors were given.

The key factor to prevent a parastomal hernia is the surgical accuracy of creation. As general rules, stomas should be placed through the rectus sheath for additional muscular support, fascial openings should be fit to the size of the exteriorized bowel circumference, prophylactic application of mesh may only be considered for those patients requiring a permanent stoma, and an extraperitoneal tunneling of the bowel may be considered [4]. The procedure of an end colostomy is usually performed as a final surgical procedure; the surgeon should do his or her best to create an appropriate because the incidence of a too loose stoma might be double the incidence of a too tight stoma.

Further detailed studies regarding the degree of herniation and standardization of the stoma-creation method may be helpful for focusing on the risk factors. This study appears to support the prophylactic use of mesh in high-risk patients.

Jin Kwon Lee

Won Kyung Kang

Risk Factors of Parastomal Hernia and Creation of an Ostomy

造口旁疝的风险因素及造口创建

See Article on Page 100-107

Total mesorectal excision (TME) was proposed by Heald et al. [1] more than 20 years ago and it is defined as the complete excision of the visceral mesorectal tissue to the level of the levators. The local recurrence rate after rectal cancer surgery has decreased dramatically to below 10% thanks to this TME technique. Currently TME is the gold standard for treatment of rectal cancer. However, if the tumor is located in upper rectum, partial mesorectal excision (PME) down to 5 cm below tumor can be performed. In 1998, Lopez-Kostner et al. [2] from Cleveland clinic insisted that TME is not necessary in case of the upper rectal cancer. And in the same year, Zaheer et al. [3] from Mayo clinic stated that appropriate mesorectal excision during anterior resection when tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. The term tumor-specific mesorectal excision (TSME) was noted first in this article. In the Europe, Maurer et al. [4] from Germany concluded that the rectal cancers of upper third are appropriately treated by PME to 5 cm below the tumor. TSME is defined as the precise perpendicular and circumferential excision of the mesorectum to the level of an appropriate distal resection margin by American Society of Colon and Rectal Surgeons.

Law and Chu et al. [5] from Queen Mary's Hospital in Hong Kong compared the patients with TME for mid and lower rectal cancer and PME for upper rectal cancer, where the rectum was transected 4 to 5 cm below the tumor. Due to longer operative times, higher anastomotic leak rates, a more technically demanding surgery and a higher incidence of stoma formation, the authors called for a more selective use of TME. The authors argue that oncologic outcome is not compromised with this approach based on similar cancer-specific survival patterns between TME and PME in this study. This conclusion was confirmed by meta-analysis. Mirnezami et al. [6] examined the long-term oncological impact of anastomotic leakage after rectal cancer surgery using meta-analysis methods. They found that anastomotic leakage has a negative impact on local recurrence after the rectal cancer surgery. A significant association between anastomotic leakage and reduced long-term cancer specific survival was also noted. Junginger and Hermanek [7] reviewed the literature concerning oncologic outcomes after the rectal surgery. The authors recommended PME, if the rectal cancer is located 12 to 16 cm from anal verge.

Oncologic outcomes after the rectal cancer surgery can be divided into the long-term survival and the local recurrence rate. Regarding rectal cancer, local recurrence rate is especially important compared to colon cancer. TSME itself and its quality is one of the most important factors to predict the local recurrence and even the long-term survival after rectal cancer surgery. Survival is mainly determined by the occurrence of distant metastasis, but TME seems to improve survival in patients without systemic disease. Therefore, the effort to improve the quality of TME is so crucial to improve oncologic outcomes after rectal cancer surgery. Preoperative concurrent chemoradiotherapy is another important factor to reduce the local failure. Pathologic results, such as distal margin, circumferential radial margin, T and N stage, lymphatic and vascular invasion, neural invasion, are also important factors to influence the oncologic results after TSME.

In conclusion, surgeon is one of the most important factors to predicting oncologic outcomes after TME. Individual surgeon should make an effort to improve surgical skill and pathologist can help him with the specimen audit. Nationwide audit program is needed to improve the oncologic results after TME in rectal cancer in South Korea. The other important factor is the preoperative radiotherapy. Preoperative radiotherapy with high quality TME can almost abolish the possibility of local recurrence.

