直肠位于盆腔，毗邻括约肌复合体及泌尿生殖器官，解剖学特性比结肠复杂得多，因此，直肠癌的处理涉及更多的问题，如盆腔放疗、侧方淋巴结清扫、经肛手术入路、术后功能、括约肌保留及非手术处理等。对比2013年版美国结直肠外科医师协会直肠癌诊疗临床实践指南，2020年版指南对直肠癌外科治疗中长久以来的及新近出现的争议提出了新的循证推荐，包括局部切除手术适应证、根治性切除术的淋巴结清扫、微创技术的开展、临床完全缓解患者的等待观察以及吻合口漏的预防。同时，指南还推荐了用于指导围手术期综合治疗的非转移性直肠癌风险分层方法，以及基于治疗意图的转移性直肠癌个体化多学科治疗方案。“,”Located in the pelvic cavity and contiguous to the anal sphincter complex and urogenital organs, the rectum has more intricate anatomical features compared with the colon. Consequently, the treatment of rectal cancer involves more consideration, including pelvic radiation, lateral lymph node dissection, transanal access, postoperative function, sphincter preservation, and nonoperative management. Based on the last set of American society of colon and rectal surgeons (ASCRS) practice parameters for the management of rectal cancer published in 2013, the 2020 guidelines present evidence-based updates for both long-existing and emerging controversies on surgical management of rectal cancer. These updates include the indication for local resection, lymph node dissection for radical proctectomy, minimally invasive surgery, the “watch and wait” strategy for patients with clinical complete response, and prevention of anastomotic leak. Meanwhile, the guidelines recommend a risk-stratified approach for perioperative therapies for non-metastatic disease, and an individualized multimodality treatment based on treatment intent for synchronous metastatic disease.