Annals of Surgery Volume 265, Number 4, April 2017
Letters to the Editor
temperature. When at least 3 of the aforementioned conditions were present in association with cholecystolithiasis (gallstones and/or sludge) or ultrasound signs of cholecystitis, patients were considered eligible to be enrolled in the trial. Some concerns arise. The clinical conditions evaluated by the protocol are commonly recognized as nonspecific6,7 and may also be present in a number of patients without acute cholecystitis suffering from different abdominal conditions. Particularly, this may be the case of patients with cholecystolithiasis experiencing biliary colics. On ultrasound examination, the study protocol considered as eligibility criteria not only signs of cholecystitis but also cholecystolithiasis per se. This means that a number of symptomatic patients received a diagnosis of acute cholecystitis despite a radiological assessment revealing none of the major ultrasonographic diagnostic criteria.8,9 In this regard, it is not clear why, once an ultrasound assessment was obtained for each patient, the diagnosis of acute disease was not made accordingly, given that ultrasonography has excellent sensitivity and specificity, far higher than clinical features.6,7 Indeed, according to the literature, in the absence of characteristic imaging findings, only a diagnosis suggestive of acute cholecystitis can be made.6,10 In conclusion, it would be extremely interesting to know how many included patients had ultrasound evidence of acute cholecystitis and how many did not. Second, it would be interesting to know in what percentage of patients the diagnosis of acute cholecystitis was confirmed at surgery by direct intraoperative assessment. We congratulate Dr Gutt et al on their elegant and timely study, although we recommend particular caution in interpreting their data. The selection criteria used to enroll patients may impair the power of the analysis and the possibility of drawing definitive conclusions from their outcomes. Disclosure: No sources of funding have been received related to this investigation. No potential competing interests exist for all authors. Francesco Guerra, MD Luca Moraldi, MD Lucia Barni, MD Stefano Amore Bonapasta, MD Division of Oncological and Robotic General Surgery Careggi University Hospital Florence, Italy [email protected] e54 | www.annalsofsurgery.com
REFERENCES 1. Gutt CN, Encke J, Ko¨ninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258:385–393. 2. Gargya V, Smolarek S, Walsh TN. Concerns about acute cholecystitis: early versus delayed cholecystectomy–a multicenter randomized trial. Ann Surg. 2015;262:e63–e64. 3. Bu¨chler MW, Harnoss JC, Daniel D. Reply to Letter: ‘‘Timing of cholecystectomy in acute cholecystitis’’. Ann Surg. 2015;262:e87. 4. de Bruijn RE, Sonneveld DJA, van IJsseldijk ALA. Timing of cholecystectomy in acute cholecystitis. Ann Surg. 2015;262:e87. 5. Godbole CB, Doctor NH. Early cholecystectomy for acute cholecystitis: how early should it be? Ann Surg. 2015;262:e74. 6. Yokoe M, Takada T, Strasberg SM, et al. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci. 2012;19:578– 585. 7. Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804–2811. 8. Schiller VL, Turner RR, Sarti DA. Color Doppler imaging of the gallbladder wall in acute cholecystitis: sonographic-pathologic correlation. Abdom Imaging. 1996;21:233–237. 9. Uggowitzer M, Kugler C, Schramayer G, et al. Sonography of acute cholecystitis: comparison of color and power Doppler sonography in detecting a hypervascularized gallbladder wall. AJR Am J Roentgenol. 1997;168:707–712. 10. Hirota M, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg. 2007;14:78–82.
