Organ preservation in rectal cancer: a synopsis of current guidelines

Aim: The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice. Method: The PubMed, Embase, Trip, National Guideline Clearinghouse and BMJ Best Practice databases were interrogated. Guidelines published before 2010 were excluded. The AGREE-II tool was used for quality assessment. Results: Twenty-four guidelines were drawn from 2278 potential publications. A consensus exists for local excision for ‘low-risk’ T1 rectal cancer but there is no agreement on how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease, but when mentioned it is recommended for unfit patients or in the context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node-negative disease and after complete response to chemoradiotherapy. Conclusion: According to current guidelines and consensus statements, organ preservation for rectal cancer beyond low-risk T1 is still considered experimental and only indicated in patients who are unsuitable for radical surgery. Follow-up strategies and cN0 staging deserve attention, highlighting the need for high-quality clinical trials.