Annals of Surgery Volume 265, Number 4, April 2017
Letters to the Editor
topic area but no trial attempted to integrate the new trial results into a previous SR by updating it. A total of 17 (33%) claimed in the ‘‘Discussion’’ or in another section to be the first RCT in the topic area, 5 (10%) claimed to be the first RCT with exactly the same population, intervention, control, and outcome, whereas 20 (39%) did not attempt to set the results in the context of other trials. Overall, of 34 trials (excluding the 17 claiming to be first in the topic area), 8 (24%) RCTs discussed an SR in the topic area in the ‘‘Introduction’’ section without mentioning that it was used to inform the trial design, 9 (26%) discussed a previous SR in the ‘‘Discussion’’ section without attempting to integrate the new results, and in no trials there were findings used to update an SR. Our results show that two thirds of the RCTs referenced an SR; however, none mentioned the use of an SR to inform the trial design and none presented an updated existing SR integrating the new results. In addition, we found only 2 RCTs to include explicit statements on whether the trial was the first RCT in the field. Our findings suggest that SRs are considered rather to summarize findings than to inform trial design or for knowledge synthesis after trial conduct. This is in line with previous findings,6–10 although even more marked. However, it is not possible to identify circumstances when an SR may have been used to inform trial design without explicit statements. In practice, the following 4-step framework has been suggested for the use of an SR to inform the design of new trials: In step 1, the research question of the proposed trial is formulated focusing on definition of the populations, interventions, comparators, outcomes, timing, and setting (PICOTS).2 In step 2, an up-to-date valid SR is identified or conducted, and in step 3, it is used to inform trial design. If there are several RCTs, but no SR in the field, we propose to first synthesize the body of evidence within an SR and if appropriate conduct a meta-analysis. Finally, in step 4, the implications for the proposed trial are summarized. This procedure is important to justify any research from a scientific, ethical, and economic point of view. Similarly, we propose that trialists report their results in the context of other trials in the field, whenever possible integrating the new findings by updating an SR. Only when evaluating study results within the overall body of evidence are well-informed decisions in health care possible. Disclosure: There is no funding related to this investigation. There are no conflicts of interest to declare. Rachel Rosenthal is an employee of F. Hoffmann-La Roche e36 | www.annalsofsurgery.com
Ltd since May 1, 2014. This study was conducted before Rachel Rosenthal joined F. Hoffmann-La Roche Ltd and has no connection to her employment by the company. Heiner C. Bucher is supported by funds from Sante´suisse and the Gottfried and Julia Bangerter-Rhyner Foundation. Rachel Rosenthal, MD, MSc Department of Surgery University Hospital Basel Basel, Switzerland [email protected] Heiner C. Bucher, MD, MPH Basel Institute for Clinical Epidemiology and Biostatistics University Hospital Basel Basel, Switzerland Kerry Dwan, PhD Department of Biostatistics The University of Liverpool Liverpool, United Kingdom
REFERENCES 1. Rosenthal R, Dwan K. Comparison of randomized controlled trial registry entries and content of reports in surgery journals. Ann Surg. 2013; 257:1007–1015. 2. Thompson M, Tiwari A, Fu R, et al. A Framework to Facilitate the Use of Systematic Reviews and Meta-analyses in the Design of Primary Research Studies. ([Prepared by the Oregon Evidence-based Practice Center under Contract HHSA 290-2007-10057-I].) Rockville, MD: Agency for Healthcare Research and Quality; 2012. AHRQ Publication No. 12-EHC009-EF. Available at: www.effectivehealthcare.ahrq.gov/reports/ final.cfm. Accessed December 4, 2013. 3. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134:663–694. 4. Graham ID. Knowledge synthesis and the Canadian Institutes of Health Research. Syst Rev. 2012;1:6. 5. Jones AP, Conroy E, Williamson PR, et al. The use of systematic reviews in the planning, design and conduct of randomised trials: a retrospective cohort of NIHR HTA funded trials. BMC Med Res Methodol. 2013;13:50. 6. Clarke M, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents? JAMA. 1998;280:280–282. 7. Clarke M, Alderson P, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals. JAMA. 2002;287: 2799– 2801. 8. Clarke M, Hopewell S, Chalmers I. Reports of clinical trials should begin and end with up-to-date systematic reviews of other relevant evidence: a status report. J R Soc Med. 2007;100:187–190. 9. Clarke M, Hopewell S, Chalmers I. Clinical trials should begin and end with systematic reviews of relevant evidence: 12 years and waiting. Lancet. 2010;376:20–21.
