The management of rectal cancer has experienced a drastic evolution over the past three decades. The introduction of circular stapling devices, total mesorectal excision and neoadjuvant chemoradiation (CRT) have made substantial advances in the management of adenocarcinoma of the rectum [1–3]. Neoadjuvant CRT for the management of patients with stage II and III rectal cancer introduced a fascinating phenomenon – in that, some patients treated with this modality achieve a clinical complete response (cCR), which is defined as the lack of detectable rectal tumor with diagnostic modalities (i.e., endorectal ultrasound [EUS], MRI, digital rectal examination or proctoscopy). The fraction of patients treated with CRT who achieve a cCR is highly variable depending on the study (10–40%) . An important question following these observation was rapidly proposed: do we need to subject patients with cCR to the substantial risks of surgical intervention?