Background and Aims For patients with mid-to-low rectal cancer who achieve clinical complete response (cCR) or near-cCR after neoadjuvant chemoradiotherapy (nCRT), the key concern for both clinicians and patients is how to preserve anal function as much as possible without significantly compromising oncological outcomes. This study was performed to evaluate the safety and feasibility of local excision as an anus-preserving approach in rectal cancer patients with cCR or near-cCR.Methods A retrospective analysis was conducted on 51 patients with mid-to-low rectal cancer who underwent local resection after achieving cCR or near-cCR following nCRT at Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, between March 2014 and July 2023. The clinical characteristics, imaging and pathological findings, surgical outcomes, as well as oncological and functional results were reviewed.Results Among the 51 patients, 34 were male and 17 were female, with a mean age of 61±14 years. Pre-nCRT imaging staging showed: cT1-2N0 in 12 cases (23.5%), cT3N0 in 13 cases (25.5%), cT1-3N0-1 in 19 cases (37.4%), and cT1-3N2 in 7 cases (13.7%). The average tumor distance from the anal verge was (4.5±1.1) cm. After achieving cCR or near-cCR following nCRT, all patients underwent local resection: 40 cases (78.4%) underwent transanal endoscopic microsurgery (TEM), 7 cases (13.7%) underwent transanal minimally invasive surgery (TAMIS), and 4 cases (7.8%) underwent conventional transanal local excision. The postoperative complication rate was 27.5% (14/51), with 71.4% classified as Clavien-Dindo grade I. Postoperative histopathology showed ypT0 in 26 cases (51.0%), ypT1 in 8 cases (15.7%), ypT2 in 16 cases (31.4%), and ypT3 in 1 case (2.0%). The concordance rate between pathological results and preoperative imaging was 54.9%. Over a median follow-up of 60 months (range: 34-79), there were 4 cases (7.8%) of local recurrence, 12 cases (23.5%) of distant metastasis, and 5 cancer-related deaths (9.8%). Six months postoperatively, both the Wexner score and the low anterior resection syndrome (LARS) score significantly improved compared to post-nCRT values [Wexner: 1 (0-2) vs. 2 (1-5); LARS: 3.3±5.75 vs. 4.3±6.86; both P<0.01].Conclusion For patients with mid-to-low rectal cancer who achieve cCR or near-cCR after nCRT, local en bloc resection of the bowel wall lesions enables accurate assessment of residual tumor status and facilitates personalized subsequent treatment, potentially sparing some patients from radical surgery. Local resection can be a viable anus-preserving option for patients who are unfit for or strongly averse to radical resection. However, local excision cannot replace radical surgery, and its precise indications warrant further investigation.