Role of local excision in the treatment of rectal cancer

Local excision (LE) of properly selected rectal cancers can provide long-term survival, with minimal morbidity, negligible mortality, and excellent functional results. The role of LE has evolved over the past century. Initially, to avoid the excessive mortality of abdominal surgery, aggressive LE was performed to control the symptoms of rectal cancer. As abdominal surgery became safer, LE was restricted for use in palliation or high-risk patients. Better preoperative tumor staging resulted in an expanded role for LE, including curative-intent treatment of selected T_1-2 rectal cancers. Techniques for LE include snare polypectomy, transanal excision, transanal endoscopic microsurgery, and posterior approaches. The high local recurrence rate and compromised survival reported in modern series, despite efforts to properly select patients with cancers suitable for LE, have convinced the authors to restrict the use of curative-intent LE in good-risk patients only to the most favorable rectal cancers. Close follow-up after LE is critical, because radical surgical salvage is usually possible if recurrence is identified promptly. Whether adjuvant chemoradiation can expand the role of curative intent LE remains controversial.