ß
10. Clarke M, Hopewell S. Many reports of randomised trials still don’t begin or end with a systematic review of the relevant evidence. J Bahrain Med Soc. 2013;24:145–148.
Transanal Total Mesorectal Excision: Will It Be A Valid Alternative in Rectal Cancer Surgery? To the Editor: e have read a recent article by Fernandez-Hevia and Lacy et al1 published in Annals of Surgery with great interest. We sincerely congratulate and admire their pioneering work in the development of this novel rectal cancer surgery—transanal total mesorectal excision (TME), which was opposite to the conventional transabdominal TME and was named ‘‘bottom to up TME’’ by Bill Heald in an editorial.2 Transanal TME has been developed as an explorative solution to the difficult anatomy encountered by laparoscopic rectal cancer surgery, especially in narrow pelvis on an obese male. After a series of preclinical experiments on animals and cadavers, this concept was first put into reality by Lacy and Sylla using a transanal TEM (transanal endoscopic microsurgery) technique with assistance of conventional laparoscopic surgery.3 Colorectal surgeons around the world quickly took great interest in the new operating method, and several centers had successfully performed the new surgery in a similar way with either TEM technique or TAMIS (transanal minimally invasive surgery) technique. High expectations were given to transanal TME because its safety and feasibility has been proven among these studies. Furthermore, it was assumed to be superior to conventional surgery with the following advantages: facilitating distal rectal mobilization to achieve precise and sufficient distal margin, ensuring better functions as neurovascular bundles can be visualized more clearly, and reducing the need for multiple stapler firings in transecting the rectum as the specimen can be extracted through the anus, which also embodied the concept of natural orifices transluminal endoscopic surgery (NOTES). However, only immediate comparisons with laparoscopic surgery like this study or further, randomized control studies in the future can prove its superiority. In their study, number of patients was increased in the transanal group from 20 in
W
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
previous reports4 to 37, comparing the shortterm outcomes with the other 37 patients who received laparoscopic surgery in a previous period. However, why the comparative group of patients was selected in such a 1:1 ratio was not fully explained. In reality, in regard with the baseline demographic characteristics, the 2 groups were not perfectly matched because patients in the transanal group received neoadjuvant chemoradiation more frequently than those in the laparoscopy group. Therefore, bias might be brought as an influence of preoperative chemoradiation.5 Without doubt, the number of patients who underwent laparoscopic surgical procedure far exceeded that of new surgery, so it may be unreasonable that only a small portion of the former group was included in this comparison. We supposed the author had tried hard to achieve comparability of both cohorts but the detailed statistical methods were not depicted. As a matter a fact, propensity score matching, which has been exploited by many studies,6 is such a method that is utilized to wipe out confounding biases as much as possible, creating randomized-like data between the 2 comparative arms. The discussion on the detailed process of propensity score matching, which needs the help of statistical software, that is, R program, is beyond the scope of this letter. As a matter of fact, a similar study by Velthuis et al7 was published a little earlier in which 25 patients who had undergone the new surgical procedure was compared with the other 25 patients who had undergone conventional laparoscopic surgery. The 2 cohorts were matched only in gender and type of procedure (low anterior resection or abdominoperineal resection). Apart from statistical and comparative method in which patients were not necessarily matching in a ratio of 1:1, it is noteworthy that laparoscopic groups in each study were both retrospective cohorts which was operated 1 year earlier and whether they were performed by the same team of surgeons was not mentioned either. One more concern is that the new surgery is still in infancy and the learning curve, that is, the number of cases required to obtain a certain level of competency of a new technique, has not been illustrated by any literature. Thus, it is reasonable to suspect the real comparative effect because patients were selected at such an early stage when learning curve has not yet transited from a steep gradient to a plateau. Further studies with better design such as including patients operated at an appropriate time and prospectively comparing with laparoscopic surgery with optimized statistical methods by the same team of surgeons are warranted before conducting randomized controlled trials. ß