Weight Loss Before Bariatric Surgery To the Editor: e read with great interest the study by Anderin et al1 in the December 2014 issue of Annals of Surgery. However, we believe that external validity of those findings is questionable, and we warn readers against an over-interpretation of these data. Indeed, the influence of nutritional status on postoperative morbidity and mortality has been well documented for years in both retrospective and prospective studies and decreased weight loss before a surgical procedure has been considered to be associated with a higher postoperative mortality rate.2–5 Consequently, the Anderin et al study conclusions are in full contradiction with all current recommendations endorsed by European and American6–9 guidelines based on an updated literature review. In nonbariatric patients, Mullen et al10 have shown in a prospective, multi-institutional, risk-adjusted cohort study of 118,707 patients that patients undergoing general
W
ß
surgical procedures have paradoxically ‘‘lower’’ crude and adjusted risks of mortality compared with patients with ‘‘normal’’ preoperative weight. This study confirmed the existence of an ‘‘obesity paradox’’ in this subset of patient population. More recently, Khan et al11 showed in 44,408 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that independent predictive factors associated with significantly increased postoperative mortality included 10% weight loss during the 6 months before bariatric procedure (AOR,13.5). Furthermore, an important proportion of obese surgical patients have sarcopenic obesity at operation, with relative low levels of lean body mass despite a large body habitus. This means that those patients are at higher risk of major perioperative complications and mortality.12 In conclusion, we believe that systematic preoperative weight loss before bariatric surgery could lead to an increased postoperative mortality rate and could end up with a counter-intuitive postoperative effect.12 Disclosure: No sources of funding have been received related to this investigation. No potential competing interests exist for all authors. Didier Quilliot, MD, PhD Nicolas Reibel, MD Laurent Brunaud, MD, PhD CHU de Nancy Service de Nutrition-diabe´tologie Rue du Morvan Vandoeuvre-les-Nancy Nancy, France Service de chirurgie ge´ne´rale et urgences Hoˆpital Central Nancy, France Service de chirurgie endocrinienne et digestive Hoˆpital Central Nancy, France [email protected]
REFERENCES 1. Anderin C, Gustafsson UO, Heijbel N, et al. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg). Ann Surg. 2015;261: 909–913. 2. Velanovich V. The value of routine preoperative laboratory testing in predicting postoperative complications: a multivariate analysis. Surgery. 1991;109:236–243. 3. Dannhauser A, Van Zyl JM, Nel CJ. Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations—part II. J Am Coll Nutr. 1995;14:91–98. 4. Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of risk factors. J Surg Res. 2002;103:89–95.
2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 265, Number 4, April 2017
5. Sandstrom R, Drott C, Hyltander A, et al. The effect of postoperative intravenous feeding (TPN) on outcome following major surgery evaluated in a randomized study. Ann Surg. 1993;217: 185–195. 6. Weimann A, Braga M, Harsanyi L, et al. ESPEN Guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224– 244. 7. Chambrier C, Sztark F. French Clinical Guidelines on perioperative nutrition: update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults. J Visc Surg. 2012;149:e325–e336. 8. Klein S, Kinney J, Jeejeebhoy K, et al. Nutrition support in clinical practice: review of published data and recommendations for future research directions. Summary of a conference sponsored by the National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. Am J Clin Nutr. 1997;66:683–706. 9. Martindale RG, McClave SA, Taylor B, et al. Perioperative nutrition: what is the current landscape? J Parenter Enteral Nutr. 2013;37:5S–20S. 10. Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250:166–172. 11. Khan MA, Grinberg R, Johnson S, et al. Perioperative risk factors for 30-day mortality after bariatric surgery: is functional status important? Surg Endosc. 2013;27:1772–1777. 12. Gerber P, Anderin C, Thorell A. Weight loss prior to bariatric surgery: an updated review of the literature. Scand J Surg. 2015;104:33–39.
