To the Editor I read the article ‘Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial” by Biondo et al1 with great interest. I wanted to draw attention to certain details. The study showed that the 2-stage pull-through hand-sewn coloanal anastomosis after ultralow anterior resection for low rectal cancer is safe and does not increase the postoperative morbidity rate compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy. However, I think that this technique has some pitfalls that should be taken to consideration. Exteriorization of a segment of left colon through the anal canal needs more extensive dissection. Exteriorization sometimes can be achieved by cutting main vessels, such as the middle colic or ilecolic artery, which leads to increase the risk of ischemia. Biondo et al1 reported pancloic ischemia in 1 patient (2%) after Turnbull-Cutait pull-through coloanal anastomosis, while pancloic ischemia was not observed among the patients who underwent standard coloanal anastomosis with diverting ileostomy. Thus, this technique cannot be offered as a safe technique overall. Also, I would like to ask the authors how Turnbull-Cutait pull-through coloanal anastomosis can be performed if the remnant colon was not long enough to be exteriorized.