Rectal cancer is a highly prevalent disease. Evidence presented in the 2025 phase-III OPERA randomised trial suggests that Contact X-ray Brachytherapy (CXB), with external beam chemoradiotherapy, is a viable organ-preserving alternative to radical surgery. We conducted a systematic review and meta-analysis to assess the clinical effectiveness of CXB in the treatment of rectal cancer. This systematic review was prospectively registered (CRD42021284969) and reported following PRISMA guidelines. Multiple electronic databases were interrogated using the search terms "Rectal cancer", "Contact Brachytherapy", and synonym terms. Clinical complete response (cCR) was the primary outcome. Proportional meta-analyses were conducted and presented as forest plots with summary proportions and 95 % confidence intervals. The literature search identified 973 studies, of which 52 studies encompassing 5447 patients met the inclusion and exclusion criteria and were included in the meta-analysis. Pooled estimates of outcomes were as follows: cCR rate = 82 % (95 % CI 76-88 %), Local Regrowth rate = 20 % (95 % CI 15-25 %), regional metastasis rate = 3 % (95 % CI 2-4 %), salvage surgery rate = 14 % (95 % CI 11-18 %), long-term disease control post-salvage surgery rate = 88 % (95 % CI 78-96 %) and organ preservation = 81 % (95 % CI 74-88 %). CXB in the appropriately selected patient population can achieve long-term disease control and organ preservation whilst avoiding major surgery. Salvage surgery remains a viable option for patients who experience disease regrowth with excellent long-term disease control. Clinicians should discuss CXB with rectal cancer patients, presenting it as a viable and safe alternative to radical surgery. This is particularly pertinent for patients who are stoma-averse or older patients in frail health.

Available platforms for local excision (LE) of early rectal cancer are rigid or flexible [trans‑anal minimally invasive surgery (TAMIS)]. We systematically searched the literature to compare outcomes between platforms.

PRISMA-compliant search of PubMed and Scopus databases until September 2022 was undertaken in this random-effect meta-analysis. Statistical heterogeneity was assessed using I2 statistic. Studies comparing TAMIS versus rigid platforms for LE for early rectal cancer were included. Main outcome measures were intraoperative and short-term postoperative outcomes and specimen quality.

7 studies were published between 2015 and 2022, including 931 patients (423 females); 402 underwent TAMIS and 529 underwent LE with rigid platforms. Techniques were similar for operative time (WMD 11.1, 95%CI - 2.6 to 25, p = 0.11), percentage of defect closure (OR 0.7, 95%CI 0.06-8.22, p = 0.78), and peritoneal violation (OR 0.41, 95%CI 0.12-1.43, p = 0.16). Rigid platforms had higher rates of short-term complications (19.1% vs 14.2, OR 1.6, 95%CI 1.07-2.4, p = 0.02), although no significant differences were seen for major complications (OR 1.41, 95%CI 0.61-3.23, p = 0.41). Patients in the rigid platforms group were 3-times more likely to be re-admitted within 30 days compared to the TAMIS group (OR 3.1, 95%CI 1.07-9.4, p = 0.03). Rates of positive resection margins (rigid platforms: 7.6% vs TAMIS: 9.34%, OR 0.81, 95%CI 0.42-1.55, p = 0.53) and specimen fragmentation (rigid platforms: 3.3% vs TAMIS: 4.4%, OR 0.74, 95%CI 0.33-1.64, p = 0.46) were similar between the groups. Salvage surgery was required in 5.5% of rigid platform patients and 6.2% of TAMIS patients (OR 0.8, 95%CI 0.4-1.8, p = 0.7).

TAMIS or rigid platforms for LE seem to have similar operative outcomes and specimen quality. The TAMIS group demonstrated lower readmission and overall complication rates but did not significantly differ for major complications. The choice of platform should be based on availability, cost, and surgeon's preference.

The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.