As they pointed out, lack of functional and oncological survival outcome comparison was a most important limitation, which weighs much more in proving the superiority over conventional surgery. So, it is necessary to routinely record valuable information of functions (bladder, bowel and sexual function) and quality of life in the novel surgery cohort, which can be evaluated by not only subjective scale, that is, Wexner incontinence score, EORTC QLQ CR38 scale, but also objective measurements like rectoanal manometry. We are also eager to wait for the results of survival analysis after longtime follow-up. So far, the transanal TME surgical procedures mentioned earlier were all performed in a hybrid approach—with assistance of conventional laparoscopic surgery. But only pure transanal TME without assistance conforms to the real meaning of NOTES and will be the last step of mini-invasive rectal surgery without doubt. However, currently pure approach is hindered by problems such as mobilization of proximal colon and splenic flexure (if necessary), ligation of inferior mesenteric vessels, and worries about inadequate colon to create pouch, which makes hybrid approach more accepted as a compromise. However, it is criticized that hybrid approach needs an extra group of equipment and staff (if performed by 2-team approach) and will increase cost, which should be further analyzed in costeffective analysis. In addition, hybrid approach cannot absolutely avoid abdominal scarring and still carries the risk of suffering wound-related complications such as wound infection, abscess, hernia, and incisionalimplanted tumor, etc. In such circumstances, the realization of pure transanal TME is so meaningful that many surgeons have tried hard to accomplish it despite difficulties and successful cases have been reported in human, animals, and cadavers. Up until now, the number of patients performed by pure approach is actually 12,8–10 among which the first case was reported by a team in China,9 not just the one8 mentioned in Ferna´ndez’s article. The discussion of whether it is the right time to encourage and promote the no-scar total transanal TME surgery at present is out of the limitation here. But, we would like to know whether the author’s team has planned to perform pure approach surgery and if not, when they will consider it the perfect time. Last, but not the least, as more and more pure NOTES are being accomplished, the comparison among pure approach of transanal TME, hybrid approach, and conventional laparoscopic surgery are also warranted in the future. Disclosure: The authors declare no conflicts of interest and no source of funding.
2017 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
Wen-Hao Chen, MD Shuang-Ling Luo, MD Liang Kang, MD Department of Colorectal Surgery The Sixth Affiliated Hospital Sun Yat-Sen University Guangzhou, P. R. China [email protected]
REFERENCES 1. Fernandez-Hevia M, Delgado S, Castells A, et al. Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery [published online ahead of print September 1, 2014]. Ann Surg. 2. Heald RJ. A new solution to some old problems: transanal TME. Tech Coloproctol. 2013;17:257–258. 3. Sylla P, Rattner DW, Delgado S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24:1205–1210. 4. de Lacy AM, Rattner DW, Adelsdorfer C, et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: ‘‘down-to-up’’ total mesorectal excision (TME)—short-term outcomes in the first 20 cases. Surg Endosc. 2013;27:3165–3172. 5. Weiser MR, Quah HM, Shia J, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236–242. 6. Hamady ZZ, Lodge JP, Welsh FK, et al. One-millimeter cancer-free margin is curative for colorectal liver metastases: a propensity score case-match approach. Ann Surg. 2014;259: 543–548. 7. Velthuis S, Nieuwenhuis DH, Ruijter TE, et al. Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc. 2014;28:3494–3499. 8. Leroy J, Barry BD, Melani A, et al. Noscar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg. 2013;14:226–230; discussion 231. 9. Zhang H, Zhang YS, Jin XW, et al. Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer. Tech Coloprocto. 2013;17:117–123. 10. Chouillard E, Chahine E, Khoury G, et al. Notes total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience. Surg Endosc. 2014;28:3150–3157.
