ObjectiveThe authors' aim was to determine survival and recurrence rates in patients undergoing resection of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CM), and anterior resection (AR) without adjuvant therapy. Summary Background DataThe surgery of rectal cancer is controversial; so, too, is its adjuvant management. Questions such as preoperative versus postoperative radiation versus no radiation are key. An approach in which the entire mesorectum is excised has been proposed as yielding low recurrence rates. MethodsOf 1423 patients with resected rectal cancers, 491 patients were excluded, leaving 932 with a primary adenocarcinoma of the rectum treated at Mayo. Eighty-six percent were resected for cure. Surgery plus adjuvant treatment was performed in 418, surgery alone in 514. These 514 patients are the subject of this review. Among the 514 patients who underwent surgery alone, APR was performed in 169, CM in 19, AR in 272, and other procedures in 54. Eighty-seven percent of patients were operated on with curative intent. The mean follow-up was 5.6 years; follow-up was complete in 92%.APR and CM were performed excising the envelope of rectal mesentery posteriorly and the supporting tissues laterally from the sacral promontory to the pelvic floor. AR was performed using an appropriately wide rectal mesentery resection technique if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. The mean distal margin achieved by AR was 3 ± 2 cm. ResultsMortality was 2% (12 of 514). Anastomotic leaks after AR occurred in 5% (16 of 291) and overall transient urinary retention in 15%. Eleven percent of patients had a wound infection (abdominal and perineal wound, 30-day, purulence, or cellulitis).The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after AR; 6% and 83%, respectively, after CM; and 4% and 80%, respectively, after APR. Patients with stage Ill disease, had a 60% disease-free survival rate. ConclusionsComplete resection of the envelope of supporting tissues about the rectum during APR, CM, and AR when tumors were low in the rectum is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. Appropriate "tumor-specific" mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. However, the overall failure rate of40% in stage Ill disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve better long-term survival rates.

Urinary retention is a common postoperative complication that increases hospital stay. It is most common after hemorrhoidectomy. Disease severity (quadrants excised and analgesia requirement for Group I and number of operations for Group II) is an important risk factor for both groups studied. Older age in Group I and perioperative fluid in Group II may be important risk factors.

Bezoars are conglomerates of food or fiber in the alimentary tract of humans and certain animals, mainly ruminants. In adults, bezoars are most frequently encountered after a gastric operation, but in children, bezoars are associated with pica, mental retardation, and coexistent psychiatric pathologic disorders. We describe a 4-year-old girl with trichotillomania in whom a gastric trichobezoar resulted in failure to gain weight, iron deficiency anemia, and a painless epigastric mass. The causes of gastric bezoars are discussed, with emphasis on diagnostic considerations, treatment options, and preventive measures.

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Older age is associated with increased FNR; patients with thick, ulcerated lesions should be considered for increased nodal surveillance after negative SLNB given low NPV in this group.