The APR has often been referred to as a formidable operation associated with significant changes in body image. Devlin et al.  and Williams and Johnston  painted a very gloomy picture of colostomy patients' QoL, the majority suffering from leakage and odour restricting their social life. However, although an AR leaves patients' body image intact, the procedure may be associated with considerable functional disturbances. Excision of tumours in the mid and distal third of rectum means sacrifice of the major or entire part of the rectal ampulla thereby interfering with the delicate recto-anal nervous control of defecation and continence. Increased evacuation frequency, defecation urgency and imperfection of continence is inevitable, occurring in between half and two thirds of patients, with increasing severity the lower the colo-anal anastomosis [16,17]. The use of pre-operative radiation contributes to further deterioration of function .
From these results, it seems that a rectal stump of about 6 cm from the anal verge is necessary to maintain reasonable recto-anal function, confirming the statement of Goligher et al. . As a shorter stump may confer worse function, the fashioning of a short 5-7-cm colon J-pouch or alternatively a coloplasty procedure created by making an 8-10-cm longitudinal colostomy above the anastomosis and closed transversely with two layers of sutures has been advocated in an attempt to restore a neo-rectal reservoir and such trials have proved to be beneficial [19, 20]. It should be mentioned however that, apart from being demanding procedures with specific inherent complications, functional imperfections still remain (evacuation difficulties and incontinence) and long-term effects are unknown. The traditional view of low anterior resection seems now to have been modified to comprise total rectal excision with colopouch anal reconstruction as the standard restorative operation for tumours of the mid and lower rectum.
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