Rectal cancer is challenging to manage in elderly or frail patients, for whom chemoradiotherapy, brachytherapy, radical surgery, and local endoscopic excision may be poorly tolerated. Existing organ-preservation and palliative strategies often provide limited or short-lived benefit with significant toxicity. Early work with endoscopic electroporation (EE) has shown feasibility for palliation, but its structured role in organ preservation for stage II–III disease and escalation-free palliation in stage IV rectal cancer has not been established.The aim of this study was to evaluate the role of dual EE in supporting organ preservation, palliation, and salvage therapy in frail or medically unfit patients with treatment-naïve, residual, or recurrent rectal cancer.

Eighteen consecutive patients with rectal or rectosigmoid cancer (below the peritoneal reflection) were treated with combined calcium electroporation and irreversible electroporation between October 2023 and September 2025. Demographics, oncological history, symptoms, clinical response, complications and survival were obtained from a prospectively maintained database. Organ-preservation (stage II–III) was defined as avoidance of any rectal surgical resection after EE. Successful palliation (stage IV) required documented symptom control (bleeding, pain, obstruction) and absence of escalation of care (no new stoma, stenting, haemostatic-endotherapy, transfusion, or iron infusion). Follow-up and overall survival (OS) were calculated from first EE to death or data cut-off. All procedures were performed as day-case treatments under sedation using CE-approved equipment.

Median age was 84.9 years (range 54–93), with a male: female ratio of 2:1. Baseline symptoms included bleeding in 77.8%, pain in 61.1%, and subacute obstruction in 22.2%. Disease stages were II (11.1%), III (66.7%), and IV (22.2%). Fifteen tumours (83.3%) were mismatch-repair proficient. Eleven patients (61.1%) had residual or recurrent tumours after prior therapy (short-course radiotherapy 8/11; chemoradiotherapy 3/11), with additional brachytherapy (3/11), attempted endoscopic resection (3/11), or systemic therapy (2/11). Seven patients (38.9%), including all four rectosigmoid tumours, were treatment-naïve. Nine (50%) patients received a single EE session, and nine received multiple sessions (2–6). Median follow-up was 6.9 months (range 2.9–24.9). Median OS was 6.4 months (range 2.9–25.9), with 88.9% (16/18) alive at data cut-off. Organ-preservation occurred in 100% (14/14) of stage II-III patients at 6 months, with a 28.6% (4/14) complete clinical response rate. Among stage IV patients, 75% (3/4) achieved successful palliation, and 100% avoided invasive escalation of care. Overall symptomatic response was 88.9% (16/18), and tumour response was 77.8% (14/18). No procedure-related severe adverse events occurred.

Dual EE enabled universal organ preservation in stage II–III rectal cancer and meaningful escalation-free palliation in stage IV disease, with high symptomatic response and excellent safety in a frail, elderly cohort. EE may represent a versatile option for organ preservation, salvage therapy, and palliation in selected patients. Larger prospective comparative studies are warranted.