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BACKGROUND: Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. METHODS: Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. RESULTS: Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. CONCLUSION: EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.