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Figure 4. An obstructing T3 tumor excised by transanal minimally invasive surgery for palliation in a patient with liver and lung metastases

ing and refuse radical resection to avoid its complications like fecal or sexual dysfunction, or to maintain
intestinal continuity and avoid a permanent colostomy with an acceptable risk of higher recurrence rate.

Knowledge about the role of local excision for lesions deeper than T1 is mostly limited to small series of
[19]
patients who declined TME or were unfit for abdominal surgery [Figure 5]. These series have reported
significantly higher local recurrence rates. These series also do not follow a standard protocol of chemo-
therapy or radiotherapy.

[38]
Lezoche et al. studied the long-term outcomes of 70 patients with T2N0 rectal cancer randomized to
TEM or laparoscopic TME. All patients in each group had received neoadjuvant chemoradiation. They re-
ported a local recurrence rate of 5.7% after local excision versus 2.8% percent after laparoscopic TME, with
a median follow-up of 84 months. There was no difference in disease-free survival.

Similarly, American College of Surgeons Oncology Group (ACOSOG) Z6041 trial investigated the role of
local excision for clinically staged T2N0 rectal cancer following neoadjuvant chemoradiation. Local recur-
[39]
rence rate was reported as 4% and distant metastasis as 6% after a median follow-up of 56 months .

FUNCTIONAL OUTCOMES AND QUALITY OF LIFE
The biggest driving force behind less invasive approaches for rectal cancer - especially for early rectal can-
cer - is the high morbidity of gold standard technique; TME. Functionally unfavourable outcomes in intes-
tinal, urinary and sexual functions are the major concerns for patients’ postoperative quality of life (QoL).
Local excision can potentially decrease the incidence of these complications and improve QoL. TEM has
been associated with fecal incontinence due to its 4-cm diameter scope and rates of up to 37% worse in-
[40]
continence has been reported after TEM . TAMIS seems more advantageous in this regard as it utilizes
a flexible port to access rectum. Although longer term follow-up data is available for TEM, the impact of
TAMIS on patients’ QoL is unclear - due to it being a relatively new technique.

[41]
Recently, Clermonts et al. published their data of 37 patients who underwent TAMIS for dysplastic ses-
sile polyps or cT1 rectal cancer. They compared Short-Form 36 Health Survey responses of 37 patients to a
healthy case-matched population. This study demonstrated that patients scored worse than healthy control
group in physical functioning, general health perception and social functioning domains. After a 3-year
follow-up, 9 patients reported improved fecal incontinence severity index (FISI) scores, 19 patients deterio-
rated and 9 patients remained same.

[42]
On the other hand, Verseveld et al. compared QoL of 24 patients undergoing TAMIS before and 6