Low-risk early rectal cancer

The treatment pathways for rectal cancer are evolving, in particular for patients who present with an early detected rectal cancer. Currently, the golden standard for rectal cancer treatment is radical surgery, i.e. low anterior resection or abdominoperineal resection both with adherence to the total mesorectal excision (TME) principles as advocated by Bill Heald. This type of meticulous surgical technique together with neo-adjuvant (chemo)radiotherapy in selected cases has led to high cure rates. However, the excellent oncological results are offset by signifi cant morbidity, adverse functional outcome (bowel, urinary and sexual function) and even mortality. In patients with early rectal cancer, these ‘side effects’ of radical surgery become even more signifi cant since in a proportion of these patients, radical surgery is overtreatment and local excision with preservation of the rectum is adequate. It is undisputed that local excision of poorly selected rectal cancers results in an unacceptably high incidence of local recurrence; however, some impressive results have been obtained with the use of local excision for low-risk early stage cancers or when used in combination with neo-adjuvant treatment for less favourable T2 disease. Here we will describe the application of local excision (predominantly transanal endoscopic microsurgery, TEM) for early rectal cancer (ERC), from pragmatic assessment of patients, operative techniques and most importantly management decisions on the basis of postoperative pathology.