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Anorectal myectomy has been evaluated in 29 patients with chronic constipation associated with outlet obstruction. Eight patients had histological evidence of aganglionosis. No patient was able to defaecate spontaneously more than once a week before operation. Eighteen (62 per cent) patients were able to defaecate spontaneously more than 3 times a week after operation (good results) whereas 11 patients were not. There was a significant fall in maximum resting anal pressure after operation in the patients having a good result (102·7±16·7 to 79·5 ± 27·8 cm H2O) whereas there was no significant fall in those having a poor result (118·4±25·0 to 108·8±28·5 cm H2O). The operation had no influence on squeeze pressures, length of the high pressure zone, rectal sensation or the anorectal angle. These results seem to indicate that the therapeutic effect of anorectal myectomy is merely due to reduced resting anal canal pressures.

Ninety-five patients have been referred for the assessment and treatment of faecal incontinence. Incontinence was associated with previous anal trauma in 49 cases: 13 occurred after vaginal delivery, 32 were associated with anal operations and in 4 severe perineal trauma occurred after road accidents. Other causes were: idiopathic incontinence in 18, persistent incontinence despite successful rectopexy for prolapse in 10, diabetic neuropathy in 5 and in 13 the cause was not identified. Conservative treatment by control of diarrhoea, physiotherapy or electrical therapy was often successful in patients with minor incontinence. Fifty-six patients have been treated surgically. Complete continence was achieved in 67 per cent of patients treated by postanal repair and in 61 per cent by sphincter reconstruction. We believe that postanal repair is the treatment of choice for idiopathic incontinence and incontinence after rectopexy or anal dilatation. Sphincter repair should only be performed with a covering colostomy and is the treatment of choice for recent or long standing division of the external sphincter ring.

One hundred and twenty-four patients had a postanal repair for the treatment of faecal incontinence between January 1976 and July 1987. One hundred and sixteen of these patients have been followed up for more than 1 year with a median follow-up of 5 years. Incontinence was improved in 81 per cent of patients. Furthermore, bowel frequency fell: 58 per cent had more than four bowel movements before operation compared with 19 per cent after operation. However, 60 per cent of patients still claimed urgency, 76 per cent still leaked faeces and 52 per cent continued to wear pads after the operation. Maximum resting anal pressure and maximum squeeze pressure did not change significantly after operation either in patients whose bowel control was improved or in those who were not. The results indicate that the quality of continence after postanal repair is poor.

Fifty patients attending for surgical treatment of chronic constipation (n = 21) or faecal incontinence (n = 29) were studied using two psychiatric screening tests: the Hospital Anxiety and Depression (HAD) scale and the General Health Questionnaire (GHQ). Each patient was assessed preoperatively and 6–12 months postoperatively. Results were compared with age and sex-matched controls (n = 50). Constipated patients had significantly higher HAD depression scores compared with controls (median and range): 6 (2–12) versus 4 (0–8), P < 0·05. Constipated patients who were improved by operation (n = 13) had significantly lower preoperative HAD anxiety scores compared with those who were not improved (n = 8): 8 (3–14) versus 15 (10–19), P < 0·01; they also had significantly lower HAD depression scores: 4 (2–12) versus 7 (5–11), P < 0·05. Using these parameters incontinent patients did not differ from controls, but patients who had a bad result after operation (n = 15) had significantly higher HAD anxiety scores than those who obtained clinical benefit (n = 14): 10 (2–15) versus 6 (2–12), P < 0·05; HAD depression scores were also greater: 5 (2–15) versus 3 (0–9), P < 0·05; and GHQ scores were greater: 12 (0–47) versus 4 (0–41), P < 0·05.

Subtotal colectomy has been performed in 40 patients with severe constipation. Only one patient was male. Five patients (13 per cent) had a history of a serious psychiatric disorder. Twenty-six patients (65 per cent) could not expel a 100-ml air-filled balloon and 19 patients (48 per cent) had electromyographic evidence of abnormal puborectalls contraction during attempted defaecation before operation. Median preoperative passage of 50 radio-opaque markers over 5 days was 16 per cent. Sixteen patients had had a previous anorectal myectomy to exclude Hirschsprung's disease. Initial resections were subtotal colectomy and ileorectal anastomosis (n = 34), caecorectal (n = 5) or ileosigmoid (n = 1) anastomosis. Secondary operations included restorative proctocolectomy and ileal pouch—anal anastomosis (n = 6) and six patients eventually had an ileostomy. Median bowel frequency per week significantly increased after operation (0·3 (range 0–1) preoperatively to 21 (range 2–70) postoperatively, P < 0·005), the percentage of patients with abdominal pain fell after operation from 93 to 39 per cent but symptoms of abdominal distension remained the same (86 per cent preoperatively and 82 per cent postoperatively).

We have investigated changes in colonic motility and anorectal function in 6 continent patients with a rectal prolapse; in 10 incontinent patients with rectal prolapse and in 16 patients with idiopathic faecal incontinence compared with 26 age and sex match controls. A history of incontinence, irrespective of a prolapse, was associated with significantly lower anal squeeze pressures (P < 0·05), a deficient anorectal angle (P < 0·05), failure to retain a balloon containing more than 250 cm3 of air in the rectum (P < 0·01) and increased sigmoid motility (P < 0·02) compared with controls. By contrast patients with rectal prolapse and no incontinence had normal anal pressures, a normal anorectal angle and normal sigmoid motility, but transit was delayed. These results indicate that abnormal sigmoid motility is commonly associated with faecal incontinence and that slow transit constipation is frequent in patients with rectal prolapse who are continent.

A randomized controlled study has compared anorectal myectomy (n=13) with anal dilatation (n=10) using Park's anal retractor for patients with constipation. No patient was able to defaecate spontaneously more than three times a week before the operation. Of the 13 patients, 7 were able to defaecate spontaneously more than three times a week after anorectal myectomy, compared with none after anal dilatation (P

Four cases of adult ectopic anus are described. All patients presented with incontinence; in two there was a history of constipation. Electromyography correctly identified the site of the anal sphincters pre-operatively. The anorectum was mobilized and re-routed through the sphincter ring with repair of the perineal body. There was improvement in anal canal pressures on voluntary contraction after operation in all three cases studied. Continence was restored in three patients but results were poor in one patient because of persistent constipation. Severe constipation may be a contra-indication to this procedure.

A high incidence of infective complications followed choledochotomy and T-tube drainage when compared with closed biliary-tract procedures. Organisms cultured from infective sites were identical to those isolated from the T-tube in the postoperative period. Postoperative infection was associated with an increased morbidity in terms of length of hospital stay. As infection in these sites was independent of the presence of stones in the common bile-duct, complications would have been reduced if unnecessary exploration had been avoided. The routine use of operative cholangiography in the avoidance of these complications is discussed.

The incidence of pancreatitis complicating biliarytract operations is reported from a prospective survey of 75 patients. This study confirms that pancreatitis is much more frequent after choledochotomy than after cholecystectomy alone. Biochemical pancreatitis was demonstrated in over a third of the patients in whom the duct was explored. The validity of elevated serum amylase in the diagnosis of this complication is established provided that clinical evidence of pancreatitis is also present. The significance of amylasaemia in the immediate postoperative period in the absence of clinical signs is questioned. Reflux of duodenal contents into the pancreatic duct may be provoked by operative damage to the sphincter of Oddi. In these patients clinical pancreatitis invariably occurred. The avoidance of sphincterotomy in the prevention of this potentially serious postoperative complication is advised. Since pancreatitis was more common after negative exploration of the common bile-duct the value of operative cholangiography in the avoidance of this complication is discussed.