Dear Editor:

We thank Miss Warwick and colleagues for their interest in our paper and we appreciate the opportunity to respond to their letter. The heart of the matter is our conclusion from the study that the observed rate of anastomotic leakage is lower than expected from the literature.

Several definitions of anastomotic leakage are used in the literature, we chose to use anastomotic leakage leading to re-intervention as this is a ‘hard’ end point leaving little room for discussion. This is in accordance with the definition used by the Dutch Surgical Colorectal Audit and other groups. It is true of course that there are patients with an anastomotic leakage who will not undergo treatment for this leak. This may be a radiologic leakage with no clinical consequence or a perianastomotic abscess that becomes asymptomatic after spontaneous drainage. We observed these cases in our study as mentioned by Miss Warwick. We hypothesized that some of these ‘minor’ leaks could have been ‘major’ without the use of C-seal.

Our inclusion criteria are clearly stated in the paragraph ‘Study Population’ in the Methods section of the paper: age ≥18 years and ASA score ≤3 undergoing colorectal resection with creation of a stapled anastomosis at maximally 15 cm from the anal verge.

The C-seal trial will give us the answers we both are waiting for.