Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancers—Reply

Abstract

The recommendation for omission of SLNB in elderly patients is based on the CALGB 9343 study 2 in which only about one-third of patients underwent axillary surgical staging. Without axillary dissection, only 3% (6 of 200) treated with lumpectomy and tamoxifen experienced axillary recurrence. 2 There was no difference in overall survival between treatments with or without radiation therapy (RT), which is the basis for another Choosing Wisely campaign recommendation-omission of RT in elderly patients with stage I ER+BC. What is often overlooked is the characteristics of the patients in CALGB 9343. With a median age of 75 years in both treatment groups, more than 50% in each group had died, most often from non-BC-related causes, on long-term follow-up. 3 Therefore, we agree that omitting SLNB (and RT) is reasonable for patients in their mid-70s and older with significant comorbidities, but it is difficult to broadly apply these recommendations to all patients 70 years and older with stage I ER+BC.Furthermore, axillary staging affects RT recommendations. For fit septuagenarians, accelerated partial breast irradiation (APBI) over 1 week is an excellent way to de-escalate therapy compared with the 5 weeks of RT that was performed in CALGB 9343. However, randomized studies comparing APBI and whole-breast RT required axillary surgical staging. 4 It gives us substantial pause to recommend APBI in the absence of known pN0 status by SLNB, particularly when a patient is hesitant about adjuvant hormonal therapy (HT).This leads to another important assumption when omitting SLNB: that patients will take adjuvant HT. The patientreported HT-related adverse events are not insignificant. Adverse events, such as joint pain and vaginal dryness, can be especially debilitating in elderly patients. The adherence to HT is suboptimal and there is trend for higher likelihood for discontinuing HT early with increasing age. 5 Thus, until better strategies are developed to reduce early discontinuation of HT, understanding the surgical axillary stage in this population will continue to be of importance.

Turnbull-Cutait Pull-Through—An Old Procedure With a New Indication?

“…This is consistent with systematic reviews . Of note, the anastomotic leak rate may be further lowered following a TCA by delaying the hand-sewn anastomosis beyond the 6 to 10 days used in the study by Biondo et al In fact, in his original description, Daher Cutait did not undertake the hand-sewn anastomosis component until at least several weeks after resection to allow adequate time for the delivered left colon to scar/adhere to the pelvis and anorectal musculature. Similarly, because DLI increases risk for bowel obstruction, the rate of postoperative paralytic ileus of 24% in the CAA/DLI group vs none in the TCA group was not surprising.…”

“…Similarly, because DLI increases risk for bowel obstruction, the rate of postoperative paralytic ileus of 24% in the CAA/DLI group vs none in the TCA group was not surprising. However, anastomotic stricture, a recognized common problem encountered following a hand-sewn coloanal anastomosis, was not discussed and is a limitation of this study . Furthermore, although short-term results suggest that TCA does not increase postoperative morbidity rates compared with a standard CAA/DLI, we disagree with the authors in calling the TCA a safe procedure given the postoperative complication rate of 35% in a relatively healthy population: 80% with an American Society of Anesthesiologists II score, none with a body mass index (calculated as weight in kilograms divided by height in meters squared) greater than 30, and none with anemia nor malnourished.…”

“…In the study by Biondo et al in this issue of JAMA Surgery , although 30-day postoperative morbidity was similar between the Turnbull-Cutait pull-through procedure with 2-stage hand-sewn coloanal anastomosis (TCA) and a standard hand-sewn coloanal anastomosis and diverting loop ileostomy (CAA/DLI), the anastomotic leak rate was 24% vs 13% for the CAA/DLI and TCA groups, respectively, suggesting a possible trend toward superiority of TCA over CAA/DLI in terms of anastomotic leakage. This is consistent with systematic reviews .…”

Construction of a Coloanal Anastomosis vs Closure of a Diverting Ileostomy

“…Biondo et al and the members of the TURNBULL-BCN study group have published both short-term and, more recently, 3-year data on TCA applied to sphincter-sparing rectal cancer resections with curative intent, compared to the more common approach of creating a hand-sewn coloanal anastomosis with a diverting loop ileostomy. With 2 well-balanced groups, the TURNBULL-BCN has demonstrated that oncologic results and functional results (including incontinence, low anterior resection syndrome, and overall quality of life after surgery) were similar between both groups, as were morbidity rates and rates of permanent stoma formation.…”