Response to ‘‘Weight Loss Before Bariatric Surgery and Postoperative Complications’’ Reply: e would like to comment on the letter by Quilliot and collaborators regarding our study over the effects of weight loss before bariatric study.1 The authors claim that our conclusions are in conflict with previous data demonstrating an association between weight loss and increased postoperative morbidity/mortality. To our understanding, this misinterpretation must reflect unawareness of the crucial distinction between unintentional and intentional weight loss. In none of the studies cited in the letter was unintentional, disease-associated weight loss controlled for. Thus, in patients losing weight, any underlying condition could have been expected to simultaneously influence weight and postoperative outcome. This is in similarity to the large SOS (Swedish Obese Subjects) interventional study, in which intentional (surgical) weight
loss was shown to be associated with almost 30% reduced mortality after 15 years,2 although most epidemiological studies by that time had demonstrated a relationship between (unintentional) weight loss and mortality.3–5 We appreciate that we have been given the opportunity to make this important clarification. We are, however, confident that most readers of Annals of Surgery are well aware of the difference between unintentional, diseaseassociated weight loss and an intervention that is aimed at, and now convincingly demonstrated to be associated with, improved outcome after bariatric surgery. Disclosure: The authors declare no conflicts of interest. Claes Anderin, MD, PhD Surgical Department Ersta Hospital Stockholm, Sweden [email protected]
REFERENCES 1. Anderin C, Gustafsson UO, Heijbel N, et al. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg). Ann Surg. 2015;261:909–913. 2. Sjo¨stro¨m L, Narbro K, Sjo¨stro¨m CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–752. 3. Lee IM, Paffenbarger RS Jr. Change in body weight and longevity. JAMA. 1992;268:2045–2049. 4. Walker M, Wannamethee G, Whincup PH, et al. Weight change and risk of heart attack in middle-aged British men. Int J Epidemiol. 1995;24:694–703. 5. Lissner L, Odell PM, D’Agostino RB, et al. Variability of body weight and health outcomes in the Framingham population. N Engl J Med. 1991;324: 1839–1844.
Are We Ready for Extralevatory Abdominoperineal Excision?
W
ß
Letters to the Editor
To the Editor: lein et al1 reported an interesting nationwide investigation focusing on extralevatory abdominoperineal excision (ELAPE) efficacy, based on Danish Colorectal Cancer Group’s prospective database from 2009 to 2012. The authors concluded that, when compared with conventional abdominoperineal excision (APE), rectal tumor resection after ELAPE had a higher rate of positive circumferential resection margin [CRM(þ)] and comparable rate of intraoperative perforation (IOP). However, we would like
K
2017 Wolters Kluwer Health, Inc. All rights reserved.
to comment on the effectiveness of ELAPE and routine practice of this procedure. APE is the standard treatment of rectal cancer when there is evidence of anal sphincter invasion. However, this traditional technique may be concurrent with higher CRM(þ) and IOP rates than anterior resection using total mesorectal excision principle, leading to poorer long-term local control. This may be associated with an anatomical reduction in the natural mesorectal tissue volume in the distal rectum when following the mesorectal plane.2 Thus, ELAPE is introduced to improve the oncological outcomes of low advanced cancer of the rectum and the anus. Among the published, institution-based control studies with relatively large volume, some literatures indicated decreased CRM(þ) and IOP rates3,4 whereas others showed comparable pathological outcomes.5,6 Besides the Danish data mentioned earlier, Ortiz et al7 reported the Spanish nationwide propensity score matching study, which indicated that ELAPE was not more effective than APE in improving CRM involvement ratio. Only one small randomized control study was available and supported the superiority of ELAPE.8 Pooled analysis of all current evidences is not practical because of significant heterogeneities between studies. [In our preliminary test of CRM(þ), P value of heterogeneity ¼ 0.007, I2 ¼ 86%.] We support the issue that ELAPE should only be performed by experienced colorectal specialists instead of any surgical caregivers in a certified large-volume hospital. The latest quantitative systematic review of those institution-based studies concluded that ELAPE still had more advantages than conventional APE, according to the pooled OR (odds