Many studies demonstrates that neoadjuvant RCT for low rectal cancer leads to an improvement in survivals and recurrence's rates after a local downstaging. Nevertheless, the percentages of definitive stomas has never been considered as an end-point of these kind of studies and the surgical decision should be planned and discussed with the patient before the beginning of the multimodal treatment. Moreover, an irradiated tissue should increase the complications' rates (i.e: leakage, incontinence) after a borderline ultra-low reconstruction.
Very few prospective studies have done this.
most surgeons they operate based on 1st MRI, so if sphincter or levator involved , even after lcrt good response, patients still undergo aper. However
3 situation sphincter can be saved
1. Large bulky tumors, where getting a contour safely below tumor difficult to perform technically despite safe margins.these tumors if respond are easier to handle and fire contour hence save sphincter
2. 10% patients after CTRT complete response and in centers favoring close observation, habr gama sphincter preserved
3 in tumors with involvement of internal sphincter but intersphincteric space free, isr can be performed safely if good response ctrt
chsnging conch of distal resection margin less than 1 cm also helps sphincter preservation
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