BackgroundTextbook outcome has been incorporated into quality assessment measures in various oncology settings; however, it has not been applied to patients with low rectal cancer after neoadjuvant chemoradiotherapy (nCRT). This study aimed to examine the prevalence and predictors of achieving a textbook outcome in patients undergoing surgical resection of low rectal cancer after nCRT. Patients and methodsThis study was a post hoc subgroup analysis of the prospective multicentric LASRE trial, which specifically enrolled patients with rectal cancer located within 5 cm from the dentate line at diagnosis, tumors with diameters less than 6 cm, and patients who underwent radical laparoscopic or open resection. A total of 597 patients who had clinically staged cT3-4aN0-2M0 tumors with diameters less than 6 cm and who underwent neoadjuvant chemoradiotherapy followed by radical resection were included. ResultsTextbook outcome was achieved in 60.0% of patients. Multivariate logistic regression analysis revealed that body mass index > 25 kg/m2 (OR = 0.594, P = 0.01), tumor distance from the anal verge > 40 mm (OR = 5.518, P < 0.001), operative time > 202 minutes (OR = 0.675, P = 0.04), and laparoscopic approach (OR = 1.497, P = 0.04) were independently predictive factors for the achievement of a textbook outcome in low rectal cancer patients undergoing nCRT and radical resection. A predictive nomogram for achieving a textbook outcome was constructed, yielding a C-index of 0.724. ConclusionsLaparoscopic resection exhibited promising potential in improving the probability of achieving a textbook outcome.