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Patients' Preferences For Sphincter Preservation Versus Abdominoperineal Resection For Low Rectal Cancer
Lawrence Lee, *Maude Trepanier, *Julien Renaud, *Sender Liberman, *Patrick Charlebois, *Barry Stein, Gerald M Fried, *Julio F Fiore, Jr., Liane S Feldman
McGill University Health Centre, Montreal, QC, Canada

Objectives: Proctectomy with primary anastomosis (i.e. sphincter preservation (SP)) for low rectal cancer can be associated with severe anorectal dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction after SP and permanent colostomy after abdominoperineal resection (APR). Therefore, the objective was to determine patients' preferences for SP versus APR for low rectal cancer.
Methods: All ambulatory patients consulting at a single high-volume academic colorectal referral centre from 09/2019-12/2019 were eligible for participation. Patients with malignancy, a pre-existing or past stoma, or prior rectal surgery were excluded. Consenting patients were presented with a hypothetical scenario describing a low rectal cancer without sphincter invasion amenable to proctectomy with SP or APR. They then completed a structured in-person interview consisting of a demographic questionnaire, threshold task, and the Wexner incontinence score. The threshold task focused on patients' preferences for functional and oncologic outcomes after proctectomy with SP, and determined the threshold at which patients would choose APR over SP.
Results: A total of 56 patients were recruited (mean age 49.5 years (SD13.8), 58% male, 81% consulting for hemorrhoids/fistula-in-ano). The median Wexner score was 0 [IQR0-0, range 0-11]. The median number of daily bowel movements that patients were willing to accept before choosing APR over SP was 5 [IQR3-6], daily episodes of stool incontinence 1 [IQR0-1], and gas incontinence 7 [IQR2.5-9]. APR was preferred over SP in 25% if patients had to alter their daily activities due to fecal urgency, and 37% if daily clustering symptoms were present. Patients were willing to accept an 8% [IQR5-20] absolute increase in risk of margin involvement with SP to avoid APR. APR was the preferred option overall for 27% of patients, who reported lower thresholds for daily bowel movements (p=0.041) and fecal incontinence (p=0.007).
Conclusions: Thresholds of anorectal dysfunction at which APR is preferred over SP are surprisingly low, and an important proportion of patients would prefer APR over SP due to impairments in anorectal function. The decision to perform SP or APR should consider how the patients' value functional outcomes with a low colorectal anastomosis.


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