Sphincter preservation for distal rectal cancer--a goal worth achieving at all costs?

To assess the merits of currently available treatment options in the management of patients with low rectal cancer, a review of the medical literature pertaining to the operative and non-operative management of low rectal cancer was performed, with particular emphasis on sphincter preservation, oncological outcome, functional outcome, morbidity, quality of life, and patient preference. Low anterior resection (AR) is technically feasible in an increasing proportion of patients with low rectal cancer. The cost of sphincter preservation is the risk of morbidity and poor functional outcome in a significant proportion of patients. Transanal and endoscopic surgery are attractive options in selected patients that can provide satisfactory oncological outcomes while avoiding the morbidity and functional sequelae of open total mesorectal excision. In complete responders to neo-adjuvant chemoradiotherapy, a non-operative approach may prove to be an option. Abdominoperineal excision (APE) imposes a permanent stoma and is associated with significant incidence of perineal morbidity but avoids the risk of poor functional outcome following AR. Quality of life following AR and APE is comparable. Given the choice, most patients will choose AR over APE, however patients following APE positively appraise this option. In striving toward sphincter preservation the challenge is not only to achieve the best possible oncological outcome, but also to ensure that patients with low rectal cancer have realistic and accurate expectations of their treatment choice so that the best possible overall outcome can be obtained by each individual.