The Brave Challenge of NOM for Abdominal GSW Trauma and the Role of Laparoscopy As an Alternative to CT Scan To the Editor: e are amazed and we all would like to congratulate with Navsaria et al for
W
www.annalsofsurgery.com | e37
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
topic area but no trial attempted to integrate the new trial results into a previous SR by updating it. A total of 17 (33%) claimed in the ‘‘Discussion’’ or in another section to be the first RCT in the topic area, 5 (10%) claimed to be the first RCT with exactly the same population, intervention, control, and outcome, whereas 20 (39%) did not attempt to set the results in the context of other trials. Overall, of 34 trials (excluding the 17 claiming to be first in the topic area), 8 (24%) RCTs discussed an SR in the topic area in the ‘‘Introduction’’ section without mentioning that it was used to inform the trial design, 9 (26%) discussed a previous SR in the ‘‘Discussion’’ section without attempting to integrate the new results, and in no trials there were findings used to update an SR. Our results show that two thirds of the RCTs referenced an SR; however, none mentioned the use of an SR to inform the trial design and none presented an updated existing SR integrating the new results. In addition, we found only 2 RCTs to include explicit statements on whether the trial was the first RCT in the field. Our findings suggest that SRs are considered rather to summarize findings than to inform trial design or for knowledge synthesis after trial conduct. This is in line with previous findings,6–10 although even more marked. However, it is not possible to identify circumstances when an SR may have been used to inform trial design without explicit statements. In practice, the following 4-step framework has been suggested for the use of an SR to inform the design of new trials: In step 1, the research question of the proposed trial is formulated focusing on definition of the populations, interventions, comparators, outcomes, timing, and setting (PICOTS).2 In step 2, an up-to-date valid SR is identified or conducted, and in step 3, it is used to inform trial design. If there are several RCTs, but no SR in the field, we propose to first synthesize the body of evidence within an SR and if appropriate conduct a meta-analysis. Finally, in step 4, the implications for the proposed trial are summarized. This procedure is important to justify any research from a scientific, ethical, and economic point of view. Similarly, we propose that trialists report their results in the context of other trials in the field, whenever possible integrating the new findings by updating an SR. Only when evaluating study results within the overall body of evidence are well-informed decisions in health care possible. Disclosure: There is no funding related to this investigation. There are no conflicts of interest to declare. Rachel Rosenthal is an employee of F. Hoffmann-La Roche e36 | www.annalsofsurgery.com
Ltd since May 1, 2014. This study was conducted before Rachel Rosenthal joined F. Hoffmann-La Roche Ltd and has no connection to her employment by the company. Heiner C. Bucher is supported by funds from Sante´suisse and the Gottfried and Julia Bangerter-Rhyner Foundation. Rachel Rosenthal, MD, MSc Department of Surgery University Hospital Basel Basel, Switzerland [email protected] Heiner C. Bucher, MD, MPH Basel Institute for Clinical Epidemiology and Biostatistics University Hospital Basel Basel, Switzerland Kerry Dwan, PhD Department of Biostatistics The University of Liverpool Liverpool, United Kingdom
REFERENCES 1. Rosenthal R, Dwan K. Comparison of randomized controlled trial registry entries and content of reports in surgery journals. Ann Surg. 2013; 257:1007–1015. 2. Thompson M, Tiwari A, Fu R, et al. A Framework to Facilitate the Use of Systematic Reviews and Meta-analyses in the Design of Primary Research Studies. ([Prepared by the Oregon Evidence-based Practice Center under Contract HHSA 290-2007-10057-I].) Rockville, MD: Agency for Healthcare Research and Quality; 2012. AHRQ Publication No. 12-EHC009-EF. Available at: www.effectivehealthcare.ahrq.gov/reports/ final.cfm. Accessed December 4, 2013. 3. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134:663–694. 4. Graham ID. Knowledge synthesis and the Canadian Institutes of Health Research. Syst Rev. 2012;1:6. 5. Jones AP, Conroy E, Williamson PR, et al. The use of systematic reviews in the planning, design and conduct of randomised trials: a retrospective cohort of NIHR HTA funded trials. BMC Med Res Methodol. 2013;13:50. 6. Clarke M, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents? JAMA. 1998;280:280–282. 7. Clarke M, Alderson P, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals. JAMA. 2002;287: 2799– 2801. 8. Clarke M, Hopewell S, Chalmers I. Reports of clinical trials should begin and end with up-to-date systematic reviews of other relevant evidence: a status report. J R Soc Med. 2007;100:187–190. 9. Clarke M, Hopewell S, Chalmers I. Clinical trials should begin and end with systematic reviews of relevant evidence: 12 years and waiting. Lancet. 2010;376:20–21.
