Intraarterial thrombolysis is of value in restoring the distal run off before bypass in PA presenting as acute limb-threatening ischemia. However, the results do not justify an expectant policy for asymptomatic aneurysms.

To assess the functional results of treatment of faecal incontinence we carried out physiological and radiological measurements in 46 patients and 20 controls. Twenty patients were selected for conservative treatment and 26 for surgery (including 17 postanal repairs and 6 anterior sphincter repairs). The degree of incontinence was scored before and after treatment and postoperative investigations carried out on 17 patients (11 postanal repairs). Forty per cent of the conservative treatment group had a successful result compared with sixty-five per cent of the operative group as a whole and fifty-nine per cent of the postanal repair patients. Resting and 'squeeze' anal canal pressures were improved following postanal repair as was upper anal canal sensation but there was no change in the anorectal angle. We conclude that the anorectal angle is not crucial in maintaining continence.

Submucosal (SM) and ligation excision (LE) haemorrhoidectomy were compared to establish whether SM is a less painful procedure and whether anal sensation is better preserved by SM, and, if so, how this relates to postoperative function. There were 18 SM and 22 LE patients. Anal sphincter manometry and anal mucosal electrosensitivity were measured pre-operatively and 6 weeks after surgery. Postoperative pain was assessed by linear analogue scale. Anal sphincter pressures which were high pre-operatively fell to normal after surgery. Neither operation affected functional sphincter length or the recto-anal inhibitory reflex. Forty per cent of patients showed ultraslow waves on sphincter motility studies. These were associated with the highest pressures and in all but three cases disappeared after surgery. There were no differences in postoperative pain scores between the two techniques but there was a wide range from no pain to very severe pain in both groups. Submucosal haemorrhoidectomy preserved anal sensation better than ligation excision but this was not reflected in improved function. There was minor leakage and soiling in 50 per cent of patients from both groups and two SM and LE patients had initial faecal incontinence. All these symptoms had resolved by 6 weeks.

Obstructed defaecation in the descending perineum syndrome has been attributed to anterior mucosal prolapse. Manometric and radiological measurements together with evacuation proctograms in 49 patients with obstructed defaecation and normal whole gut transit times were carried out and compared in a total of 25 controls. Proctography delineated four groups: (I) puborectalis accentuation, n = 11; (II) rectal intussusception, n = 25; (III) anterior rectal wall prolapse, n = 11; (IV) rectocele, n = 2. The anorectal angle at rest, maximum basal sphincter pressures and the rectoanal inhibitory reflex did not differ between the groups and controls. Group III achieved a greater increase in anorectal angle on straining than controls. Groups II and III exhibited significant perineal descent below the pubococcygeal line whereas group I did not. In perineal descent intussusception was the commonest morphological abnormality associated with obstructed defaecation. Isolated anterior mucosal prolapse was not observed, making local treatment aimed at reducing its bulk questionable.

This study examined differences in anorectal function, with particular reference to anismus, which might explain why some patients with intractable constipation have slow and others have normal whole gut transit times. Twenty-four patients were studied; 13 with slow transit (all female, median age 32 years, range 16-52 years) and 11 with normal transit (eight women, three men, median age 37 years, range 21-60 years). Videoproctography with synchronous sphincteric electromyography and anorectal manometry was performed. There were no differences between the two groups, suggesting that slow transit constipation is not secondary to any abnormality in anorectal function and may therefore be a primary disorder of colonic motility. There was no correlation between electromyographic evidence of anismus (pelvic floor contraction on defaecation) and the ability of the patient to evacute the rectum or symptoms of obstructed defaecation. Electromyography findings alone can be misleading and should be related to proctographic evidence of incomplete rectal evacuation before functional anismus can be said to be present.