ratio) of oncological outcomes [CRM(þ): OR ¼ 0.36, 95% CI (confidence interval) ¼ 0.23–0.58; IOP: OR ¼ 0.31, 95% CI ¼ 0.12–0.80; both compared with APE, no statistical heterogeneity between groups in each comparison].9 The background, like specially trained colorectal surgeons and high-volume hospitals, may be the potential reason of explanation. Another issue of ELAPE is filtering appropriate candidates instead of any patients with low rectal cancer. The Danish data showed that significantly more patients with locally advanced tumors received ELAPE than APE, which indicates potential selection bias by surgeons, leading to the higher CRM(þ) risk in the former group.1 Clinical and pathological T0–2 patients were enrolled in several studies without preoperative restaging1,3,4,7 while the necessity of ELAPE for them was quite doubtable. Even if it has to be accepted that current imaging tools are neither sensitive nor specific enough for www.annalsofsurgery.com | e55
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
temperature. When at least 3 of the aforementioned conditions were present in association with cholecystolithiasis (gallstones and/or sludge) or ultrasound signs of cholecystitis, patients were considered eligible to be enrolled in the trial. Some concerns arise. The clinical conditions evaluated by the protocol are commonly recognized as nonspecific6,7 and may also be present in a number of patients without acute cholecystitis suffering from different abdominal conditions. Particularly, this may be the case of patients with cholecystolithiasis experiencing biliary colics. On ultrasound examination, the study protocol considered as eligibility criteria not only signs of cholecystitis but also cholecystolithiasis per se. This means that a number of symptomatic patients received a diagnosis of acute cholecystitis despite a radiological assessment revealing none of the major ultrasonographic diagnostic criteria.8,9 In this regard, it is not clear why, once an ultrasound assessment was obtained for each patient, the diagnosis of acute disease was not made accordingly, given that ultrasonography has excellent sensitivity and specificity, far higher than clinical features.6,7 Indeed, according to the literature, in the absence of characteristic imaging findings, only a diagnosis suggestive of acute cholecystitis can be made.6,10 In conclusion, it would be extremely interesting to know how many included patients had ultrasound evidence of acute cholecystitis and how many did not. Second, it would be interesting to know in what percentage of patients the diagnosis of acute cholecystitis was confirmed at surgery by direct intraoperative assessment. We congratulate Dr Gutt et al on their elegant and timely study, although we recommend particular caution in interpreting their data. The selection criteria used to enroll patients may impair the power of the analysis and the possibility of drawing definitive conclusions from their outcomes. Disclosure: No sources of funding have been received related to this investigation. No potential competing interests exist for all authors. Francesco Guerra, MD Luca Moraldi, MD Lucia Barni, MD Stefano Amore Bonapasta, MD Division of Oncological and Robotic General Surgery Careggi University Hospital Florence, Italy [email protected] e54 | www.annalsofsurgery.com
REFERENCES 1. Gutt CN, Encke J, Ko¨ninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258:385–393. 2. Gargya V, Smolarek S, Walsh TN. Concerns about acute cholecystitis: early versus delayed cholecystectomy–a multicenter randomized trial. Ann Surg. 2015;262:e63–e64. 3. Bu¨chler MW, Harnoss JC, Daniel D. Reply to Letter: ‘‘Timing of cholecystectomy in acute cholecystitis’’. Ann Surg. 2015;262:e87. 4. de Bruijn RE, Sonneveld DJA, van IJsseldijk ALA. Timing of cholecystectomy in acute cholecystitis. Ann Surg. 2015;262:e87. 5. Godbole CB, Doctor NH. Early cholecystectomy for acute cholecystitis: how early should it be? Ann Surg. 2015;262:e74. 6. Yokoe M, Takada T, Strasberg SM, et al. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci. 2012;19:578– 585. 7. Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804–2811. 8. Schiller VL, Turner RR, Sarti DA. Color Doppler imaging of the gallbladder wall in acute cholecystitis: sonographic-pathologic correlation. Abdom Imaging. 1996;21:233–237. 9. Uggowitzer M, Kugler C, Schramayer G, et al. Sonography of acute cholecystitis: comparison of color and power Doppler sonography in detecting a hypervascularized gallbladder wall. AJR Am J Roentgenol. 1997;168:707–712. 10. Hirota M, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg. 2007;14:78–82.