ß
10. Clarke M, Hopewell S. Many reports of randomised trials still don’t begin or end with a systematic review of the relevant evidence. J Bahrain Med Soc. 2013;24:145–148.
Transanal Total Mesorectal Excision: Will It Be A Valid Alternative in Rectal Cancer Surgery? To the Editor: e have read a recent article by Fernandez-Hevia and Lacy et al1 published in Annals of Surgery with great interest. We sincerely congratulate and admire their pioneering work in the development of this novel rectal cancer surgery—transanal total mesorectal excision (TME), which was opposite to the conventional transabdominal TME and was named ‘‘bottom to up TME’’ by Bill Heald in an editorial.2 Transanal TME has been developed as an explorative solution to the difficult anatomy encountered by laparoscopic rectal cancer surgery, especially in narrow pelvis on an obese male. After a series of preclinical experiments on animals and cadavers, this concept was first put into reality by Lacy and Sylla using a transanal TEM (transanal endoscopic microsurgery) technique with assistance of conventional laparoscopic surgery.3 Colorectal surgeons around the world quickly took great interest in the new operating method, and several centers had successfully performed the new surgery in a similar way with either TEM technique or TAMIS (transanal minimally invasive surgery) technique. High expectations were given to transanal TME because its safety and feasibility has been proven among these studies. Furthermore, it was assumed to be superior to conventional surgery with the following advantages: facilitating distal rectal mobilization to achieve precise and sufficient distal margin, ensuring better functions as neurovascular bundles can be visualized more clearly, and reducing the need for multiple stapler firings in transecting the rectum as the specimen can be extracted through the anus, which also embodied the concept of natural orifices transluminal endoscopic surgery (NOTES). However, only immediate comparisons with laparoscopic surgery like this study or further, randomized control studies in the future can prove its superiority. In their study, number of patients was increased in the transanal group from 20 in
W
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
previous reports4 to 37, comparing the shortterm outcomes with the other 37 patients who received laparoscopic surgery in a previous period. However, why the comparative group of patients was selected in such a 1:1 ratio was not fully explained. In reality, in regard with the baseline demographic characteristics, the 2 groups were not perfectly matched because patients in the transanal group received neoadjuvant chemoradiation more frequently than those in the laparoscopy group. Therefore, bias might be brought as an influence of preoperative chemoradiation.5 Without doubt, the number of patients who underwent laparoscopic surgical procedure far exceeded that of new surgery, so it may be unreasonable that only a small portion of the former group was included in this comparison. We supposed the author had tried hard to achieve comparability of both cohorts but the detailed statistical methods were not depicted. As a matter a fact, propensity score matching, which has been exploited by many studies,6 is such a method that is utilized to wipe out confounding biases as much as possible, creating randomized-like data between the 2 comparative arms. The discussion on the detailed process of propensity score matching, which needs the help of statistical software, that is, R program, is beyond the scope of this letter. As a matter of fact, a similar study by Velthuis et al7 was published a little earlier in which 25 patients who had undergone the new surgical procedure was compared with the other 25 patients who had undergone conventional laparoscopic surgery. The 2 cohorts were matched only in gender and type of procedure (low anterior resection or abdominoperineal resection). Apart from statistical and comparative method in which patients were not necessarily matching in a ratio of 1:1, it is noteworthy that laparoscopic groups in each study were both retrospective cohorts which was operated 1 year earlier and whether they were performed by the same team of surgeons was not mentioned either. One more concern is that the new surgery is still in infancy and the learning curve, that is, the number of cases required to obtain a certain level of competency of a new technique, has not been illustrated by any literature. Thus, it is reasonable to suspect the real comparative effect because patients were selected at such an early stage when learning curve has not yet transited from a steep gradient to a plateau. Further studies with better design such as including patients operated at an appropriate time and prospectively comparing with laparoscopic surgery with optimized statistical methods by the same team of surgeons are warranted before conducting randomized controlled trials. ß
