It is very difficult to divide epidemiological data of colon and rectal cancer as they are traditionally reported together. In 2002, there were 1 million new cases of colon and rectum cancer [1] (9.4% of the world total of new cancers). This means that it is fourth in incidence frequency in men and third in women. Among all large bowel tumours, rectal cancer accounts for about 30-40% of cases. Although the incidence is higher in developed countries, changes in environmental exposure, mainly dietary, have led to an increase in developing countries too. The high socioeconomic impact and increasing attention is easy understandable not only in the treatment but in prevention and early detection too, as demonstrated by the number of screening programmes developed.

The modern history of rectal cancer treatment began in 1908, when Miles [2] wrote "Method for performing abdominoperineal excision for carcinoma of the rectum and the terminal portion of the pelvic colon". This paper was the milestone of surgical treatment of rectal cancer and it was based on the concept of the "cylindrical spread of rectal cancer". Miles suggested that the location of the tumour in rectum was not important for the surgeon because only mutilating surgery (based on abdominal and perineal approach) could be an efficient treatment. The high impact of this kind of operation pushed surgeons into finding a new surgical approach.

In the 1940s, Dixon [3] described the anterior resection (AR) for rectal cancer, in order to avoid a definitive stoma, but the high incidence of technical failure and the lack of information about the biological history of cancer contributed to make the abdominoperineal procedure more popular than other procedures and it was not outdated for a long time. Only at the end of 1970s did the exponential growth in oncologic knowledge and technical devices begin to lead to dramatic change in the treatment of rectal cancer. First, the introduction of mechanical stapling devices overcame the technical problems of handsaw anastomosis at the distal rectum and anal canal. Also, the introduction of the "mesorectum" [4] concept (the milestone of rectal cancer behaviour) and the introduction of an efficient adjuvant and neoadjuvant therapy have dramatically reduced the incidence of Miles procedure.

Rectal surgery has shifted from the idea that "rectal surgery means permanent colostomy" to the new idea of surgery with sphincter saving, as there is a "consensus" that avoiding a permanent stoma is now generally regarded as favourable. This can be easily understood from the title of a recent review: "Do we still need a permanent colostomy in 21st century?" [5].

In our experience, as described in another chapter of the book, the introduction of triple neoadjuvant therapy (hyperthermia, radio- and chemotherapy) allows us to treat very low rectal cancer with a sphincter-saving procedure, but we do think that technical feasibility should not be the only parameter that surgeons consider when planning surgery.

The main end-points for judging the results of rectal surgery should include survival, recurrence and complication, but also quality of life (QoL).

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