1. TME: increased rate of sphincter saving resections

2. Nationwide decline in APR Engel AF Col Dis 2005 APR % 1994 versus 1999 No rise in hospital mortality Decline APR coincided with TME instruction

3. Determinants for success of sphincter preservation Young age Good preoperative function Proximal tumour location Absence of radiotherapy Wish of the patient

4. “Temporary” defunctioning stomas 19% of “temporary” stomas are never reversed Increased risk in case of postoperative complications or secondary constructed stomas Den Dulk M Lancet oncol 2007

5. Stoma related problems Noises60.8% Smell47.6% Bleeding33.5% Irritation skin33.0% Leaking25.0% Pain14.3% Peeters KC J Clin Oncol 2005

6. Restrictions with regard to defaecation RT+TME TME RT+TME TME no stoma stoma * * 0102030405060 cinema / theatre visit outdoor activities household activities * p < 0.01 Peeters KC J Clin Oncol 2005

7. 20 40 60 80 100 StomaNo stoma p=n.s.p=0.009 5-10 cm10-15 cm p=0.04p=0.02 RT+TME TME p=n.s.p=0.009p=0.04 → APR patients are more satisfied about defaecation Satisfaction about defaecation Peeters KC J Clin Oncol 2005

8. Acceptance of faecal incontinence Analysis of treatment and time trade-offs: Bossema E Eur J Surg Oncol 2007

9. Quality of life: APR versus LAR Cochrane report no difference 1 Age-specific Cultural differences Religious considerations Preoperative information 1 Pachler J Cochrane Database Syst Rev 2005