As they pointed out, lack of functional and oncological survival outcome comparison was a most important limitation, which weighs much more in proving the superiority over conventional surgery. So, it is necessary to routinely record valuable information of functions (bladder, bowel and sexual function) and quality of life in the novel surgery cohort, which can be evaluated by not only subjective scale, that is, Wexner incontinence score, EORTC QLQ CR38 scale, but also objective measurements like rectoanal manometry. We are also eager to wait for the results of survival analysis after longtime follow-up. So far, the transanal TME surgical procedures mentioned earlier were all performed in a hybrid approach—with assistance of conventional laparoscopic surgery. But only pure transanal TME without assistance conforms to the real meaning of NOTES and will be the last step of mini-invasive rectal surgery without doubt. However, currently pure approach is hindered by problems such as mobilization of proximal colon and splenic flexure (if necessary), ligation of inferior mesenteric vessels, and worries about inadequate colon to create pouch, which makes hybrid approach more accepted as a compromise. However, it is criticized that hybrid approach needs an extra group of equipment and staff (if performed by 2-team approach) and will increase cost, which should be further analyzed in costeffective analysis. In addition, hybrid approach cannot absolutely avoid abdominal scarring and still carries the risk of suffering wound-related complications such as wound infection, abscess, hernia, and incisionalimplanted tumor, etc. In such circumstances, the realization of pure transanal TME is so meaningful that many surgeons have tried hard to accomplish it despite difficulties and successful cases have been reported in human, animals, and cadavers. Up until now, the number of patients performed by pure approach is actually 12,8–10 among which the first case was reported by a team in China,9 not just the one8 mentioned in Ferna´ndez’s article. The discussion of whether it is the right time to encourage and promote the no-scar total transanal TME surgery at present is out of the limitation here. But, we would like to know whether the author’s team has planned to perform pure approach surgery and if not, when they will consider it the perfect time. Last, but not the least, as more and more pure NOTES are being accomplished, the comparison among pure approach of transanal TME, hybrid approach, and conventional laparoscopic surgery are also warranted in the future. Disclosure: The authors declare no conflicts of interest and no source of funding.
2017 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
Wen-Hao Chen, MD Shuang-Ling Luo, MD Liang Kang, MD Department of Colorectal Surgery The Sixth Affiliated Hospital Sun Yat-Sen University Guangzhou, P. R. China [email protected]
REFERENCES 1. Fernandez-Hevia M, Delgado S, Castells A, et al. Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery [published online ahead of print September 1, 2014]. Ann Surg. 2. Heald RJ. A new solution to some old problems: transanal TME. Tech Coloproctol. 2013;17:257–258. 3. Sylla P, Rattner DW, Delgado S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24:1205–1210. 4. de Lacy AM, Rattner DW, Adelsdorfer C, et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: ‘‘down-to-up’’ total mesorectal excision (TME)—short-term outcomes in the first 20 cases. Surg Endosc. 2013;27:3165–3172. 5. Weiser MR, Quah HM, Shia J, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236–242. 6. Hamady ZZ, Lodge JP, Welsh FK, et al. One-millimeter cancer-free margin is curative for colorectal liver metastases: a propensity score case-match approach. Ann Surg. 2014;259: 543–548. 7. Velthuis S, Nieuwenhuis DH, Ruijter TE, et al. Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc. 2014;28:3494–3499. 8. Leroy J, Barry BD, Melani A, et al. Noscar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg. 2013;14:226–230; discussion 231. 9. Zhang H, Zhang YS, Jin XW, et al. Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer. Tech Coloprocto. 2013;17:117–123. 10. Chouillard E, Chahine E, Khoury G, et al. Notes total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience. Surg Endosc. 2014;28:3150–3157.
The Brave Challenge of NOM for Abdominal GSW Trauma and the Role of Laparoscopy As an Alternative to CT Scan To the Editor: e are amazed and we all would like to congratulate with Navsaria et al for
W
www.annalsofsurgery.com | e37
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
