[Comment] Long-term results of 2-stage turnbull-cutait pull-through coloanal anastomosis for low rectal cancer: a randomized clinical trial

[Importance] In patients operated on for low rectal cancer, 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis provides benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal. [Objective] To compare long-term results of these 2 techniques after ultralow rectal resection for rectal cancer. [Design, setting, and participants] In this randomized multicenter clinical trial, neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis (n＝46) or standard hand-sewn coloanal anastomosis associated with diverting ileostomy (n＝46). [Interventions] All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal. After 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy during the first operation. Ileostomy closure was scheduled after adjuvant treatment was completed in about 6 to 8 months. [Main outcome and measure] The study aimed to compare the differences between the 2 groups in terms of long-term surgery-related morbidity, functional, and oncological outcomes at 3 years postoperatively. Data were analyzed from October 1, 2018, through October 31, 2021. [Results] The 92 patients randomized in the first study were included for the 3-year follow-up. The overall morbidity rate in the 2 groups showed that 15 patients (16.3%) had complications with a difference of 6.52 (95%CI, -8.93 to 21.79). Nine patients (19.6%) and 6 patients(13.0%) in the 2-stage Turnbull-Cutait pull-through group and hand-sewn coloanal anastomosis group, respectively, had complications without statistically significant differences (P＝0.57). Oncological results were comparable between the groups. Long-term fecal continence in the CCA and TCA groups, respectively, assessed using the Wexner Incontinence Score was 10.9 (5.50-15.5) vs.13.0 (7.25-16.0; P＝0.92), Low Anterior Resection Syndrome score was 32.0 (21.0-37.0) vs.34.0 (23.2-38.5; P＝0.76), and Colorectal Functional Outcome score was 38.5 (23.0-47.1) vs.40.8 (23.3-58.2; P＝0.30). [Conclusions and relevance] In this study, after a 3-year follow-up period, 2-stage Turnbull-Cutait anastomosis for ultralow rectal cancer could be considered as a surgical alternative that has the valuable benefit of avoiding a temporary stoma with similar results in terms of morbidity, fecal continence, patient satisfaction, quality of life, and oncological outcomes when compared with hand-sewn coloanal anastomosis with ileostomy. ClinicalTrials. gov identifier: NCT01766661.