Beyond sphincter preservation in low rectal cancer: Context-Adapted reconstruction in France and Morocco – A bicentric retrospective cohort study

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BACKGROUND: Management of low locally advanced rectal cancer (LARC) requires balancing oncologic radicality, sphincter preservation, postoperative function, and long-term stoma acceptability. These challenges are amplified in settings where socioeconomic and cultural factors influence treatment decisions. This study aimed to provide a descriptive comparison of surgical and reconstructive pathways for LARC in France and Morocco. METHODS: This retrospective bicentric study included patients operated on between January 2017 and December 2024 for low LARC (cT3/T4 and/or node-positive adenocarcinoma within 5 cm of the anal verge). Outcomes were compared between Tours University Hospital, France (LARC-Fr), and the National Institute of Oncology, Rabat, Morocco (LARC-Mo). RESULTS: A total of 224 patients were included (80 LARC-Fr; 144 LARC-Mo). French patients were older (68 vs 57 years, p < 0.001) and had higher ASA III-IV scores (26.3% vs 2.1%, p < 0.001), whereas cT4 tumors were more frequent in Morocco (22.9% vs 7.5%, p = 0.003). Sphincter-preserving procedures, including intersphincteric resection (35.0% vs 0%, p < 0.001) and TaTME (35.0% vs 2.8%, p < 0.001), were more common in France, while abdominoperineal resection (APR) predominated in Morocco (79.2% vs 48.8%, p < 0.001). Among Moroccan patients with a definitive stoma, pseudocontinent perineal colostomy (PCPC) was performed in 64.1%. Major postoperative morbidity and reoperation rates did not differ significantly between cohorts. Complete mesorectal excision and R1 resection rates did not differ significantly. Three-year disease-free survival was 74.5% versus 73.2% (p = 0.075), and overall survival was 85.0% versus 71.9% (p = 0.279), respectively. CONCLUSIONS: This bicentric retrospective study describes distinct surgical and reconstructive pathways for low rectal cancer in France and Morocco. In the Moroccan cohort, PCPC was used after abdominoperineal resection as an alternative to a conventional permanent abdominal colostomy when sphincter preservation was not considered appropriate.

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