Increased incidence of local recurrence rate and decreased survival is the main problem of local resections (for cancers) when compared to radical surgery. The rate of local recurrence has been reported to occur in 0-37% of patients with T1 or T2 cancers [17,18]. Table 3 shows the recurrence rates in recent series using various techniques. Although TEM seems to be associated with a lower local recurrence rate (9 vs. 22%), one must note the shorter follow up in the TEM patients and the more favourable pathology (71% Ca in situ/Tl in TEM vs. 57% in local resection). Also, the local resection articles tend to include patients that had other techniques such as Localio (Kraske), Mason or fulguration.
The increased risk of local recurrence following local resections is due to the less radical nature of surgery and the fact that perirectal nodes are not excised. Thus patient selection is based on selecting tumours with a low risk of lymph node metastases. Histological features associated with increased risk of lymph node metastases are: poor differentiation, lymphovascular invasion and more advanced T stage. If any of these histological features are found, then one should consider adjuvant therapy or performing radical resection [16, 19]. However, the risk of lymph node involvement is present in all cancers. Blumberg et al.  found that even T1 cancers (that underwent a radical resection) with no adverse histo-logical features had a 7% risk of lymph node involvement.
Salvage surgery for recurrences is only successful in 45-60% of cases that were initially treated with local resection for Stage I rectal cancer .
A very interesting use of TEM has been described by Lev-Chelouche et al. . He pointed out synchronous colorectal neoplasms that are a common pathology which at times necessitate extensive abdominal surgery. When one of the lesions is located in the rectum, the operation has even higher rates of morbidity and mortality. In such cases, they suggested a two-step procedure, comprising TEM resection for the rectal tumour followed by a less extensive abdominal resection for the second.
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