Summary: Preservation of the anal sphincters is now consistent with adequate extirpation of the majority of rectal neoplasms. However, there is still a troublesome incidence of leakage through colorectal anastomoses. A number of different factors, working in combination, are responsible for this. Although most problems have been solved, and the mortality is low, the anastomotic leak rate described in the present series, and in the hands of most surgeons, remains high. Efficient suturing without tension, adequate filling and drainage of the presacral space, and antimicrobial prophylaxis effective enough to abolish abdominal wound sepsis, have been applied. The large vessel arterial blood supply to the suture line is good but the microcirculation of the left colon and rectum, upon which suture line healing ultimately depends, is suspect. Reduction of blood viscosity by deliberate lowering of the haemoglobin level before operation has been practised in the hope of improving the microcirculatory flow. The results so far are encouraging and suggest that the method is worth a continued trial. IntroductionTo preserve the anal sphincter after adequate and safe removal of a rectal neoplasm is the major challenge with which colorectal surgeons are most frequently faced at present. The majority of invasive large bowel growths are found in the lower sigmoid colon and upper rectum (Gillespie et al. 1979). Up to 1950, most malignant neoplasms within 15cm of the anus were treated by total rectal excision. In terms of operative mortality and cure, the results achieved by this method have not been bettered. Where there has been progress has been in the avoidance for most patients with rectal cancer of a permanent colostomy. In the three years of the present study the ratio of abdominoperineal excisions to restorative resections of the rectum was about 1 to 6.The reasons for former doubts about restorative excision were three. Most important was the dire consequence for the patient of suture line leakage, which occurred in a consistent proportion of cases. The very active antimicrobial agents now available have greatly reduced this risk but have not abolished suture line leakage. The other doubts concerned the adequacy of the excision of malignant tissue and the fear that malignant cells would be implanted in the suture line. Most surgeons now discount these last two fears. For example, Nicholls et al. (1979) showed that for Dukes B and C tumours of average malignancy there was, in terms of five year survival, no difference between restorative and total excision; while Rosenberg (1979) studied malignant implantation in a number of different ways and concluded that, if the rectal stump was well irrigated at operation, it was a very rare event.The present study The peculiar problems of the operation are all connected with leakage from the colorectal anastomosis and are influenced by four factors: the shape of the pelvis; the virulently infective nature of the colonic contents; suturing technique; and the blood supply to the cut bow...

BRrr= 475are chosen by the current machinery of selection to meet the national need for leadership in industry; after obtaining a university degree they not unnaturally prefer a niche with academic freedom to the more strenuous daily demands of industrial life. -Willis, 1946), the presence in the bowel of a mass of worms or some other foreign body, and a tumour of the bowel or its covering (Allen and Welch, 1947). In the case reported below the increase in bulk was due to an ileo-ileal intussusception, the head of which had entered the ascending colon. The intussusception itself was caused by the invagination of a Meckel's diverticulum containing a polyp of gastric mucosa. Clark (1944) reported a similar case. CASE REPORT A schoolboy aged 9 was admitted to hospital complaining of abdominal pain which had started 15 hours earlier.The pain was situated to the right of the umbilicus and was of a dull and persistent nature; it had been mild at first, but had steadily grown more severe. He had eaten a meal after it started but with no enjoyment, and had been sick twice, bringing up small quantities only. The vomit contained the pulp of an orange which he had eaten 24 hours previously. The bowels had been open normally in the morning, and there was no disturbance of micturition. This was the first attack of its kind that he had suffered.There was nothing relevant in the past history.On examination the boy was strikingly pale; his temperature was 97.4°F. (36.3°C.), pulse 90, and respirations 20. The tongue was moist but covered with a white fur; there was no fetor oris. He appeared to be most comfortable lying on his left side. The abdomen was not unduly fat, and a lump was visible to the right of the umbilicus. There was no visible peristalsis, respiratory movement of the abdominal wall was free, and acute tenderness and guarding were present over the lump, but not elsewhere. The mass, which was about 2 in. (5 cm.) in diameter, had a smooth surface and appeared to be bilobed; it was freely mobile and slightly more resonant to percussion than its surroundings. No signs of free fluid were present in the peritoneal cavity, and bowel sounds, though reduced in quantity, were normal in character. There were faeces in the rectum, and blood was not found on the examining finger. No abnormality was found in the respiratory or cardiovascular system. Plain x-ray films of the abdomen in the erect and supine positions showed no significant abnormality.The provisional diagnosis was not certain. The presence of a position of relief (Evans and Bigger, 1947) suggested intestinal volvulus, but intussusception was thought to be a possibility.Operation.-The abdomen was opened through a right paramedian incision, and two purple, distended loops of intestine-one the caecum, the other a coil of ileum-presented themselves in the wound. The caecum and ascending colon were attached to the posterior abdominal wall by a mesentery 2 in. (5 cm.) long and, with the terminal ileum, were rotated on this mesentery through 360 degrees in a clockwis...

Anatomical studies have shown that three different appearances may be seen at the lower end of the oesophagus-namely, inferior oesophageal sphincter and vestibule relaxed, inferior oesophageal sphincter contracted and vestibule relaxed, and both the inferior oesophageal sphincter and the vestibule contracted. These studies have also demonstrated that the sling fibres of the stomach which hook around the notch between the lower end of the oesophagus and the fundus of the stomach mark the oesophago-gastric junction, and that a transverse mucosal fold forms at the same level as the sling fibres of the stomach when the vestibule is relaxed and distended. The behaviour of these structures in living persons was investigated radiologically, and in this paper an analysis of our findings is presented. As a result of these studies, a rational approach to the surgical repair of the hiatus in a patient with a hiatal hernia has been evolved.The value of radiological studies of the lower end of the oesophagus is that they can demonstrate flow and movement. Flow in the lumen of the oesophagus can be observed during a barium meal examination. As the margins of the hiatus are not visible radiologically, movement of the hiatus cannot ordinarily be seen. In 15 patients who required a vagotomy, radio-opaque markers were placed on the anterior and lateral walls of the hiatus during the operation. The movement of the hiatus during normal and deep respiration and the effect such movements have on the lower oesophagus were subsequently studied radiologically. Movement of the wall of the oesophagus can be deduced, to some extent, by a radiological study of movement of the various rings and constrictions seen at the lower end of the oesophagus in adult patients during a barium swallow examination (Berridge, 1961). In 12 of the 15 patients mentioned above, radio-opaque ILPresent address: Hospital for Sick Children, Great Ormond Street, London, W.C.l. and University College Hospital, London, w.c.1 markers were also attached to a number of points along the external wall of the oesophagus. Subsequently, the movement of the wall of the oesophagus during deglutition was investigated radiologically, and the effect of normal and deep respiration on the wall of the oesophagus was analysed.The paper concludes with a discussion of the radiological appearances in the lower oesophagus studied in a large number of other patients and a description of the radiological landmarks in this region. PATIENTS STUDIED AND TECHNIQUEVarious types of markers were placed on the hiatus of patients at operations for vagotomy: skin clips, tantalum wire as a skein, two pieces of tantalum wire hinged together at the top, and stainless steel rings. In nearly all cases the markers were so arranged that the movements of the two walls of the hiatus could be compared.The oesophagus was marked with loops of tantalum wire or steel rings of a different size to those used on the hiatus. The types of marker used and the age and sex of the patients are set out in Table I. During t...

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