Nearly complete TME quality conundrum
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In their systematic review and meta-analysis of 11 randomized controlled trials (RCT), Pedziwiatr et al.  concluded that there was no difference in oncological outcomes between laparoscopic and open proctectomy for rectal cancer. Previous enthusiasm for a laparoscopic approach has been recently counterbalanced by the increased rates of circumferential resection margin involvement secondary to the impaired ergonomics of non-articulating laparoscopic instruments in the confined space of the pelvis .
In their review, Pedziwiatr et al. provided (1) no data from 1966 to 2005; (2) no data on tumor distance from the anal verge; (3) no data on the quality of total mesorectal excision (TME) for 6 of 11 RCTs; (4) no emphasis on the non-inferiority design of the RCTs utilizing intent-to-treat analysis.
In a recent meta-analysis, Martinez-Perez et al.  reported that laparoscopic proctectomy for rectal cancer was inferior to its open counterpart in terms of TME quality. Martinez-Perez et al.  drew such conclusions analyzing nearly complete together with incomplete TME quality specimens as compared to complete. Conversely, Pedziwiatr et al.  analyzed nearly complete with complete TME quality and compared them to incomplete cases. It is our opinion that the nearly complete resected specimens in Nagtegaal et al.'s  three-tiered classification were not intended to be considered as complete TME quality.
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Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants performed by any of the authors.
Informed consent is not applicable as this is a correspondence paper.