Are There any Limitations for Advising a Low Anterior Resection and to Whom Should an APR be Recommended

Most patients think of the stoma as a terrible disaster that might put an end to a normal life and many studies in the past have painted a gloomy picture of the stoma patient's lifestyle. Therefore the patient's personal preference would probably be for an operation that retains normal anal function, even at the price of functional imperfections and maybe even a somewhat reduced prospect of ultimate cure. But patients should know the shortcomings of each procedure. Patients have to know that with a properly sited and well constructed stoma, a perfectly fitted stoma appliance and the advice and support of a stoma nurse the patient will be able to lead a normal life. Patients should be informed that despite all precautions taken to avoid technical errors, the risk of anastomotic leaks and pelvic septic complications still remains a problem, particularly after low anastomosis; and the post-operative course is unpredictable. Patients have to know that such a complication may often be associated with a painful protracted post-operative course and a long hospital stay and that in some unfortunate cases the consequences may lead to rectal stump/pouch excision and eventually a permanent colostomy. Even with an uncomplicated post-operative course the functional result may be far from acceptable and quite a few patients will suffer from increased frequency, urgency, faecal incontinence, and permanent or occasional soiling. Although alternative neorectal constructions may improve function, they are demanding and risky pro cedures, they are still associated with functional imperfections, and it is doubtful if they will stand the test of the time.

Although the curative value and the radicality of the AR and APR are probably similar, the development of a local pelvic recurrence after a sphincter-saving operation is particularly distressing. The risk of pelvic recurrence may not be greater than after an APR, but a recurrence will give distressing symptoms at an earlier stage. The symptoms are more difficult to manage and may require another major operation, often at a time when the patient may just have recovered from the first operation, and this operation will seldom be curative.

Many experienced surgeons would probably advise against a low anterior resection for anaplastic tumours, and otherwise bulky and/or fixed tumours, reserving the operation for mainly local and limited growths, and those with low-grade malignancy. An APR may also be preferable for old age, particularly for those with a short life expectancy and those with a serious contemporary disease (diabetes, cardiac or pulmonary insufficiency etc.). In these patients an "ultralow" rectal resection - with square stapling of the anorectal remnant, omitting the perineal dissection - would be justified, considerably reducing the operative trauma and post-operative morbidity.

Considering the defecation urgency and imperfections of continence after an AR, it appears reasonable also to advise against the operation for immobile and bedridden patients i.e., for those who have difficulty reaching a toilet in time and for those who for their daily care are dependent on nursing staff.

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