Weight Loss Before Bariatric Surgery To the Editor: e read with great interest the study by Anderin et al1 in the December 2014 issue of Annals of Surgery. However, we believe that external validity of those findings is questionable, and we warn readers against an over-interpretation of these data. Indeed, the influence of nutritional status on postoperative morbidity and mortality has been well documented for years in both retrospective and prospective studies and decreased weight loss before a surgical procedure has been considered to be associated with a higher postoperative mortality rate.2–5 Consequently, the Anderin et al study conclusions are in full contradiction with all current recommendations endorsed by European and American6–9 guidelines based on an updated literature review. In nonbariatric patients, Mullen et al10 have shown in a prospective, multi-institutional, risk-adjusted cohort study of 118,707 patients that patients undergoing general
W
ß
surgical procedures have paradoxically ‘‘lower’’ crude and adjusted risks of mortality compared with patients with ‘‘normal’’ preoperative weight. This study confirmed the existence of an ‘‘obesity paradox’’ in this subset of patient population. More recently, Khan et al11 showed in 44,408 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that independent predictive factors associated with significantly increased postoperative mortality included 10% weight loss during the 6 months before bariatric procedure (AOR,13.5). Furthermore, an important proportion of obese surgical patients have sarcopenic obesity at operation, with relative low levels of lean body mass despite a large body habitus. This means that those patients are at higher risk of major perioperative complications and mortality.12 In conclusion, we believe that systematic preoperative weight loss before bariatric surgery could lead to an increased postoperative mortality rate and could end up with a counter-intuitive postoperative effect.12 Disclosure: No sources of funding have been received related to this investigation. No potential competing interests exist for all authors. Didier Quilliot, MD, PhD Nicolas Reibel, MD Laurent Brunaud, MD, PhD CHU de Nancy Service de Nutrition-diabe´tologie Rue du Morvan Vandoeuvre-les-Nancy Nancy, France Service de chirurgie ge´ne´rale et urgences Hoˆpital Central Nancy, France Service de chirurgie endocrinienne et digestive Hoˆpital Central Nancy, France [email protected]
REFERENCES 1. Anderin C, Gustafsson UO, Heijbel N, et al. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg). Ann Surg. 2015;261: 909–913. 2. Velanovich V. The value of routine preoperative laboratory testing in predicting postoperative complications: a multivariate analysis. Surgery. 1991;109:236–243. 3. Dannhauser A, Van Zyl JM, Nel CJ. Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations—part II. J Am Coll Nutr. 1995;14:91–98. 4. Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of risk factors. J Surg Res. 2002;103:89–95.
2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 265, Number 4, April 2017
5. Sandstrom R, Drott C, Hyltander A, et al. The effect of postoperative intravenous feeding (TPN) on outcome following major surgery evaluated in a randomized study. Ann Surg. 1993;217: 185–195. 6. Weimann A, Braga M, Harsanyi L, et al. ESPEN Guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224– 244. 7. Chambrier C, Sztark F. French Clinical Guidelines on perioperative nutrition: update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults. J Visc Surg. 2012;149:e325–e336. 8. Klein S, Kinney J, Jeejeebhoy K, et al. Nutrition support in clinical practice: review of published data and recommendations for future research directions. Summary of a conference sponsored by the National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. Am J Clin Nutr. 1997;66:683–706. 9. Martindale RG, McClave SA, Taylor B, et al. Perioperative nutrition: what is the current landscape? J Parenter Enteral Nutr. 2013;37:5S–20S. 10. Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250:166–172. 11. Khan MA, Grinberg R, Johnson S, et al. Perioperative risk factors for 30-day mortality after bariatric surgery: is functional status important? Surg Endosc. 2013;27:1772–1777. 12. Gerber P, Anderin C, Thorell A. Weight loss prior to bariatric surgery: an updated review of the literature. Scand J Surg. 2015;104:33–39.
