Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery (Br J Surg 2009; 96: 1066–1075)

Sir We thank you for this original article. The study included data from five European trials, excluding patients over 75 years. In our experience, at least third of patients undergoing rectal surgery are over the age of 75 years. Advancing age inevitably brings increased co-morbidities, which can translate into higher rates of complications, including anastomotic leak, and has a bearing on long-term outcomes. The data come from trials that were conducted at different times, with an overall time frame from 1987 to 2002. With the advent of total mesorectal excision (TME) and improvement in surgical staplers over the years, it raises the question of whether trials carried out before the introduction of TME should even be considered for incorporation into such a study. Some 80 per cent of the eligible patients in the study had a tumour distance of over 5 cm from the anal verge. Extent of surgical resection and threshold for TME varies to some extent among specialists, and ability to construct a low anastomosis may also be influenced by the patient's sex. A man with a long anal canal and narrow pelvis is quite a different challenge for such restorative surgery. It would have been informative to have further stratification of tumour distances specifically with reference to patients' sex.