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Invited Commentary
June 3, 2020

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

Author Affiliations
  • 1Department of Surgery, UNC School of Medicine, Chapel Hill, North Carolina
  • 2Department of Surgery, University of São Paulo, São Paulo, Brazil
  • 3Department of Surgery, NYU Grossman School of Medicine, New York, New York
JAMA Surg. 2020;155(8):e201756. doi:10.1001/jamasurg.2020.1756

In the study by Biondo et al1 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.2 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.1 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,3 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,4 was not discussed and is a limitation of this study.1 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. Furthermore, it is worth noting that this is a complicated procedure best performed in high-volume centers by surgeons with vast experience in total mesorectal excision–based rectal cancer resection along with mucosectomy, intersphincteric resection, and hand-sewn coloanal anastomosis. It is also worth emphasizing that a TCA is not likely to become a commonly performed procedure because of its limited indication. This is evident by the fact that it took 3 centers a total of 6 years to accrue 92 patients. This translates into 5 cases per center per year.

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