To the Editor-We read the study by Manchon-Walsh et al 1 with great interest. The authors retrospectively analyzed short-and medium-term outcomes of transanal total mesorectal excision (TME) and anterior TME (open or laparoscopic) for rectal cancer from 2015 to 2016 using propensity score-matched analysis in Catalonia. This study contains important and necessary data. After propensity score-matched analysis, there were no statistical differences in local recurrence between the 2 groups. Both groups presented similar 2-year cumulative incidence of local recurrence (4.83% versus 3.57%) and disease-free survival. However, I have some concerns with the article.The authors included open and laparoscopic surgeries in the anterior TME group. Certainly, some articles reported that there were no significant differences in oncological outcomes between open and laparoscopic surgeries for rectal cancer. [2][3][4] Conversely, Nonaka et al 5 compared oncological outcomes of advanced middle and lower rectal cancers (pStage II-III) and reported that disease-free survival was better in the laparoscopic group than in the open group (81.1% versus 62.2%).However, conversion to laparotomy in the anterior TME group included 41 cases, whereas the transanal TME group included 6 cases. Yang et al 6 reported that conversion to laparotomy is associated with worse perioperative outcomes such as increased morbidity and mortality. Furthermore, they showed that strategic conversion (because of a lack of progression or unclear anatomy) is known to be associated with better outcomes than reactive conversion (because of an intraoperative complication such as bleeding or bowel injury). 6 Therefore, the authors should consider excluding open cases and conversion to open surgery cases.
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