Kil Yeon Lee

Factors Influencing Oncologic Outcomes after Tumor-specific Mesorectal Excision for Rectal Cancer

直肠癌肿瘤特异性直肠系膜切除术后肿瘤学结局的影响因素

A quick hemostatic effect, as well as sclerosing and shrinkage of hemorrhoids, can be attained when internal hemorrhoids are treated by using injection therapy with aluminum potassium sulfate and tannic acid (ALTA), the outcomes of treatment may be similar to those of a hemorrhoidectomy. However, if the type of hemorrhoid or the method of injection is not appropriate for ALTA treatment, complications peculiar to ALTA or recurrence may develop. Accordingly, sufficient understanding of the treatment mechanism of ALTA injection and repeated training for injection are required for effective use of the ALTA treatment. Keywords: Aluminum potassium sulfate and tannic acid; Hemorrhoid; Injection therapy

Seok Won Lim

Aluminum Potassium Sulfate and Tannic Acid Injection for Hemorrhoids

铝钾矾和鞣酸注射治疗痔疮

Purpose The aim of this study was to analyze the oncologic outcomes and the risk factors for recurrence after a tumor-specific mesorectal excision (TSME) of resectable rectal cancer in a single institution. Methods A total of 782 patients who underwent a TSME for resectable rectal cancer between February 1995 and December 2005 were enrolled retrospectively. Oncologic outcomes included 5-year cancer-specific survival and its affecting factors, as well as risk factors for local and systemic recurrence. Results The 5-year cancer-specific survival rate was 77.53% with a mean follow-up period of 61 ± 31 months. The overall local and systemic recurrence rates were 9.2% and 21.1%, respectively. The risk factors for local recurrence were pN stage (P = 0.015), positive distal resection margin, and positive circumferential resection margin (P < 0.001). The risk factors for systemic recurrence were pN stage (P < 0.001) and preoperative carcinoembryonic antigen level (P = 0.005). The prognostic factors for cancer-specific survival were pT stage (P < 0.001), pN stage (P < 0.001), positive distal resection margin (P = 0.005), and positive circumferential resection margin (P = 0.016). Conclusion The oncologic outcomes in our institution after a TSME for patients with resectable rectal cancer were similar to those reported in other recent studies, and we established the risk factors that could be crucial for the planning of treatment and follow-up. Keywords: Rectal neoplasms; Colorectal cancer recurrence; Oncologic outcome; Tumor-specific mesorectal excision

Sam Hee Kim

Ki Beom Bae

Jung Min Kim

Jae Ho Shin

Min Sung An

Tae Geun Ha

Sung Mok Ryu

Kwang Hee Kim

Tae Hyeon Kim

Chang Soo Choi

Jin Yong Shin

Minkyung Oh

Seung Hun Baek

Kwan Hee Hong

Oncologic Outcomes and Risk Factors for Recurrence after Tumor-specific Mesorectal Excision of Rectal Cancer: 782 Cases

直肠癌肿瘤特异性直肠系膜切除术后的肿瘤学结局及复发风险因素：782例病例研究

Publication Information	Publisher: Korean Society of Coloproctology，Publishing cycle: ，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 2009，Proportion of original research papers: ，Self Citation Rate:， Gold OA Rate:

Journal of the Korean Society of Coloproctology

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Application of BMS™ Avoids a Defunctioning Colostomy in the Treatment of Fournier's Gangrene

Treatment of Multiple Colorectal Cancers

POSSUM, P-POSSUM, and Cr-POSSUM Scoring Systems as Predictors of Postoperative Morbidity and Mortality in Elderly Colorectal Cancer Patients

Good Post-operative Results Depend on Strict Patient Selection and Strict Operative Procedure

Risk Factors of Parastomal Hernia and Creation of an Ostomy

Good Post-operative Results Depend on Strict Patient Selection and Strict Operative Procedure

Risk Factors of Parastomal Hernia and Creation of an Ostomy

Factors Influencing Oncologic Outcomes after Tumor-specific Mesorectal Excision for Rectal Cancer

Aluminum Potassium Sulfate and Tannic Acid Injection for Hemorrhoids

Oncologic Outcomes and Risk Factors for Recurrence after Tumor-specific Mesorectal Excision of Rectal Cancer: 782 Cases