Response to ‘‘Weight Loss Before Bariatric Surgery and Postoperative Complications’’ Reply: e would like to comment on the letter by Quilliot and collaborators regarding our study over the effects of weight loss before bariatric study.1 The authors claim that our conclusions are in conflict with previous data demonstrating an association between weight loss and increased postoperative morbidity/mortality. To our understanding, this misinterpretation must reflect unawareness of the crucial distinction between unintentional and intentional weight loss. In none of the studies cited in the letter was unintentional, disease-associated weight loss controlled for. Thus, in patients losing weight, any underlying condition could have been expected to simultaneously influence weight and postoperative outcome. This is in similarity to the large SOS (Swedish Obese Subjects) interventional study, in which intentional (surgical) weight
loss was shown to be associated with almost 30% reduced mortality after 15 years,2 although most epidemiological studies by that time had demonstrated a relationship between (unintentional) weight loss and mortality.3–5 We appreciate that we have been given the opportunity to make this important clarification. We are, however, confident that most readers of Annals of Surgery are well aware of the difference between unintentional, diseaseassociated weight loss and an intervention that is aimed at, and now convincingly demonstrated to be associated with, improved outcome after bariatric surgery. Disclosure: The authors declare no conflicts of interest. Claes Anderin, MD, PhD Surgical Department Ersta Hospital Stockholm, Sweden [email protected]
REFERENCES 1. Anderin C, Gustafsson UO, Heijbel N, et al. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg). Ann Surg. 2015;261:909–913. 2. Sjo¨stro¨m L, Narbro K, Sjo¨stro¨m CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–752. 3. Lee IM, Paffenbarger RS Jr. Change in body weight and longevity. JAMA. 1992;268:2045–2049. 4. Walker M, Wannamethee G, Whincup PH, et al. Weight change and risk of heart attack in middle-aged British men. Int J Epidemiol. 1995;24:694–703. 5. Lissner L, Odell PM, D’Agostino RB, et al. Variability of body weight and health outcomes in the Framingham population. N Engl J Med. 1991;324: 1839–1844.
Are We Ready for Extralevatory Abdominoperineal Excision?
W
ß
Letters to the Editor
To the Editor: lein et al1 reported an interesting nationwide investigation focusing on extralevatory abdominoperineal excision (ELAPE) efficacy, based on Danish Colorectal Cancer Group’s prospective database from 2009 to 2012. The authors concluded that, when compared with conventional abdominoperineal excision (APE), rectal tumor resection after ELAPE had a higher rate of positive circumferential resection margin [CRM(þ)] and comparable rate of intraoperative perforation (IOP). However, we would like
K
2017 Wolters Kluwer Health, Inc. All rights reserved.
to comment on the effectiveness of ELAPE and routine practice of this procedure. APE is the standard treatment of rectal cancer when there is evidence of anal sphincter invasion. However, this traditional technique may be concurrent with higher CRM(þ) and IOP rates than anterior resection using total mesorectal excision principle, leading to poorer long-term local control. This may be associated with an anatomical reduction in the natural mesorectal tissue volume in the distal rectum when following the mesorectal plane.2 Thus, ELAPE is introduced to improve the oncological outcomes of low advanced cancer of the rectum and the anus. Among the published, institution-based control studies with relatively large volume, some literatures indicated decreased CRM(þ) and IOP rates3,4 whereas others showed comparable pathological outcomes.5,6 Besides the Danish data mentioned earlier, Ortiz et al7 reported the Spanish nationwide propensity score matching study, which indicated that ELAPE was not more effective than APE in improving CRM involvement ratio. Only one small randomized control study was available and supported the superiority of ELAPE.8 Pooled analysis of all current evidences is not practical because of significant heterogeneities between studies. [In our preliminary test of CRM(þ), P value of heterogeneity ¼ 0.007, I2 ¼ 86%.] We support the issue that ELAPE should only be performed by experienced colorectal specialists instead of any surgical caregivers in a certified large-volume hospital. The latest quantitative systematic review of those institution-based studies concluded that ELAPE still had more advantages than conventional APE, according to the pooled OR (odds ratio) of oncological outcomes [CRM(þ): OR ¼ 0.36, 95% CI (confidence interval) ¼ 0.23–0.58; IOP: OR ¼ 0.31, 95% CI ¼ 0.12–0.80; both compared with APE, no statistical heterogeneity between groups in each comparison].9 The background, like specially trained colorectal surgeons and high-volume hospitals, may be the potential reason of explanation. Another issue of ELAPE is filtering appropriate candidates instead of any patients with low rectal cancer. The Danish data showed that significantly more patients with locally advanced tumors received ELAPE than APE, which indicates potential selection bias by surgeons, leading to the higher CRM(þ) risk in the former group.1 Clinical and pathological T0–2 patients were enrolled in several studies without preoperative restaging1,3,4,7 while the necessity of ELAPE for them was quite doubtable. Even if it has to be accepted that current imaging tools are neither sensitive nor specific enough for www.annalsofsurgery.com | e55
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
