Overview

In 1908, WE Miles described an abdominoperineal resection (APR) which became, at that time, the gold standard for treating distal rectal cancer.[1] Success of radical surgery in the form of abdominoperineal or low anterior resection has stood the test of time because of its sound oncologic principles. However, radical resection (APR or LAR) is associated with high perioperative morbidity, the potential for permanent colostomy, and negative effects on bowel, sexual, and urinary function.[2][3] Therefore, local excision of early rectal cancer has been investigated as a less morbid alternative to proctectomy. It has been proven to be effective, in terms of local control and survival, in early stage rectal cancers, especially with T1N0 lesions without negative histologic features.[4][5][6]

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 nodal disease.[7] With the advent of newer and more sophisticated local excision techniques, which allow improved visualization and the precise evaluation of 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. This study also showed that patients with T2 tumors treated with local excision had worse survival than those treated with proctectomy or multimodality therapy.[8]