Successful repair of a rectovaginal fistula caused by a tension-free vaginal mesh (TVM): a case report.

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

Immunohistochemical demonstration of fluoropyrimidine-metabolizing enzymes in various types of cancer.

Fluoropyrimidines [5-Fluorouracil (5-FU) and its prodrugs] have been widely used in the treatment of solid cancers. The anticancer effects primarily depend on intratumoral levels of enzymes metabolizing the drugs, such as dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyltransferase (OPRT), thymidine phosphorylase (TP), and thymidylate synthase (TS). In order to know the tumor types susceptible to respective fluoropyrimidines, we investigated the expression of DPD, OPRT, TP and TS in various types of cancer with the immunoperoxidase method. These four enzymes existed in all of the cancer types studied, such as pulmonary, gastric, colorectal, hepatic, cholecystic, pancreatic, renal, urocystic, and mammary cancers. Respective types of cancers presented characteristic immunohistochemical features as follows: pulmonary adenocarcinoma, DPD- and TP-high; pulmonary squamous cell carcinoma, TS- and TP-high; intestinal-type gastric adenocarcinoma, TP-high; diffuse-type gastric adenocarcinoma, DPD-low and TS-high; colorectal adenocarcinoma, DPD- and TP-low, hepatocellular carcinoma, DPD-high, and TS- and OPRT-low; cholecystic adenocarcinoma, DPD- and TS-high; renal cell carcinoma, DPD-low, and OPRT- and TP-high; urocystic transitional cell carcinoma, DPD-high and OPRT-low; and mammary ductal carcinoma, OPRT-low, and TS- and TP-high. The enzyme expression pattern in cancer tissue was generally similar to that of their normal counterparts. However, TP immunoreactivity in adenocarcinomas of the lung, stomach and gallbladder, and urothelial carcinoma of the urinary bladder was stronger, and DPD immunoreactivity in adenocarcinoma of the breast was weaker, when compared with normal epithelial cells. Non-epithelial cells were also positive for these enzymes. These results indicated that the key enzymes influencing the effects of fluoropyrimidines differ from cancer to cancer. Fluoropyrimidine treatment may be selected, based on the simultaneous immunohistochemical evaluation of the fluoropyrimidine metabolic enzymes.

Outcomes of novel transanal operation for selected tumors in the rectum.

BACKGROUND: Transanal endoscopic microsurgery facilitates access to proximal tumors in the rectum, but there is limited possibility for tumors above the peritoneal reflection because of high cost, training, and long operative time. The objectives of this study are to delineate the results achieved by novel transanal local excision (minimally invasive transanal surgery [MITAS]) with the use of a new anal retractor, stapler device, and several modified surgical techniques for selected rectal tumors. STUDY DESIGN: Ninety-one patients with 93 tumors undergoing MITAS between 1993 and 2000 were retrospectively reviewed for prospectively collected data with a minimum 2 years followup and without adjuvant radiation or chemotherapy. RESULTS: MITAS was accomplished in a median of 20 minutes with negligible blood loss, no mortality, and low morbidity for tumors locating 9 cm (range 5 to 20 cm) from the anal verge and measuring 25 mm (range 8 to 83 mm) of maximum diameter. No recurrent disease was observed in patients with 32 adenomas, 37 Tis, 5 low-risk pT1, and 14 high-risk pT1 carcinomas. Eight underwent additional operation, two patients with high-risk pT1 tumors who refused additional operations had recurrent disease, and the sole patient with surgical margin positive underwent a reexcision with MITAS for recurrence without further disease during a median of 63 months followup. CONCLUSIONS: MITAS is a feasible transanal local excision procedure that allows access to proximal rectal tumors and "total excisional biopsy" with short operative time, negligible blood loss, and low morbidity for carefully selected adenomas and early carcinomas.