Local excision is a suitable approach for treating sessile adenomas and early adenocarcinomas of the rectum. The indication for transmural rectal carcinomas (T2 and T3) is a matter of debate and no randomized studies have been reported to date. The early and long-term results of a consecutive series of 160 patients who underwent local excision in our departments are reported. Sixty-three patients (39%) had adenoma and 97 patients (61%) carcinoma. Forty-seven patients with carcinoma (48%) received adjuvant therapy. Postoperative complications occurred in 25 patients (15%). The complication rates were 13% (8/63) for adenomas and 18% (17/97) for carcinomas. Only 1 patient died during the postoperative period as a result of unrelated causes. The overall local recurrence rates were 3% and 24%, respectively. Among the adenocarcinomas recurrence was related to staging, tumour clearance at the resection margins and use of chemo- and radiotherapy. No recurrences were reported among the T2 patients submitted to neoadjuvant treatment. A difference versus radical surgery was observed for T3 patients only. Local excision and transanal endoscopic microsurgery in particular is worthwhile in adenomas and T1 carcinomas of the rectum. Patients with T2 tumors should be treated with preoperative chemo- and radiotherapy. Patients with T3 tumors should be treated with transanal endoscopic microsurgery for palliative purposes only.