The paracolpium or paravaginal tissue is surrounded by the vaginal wall, Denonvilliers' fascia and pubocervical fascia. To describe the configuration of nerves and fasciae in and around the paracolpium, we examined histological sections of 10 elderly cadavers. We used tyrosine hydroxylase (TH) as a sympathetic nerve marker and nitric oxide synthase (nNOS) and vasoactive intestinal peptide (VIP) as parasympathetic markers. The paracolpium contained distal parts of the pelvic autonomic nerve plexus including origins of nerves to the internal anal sphincter (NIAS). Nerves in the paracolpium were divided into the anterior and posterior groups by the inferomedial edge of the levator ani muscle approaching the vaginal lateral margin. Subsequently, the paracolpium was diminished greatly in size and restricted in the anterolateral side of the inferior rectum. Smooth muscles originated from the small space and reached the longitudinal muscle coat of the rectum. Likewise, the sympathetic nerve-rich NIAS originated from the inferoposterior end of the paracolpium, ran inferiorly along the extrarectal part of the longitudinal muscle coat, and joined parasympathetic-dominant Auerbach's intermuscular plexus to make the intersphincteric nerves. Surgical damage to the paracolpium or the lateral part of Denonvilliers' fascia seemed to cause dysfunction of the internal anal sphincter.

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The objective of the present study was to investigate the risk factors for developing metachronous colorectal adenomas and carcinomas during colonoscopic follow-up after initial resections. The study included 403 patients (mean age 66.2 ± 9.9 yr, M:F = 1.55:1) with initial endoscopic resections of colorectal adenomas and/or intramucosal carcinomas with repeated follow-up colonoscopies after at least a one-year interval (median follow-up period 73.9 ± 55.7 months). During surveillance, colorectal lesions less than 5 mm in diameter were not resected based on the concept of a semi-clean colon. They were classified into two patient groups according to the following clinical items at initial resection: age of patient (less or more than 65 yr), gender (male or female), number of colorectal lesions (single or multiple), size (less or more than 10 mm), location (left or right/both), histology (adenoma with low-grade dysplasia or high-grade dysplasia / cancer). Statistical comparisons were made by the Logrank test between two groups as for the cumulative percentages of patients with recurrent lesions, and those with recurrent index lesions (larger than 10 mm, adenoma with high-grade dysplasia or cancer). The cumulative percentages of patients with recurrent lesions were significantly higher in male patients (p<0.001), those with multiple lesions (p<0.0001), those with large lesions of more than 10 mm (p<0.001), those with right/both-sided lesions (p<0.05), and those with lesions of high-grade dysplasia or cancer (p<0.005). The cumulative percentage of patients with recurrent index lesions was significantly higher in male patients (p<0.01), those with multiple lesions (p<0.01), those with large lesions of more than 10 mm (p<0.0001), and those with lesions of high-grade dysplasia or cancer (p<0.0001). In conclusion, metachronous colorectal advanced lesions during surveillance were frequent among patients with multiple lesions, large lesions of more than 10 mm, and lesions with advanced pathology at initial resection.

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We report a case of mucoepidermoid carcinoma of the anal canal. A 66-year-old man was admitted to our hospital complaining of anal pain and hematochezia. Contrast-enhanced computed tomography showed an enhanced tumor, 60 mm in size, from the anus to the lower part of the rectum, and in addition, the right inguinal lymph node was swollen. Colonoscopic examination revealed a submucosal tumor-like lesion with central ulceration in the anal canal. The biopsy specimen suggested mucoepidermoid carcinoma, and abdominoperineal resection with D3 lymphadenectomy including the right inguinal lymph node was performed. Gross examination of the resected specimen revealed an ulcerated tumor, 60 mm × 60 mm in size, from the perianal skin to the lower part of the rectum. Pathological examination resulted in mucoepidermoid carcinoma, pA, int A, INFb, ly0, v1, pN2(5/24). No recurrence has been found for 2 years post-operation. Mucoepidermoid carcinoma is a rare histological type of anal cancer, and this case presented an interesting morphological type.

