In 1908, Miles described the procedure of abdominoperineal resection that became the gold standard for treatment of distal rectal cancer.[1] Success of radical surgery in the form of abdominoperineal or low anterior resection has stood the test of time due to its sound oncologic principles. However, radical resection is not without its disadvantages, including high perioperative morbidity, potential for permanent colostomy, and negative effects on bowel, sexual, and urinary function.[2],[3] Therefore, the role of local excision in the treatment of early rectal cancer has been investigated. This approach involves full thickness excision of the rectal cancer with negative radial and deep margins without inclusion of its mesorectal envelope in the pathologic specimen. Local excision provides faster postoperative recovery with low procedural morbidity and mortality.[4] However, local excision is only appropriate in selected early-stage rectal cancer cases, because recurrence rates are unacceptably high when it is used to treat more advanced tumors.[5],[6],[7],[8],[9]

High local recurrence rates following local excision of rectal cancer result from the omission of nodal staging and clearance of the lymphatic bed along with the tumor. Even T1 rectal cancers have approximately 10% risk of harboring metastatic disease in the lymph nodes.[10] With the advent of newer and more sophisticated local excision techniques that allow improved visualization and precise margins, local excision is commonly practiced for the management of early rectal cancer. A 2013 study based on the National Cancer Database reported that 46.5% of T1 rectal cancers were treated with local excision.[11] The study also showed that patients with T2 tumors treated with local excision had worse survival than those treated with proctectomy or multimodality therapy.