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Thomas et al. Mini-invasive Surg 2018;2:17 I http://dx.doi.org/10.20517/2574-1225.2018.25 Page 5 of 7

of using an evidence-based strategy that is tailored to the individual patient. In patients in whom we
can confidently predict favourable T1 disease we would offer local excision, either by TEM or standard
transanal excision as appropriate, or radical resection. In patients who opt for local excision and have
pT1 disease with unfavourable histology, then we would offer adjuvant LCCRT in addition to standard
radical resection. For pT2 disease and above, oncological options are compromised, and we would strongly
recommend completion radical surgery. In patients with cT1/T2 disease that appears amenable to local
excision, we offer the options of neoadjuvant therapy prior to LE or conventional resection. If patients elect
to undergo neoadjuvant therapy and local excision, then we undertake a detailed assessment of treatment
response using endoscopy, colonoscopic EUS and MRI prior to surgery. If a cCR is demonstrated, then
we will operate a watchful waiting policy in selected cases. Where a significant partial response or near-
cCR has been obtained, then we would proceed to local excision. This also gives us the option to offer
completion radical surgery if there has been minimal tumour regression or the disease has progressed
despite neoadjuvant treatment.

While the STAR-TREC trial aims to compare differing neoadjuvant regimens with radical surgery in early
[38]
rectal cancer (T1-T3a) , a direct comparison of neoadjuvant and local excision versus local excision and
adjuvant therapy has never been compared in a prospective study. It is possible that this debate may never
been resolved with randomized controlled trials owing to the complexity in study design. It is likely that
the neoadjuvant vs. adjuvant debate may only be answered with the use of large scale prospective registries.
The management of early rectal cancer that combines local excision techniques with neoajuvant/adjuvant
therapy is an evolving area of practice and we await the results of future studies with interest.

In patients with pT2 disease with unfavourable histology or pT3 disease not breaching the mesorectal
resection margin (based on MRI) we offer conventional laparoscopic or open anterior resection with or
without short course radiotherapy. In patients with more advanced disease our preference is to routinely
offer pre-operative CRT followed by surgery in 3-6 months. Indeed, we are moving towards at least 3
months following CRT after post-operative re staging. In patients with low disease not suitable for anterior
resection or local excision we favour extralevator abdominoperineal excision with immediate biologic
mesh reconstruction of the pelvic inlet augmented by the use of myocutaneous flaps where indicated [39,40] .
Our use of myocutaneous flaps has evolved over the last 10 years and we have recently found that bilateral
gluteal advancement flaps provide excellent healing and quality of life (unpublished data, Thomas, Warr,
Longman, Messenger).

DECLARATIONS
Authors’ contributions
Clinical and scientific data: Thomas MG, Messenger DE, Gash K
Systematic review data: Thomas MG, Messenger DE
Manuscript preparation: Thomas MG, Messenger DE, Gash K

Availability of data and materials
Not applicable.

Financial support and sponsorship
The study was supported by Fulbright Scholarship, Above and Beyond Research Trust, David Telling
Trust, RCS research Scholership, Bristol Cancer Research UK 5 year programme grant, and John James
Foundation Bristol.

Conflicts of interest
All authors declare that there are no conflicts of interest.