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The patient, a 69-year-old woman, was admitted to our hospital with rectal tumor. Computed tomography showed a rectal tumor with “multiple concentric ring sign”. Endoscopic examination and barium enema examination led to a diagnosis of rectal intussusception with rectal villous adenoma at the leading end. There were no symptoms of ileus, and palliative laparoscopic low anterior resection was performed. Invagination of the upper rectum through the lower rectum was found at the level of peritoneal reflection. We tried manual reduction at first, but it was impossible because of adhesion of the invaginated rectum. We therefore performed low anterior resection of the rectum en bloc. The resected specimen showed a villous tumor occupying the entire circumference of the rectum. The tumor had caused intussusception and was at the leading end.
In comparison with intussusception in children, intussusception in adults is rare and rectal intussusception is even rarer. Further, rectal villous tumor is a very rare cause of rectal intussusception. We present this case and discuss the relevant literature.

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Fistula formation between the gastrointestinal tract and implants placed during total hip arthroplasty or revision hip arthroplasty is a rare complication. A 79-year-old woman underwent bilateral total hip arthroplasty at another hospital in 1990 for coxarthrosis, and the left side was revised in 2004. Serous discharge from the left hip developed in 2009, and she was diagnosed as having infection of the artificial joint, which was treated conservatively. However, the wound did not improve, and she was referred to our hospital in 2013 for further care. Fistula formation between the sigmoid colon and the left hip joint as well as dislocation of the implants into the pelvis were suspected, for which she underwent removal of the implants and Hartmann's procedure. Late complications of total hip arthroplasty or revision hip arthroplasty associated with the digestive organs are very rare. We herein report a case of coloarticular fistula that developed 5 years after revision hip arthroplasty and review the literature.

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A haemodialysis patient with chronic nephritis, a man in his sixties, presented with vomiting and consciousness disturbance while receiving chemotherapy with mFOLFOX6 for recurrence of lung metastasis developing in the second year after surgery for sigmoid colon cancer. Blood tests showed abnormally high blood levels of ammonia, based on which we established the diagnosis of consciousness disturbance caused by hyperammonaemia resulting from high-dose 5-FU infusion. Emergency haemodialysis was performed, with immediate improvement of the symptoms.
Hyperammonaemia induced by mFOLFOX6 therapy appears to be due mainly to impaired metabolism of 5-FU. Patients with chronic renal failure, such as those on maintenance dialysis, receiving this treatment may lapse into a serious clinical condition as their urinary ammonia excretion is impaired; therefore, precautions against the development of hyperammonaemia are considered to be necessary in such patients. Also, emergency haemodialysis may be effective.

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We report the cases of three male patients who underwent laparoscopic surgery (mean age, 71 years) for sigmoid-vesical fistula due to colonic diverticulitis. Pneumaturia was the chief complaint in two patients, while the remaining patient was asymptomatic. Primary anastomosis was achieved after laparoscopic resection of the fistula and the affected part of the sigmoid colon. One patient with a history of ischemic colitis required temporary ileostomy. Resection of urinary bladder fistula was not performed in any patient. The median duration of surgery was 359 min (range, 344-403 min), and the median intraoperative blood loss was 120 mL (minimum amount, 250 mL). No patient required conversion to laparotomy. Furthermore, there were no postoperative complications, and the mean hospital stay after surgery was 17 days (range, 15-19 days). The results of a literature review of 24 cases reported in Japan revealed that resection of urinary bladder fistula is not necessary in laparoscopic surgery for a sigmoid-vesical fistula and that good results can be achieved by sigmoidectomy of the section containing the fistula.

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A case was a 53-year-old male with hemorrhoid who underwent (4-stage) ALTA (aluminum potassium sulfate hydrate-tannic acid) injection therapy. Three weeks after the ALTA therapy he developed frequent mucous and bloody stool and was referred to us. Lower intestinal tract endoscopy revealed erosion and ulcer on the pectinate line and irregular-shaped multiple ulcers extending towards the rectosigmoidal junction. While the distal rectal erosion and ulcers healed relatively quickly, the proximal rectal and rectosigmoidal severe ulcers did not heal, and severe rectal stenosis developed at the proximal and distal sides of the ulcers. The patient suffered from frequent stool and difficulty in defecating. Although the circumferential ulcer at 7 cm from the anal verge (AV) for 5 cm in longitudinal length gradually healed, both ends of the ulcer lesion developed severe stenosis. We carried out balloon-dilatation intervention a total of 13 times over one year, and the ulcer healed and the patient's symptoms improved.

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