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Comment on "Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial".

we look at the per-protocol analysis, the mean difference was 11.1 points (95% CI, 1.8–20.3, P 1⁄4 0.020), indicating a clinically relevant effect. In the group of patients who were randomized for conservative management but ultimately required surgery due to severe ongoing complaints, mean GIQLI scores were low from baseline up to surgery and increased on average with 21.2 (95% CI, 11.2–31.2, P< 0.001) points after surgery. In the group of patients who were successfully treated conservatively, the GIQLI score did not significantly increase compared with baseline (P 1⁄4 0.056). These findings suggest that the increase in QoL in the conservative group is the result of surgical intervention in a large part (46%) of the conservative group (crossovers). This could then result in a smaller difference between the operative and conservative group, whereas the actual treatment effect (of surgical intervention) might be higher. Average GIQLI improvement over the entire study follow-up (current GIQLI score minus baseline GIQLI score) was 19.1 (95% CI, 14.4–23.9) points in the operative group (above the MID of 10 points) and 9.7 (95% CI, 5.4–14.0) points (below the MID of 10 points) in the conservative group (P 1⁄4 0.004). The conservative group too shows an increase in QoL, but as stated before this can be attributed to the operatively treated patients in the conservative group. We must point out that the Visual Analogue Score (VAS) for pain was not the primary outcome measure of our study, nor is it specific for (pain) symptoms caused by diverticulitis. This could explain why patients in the surgical group (as well as in the conservative group) were not totally ‘‘pain free’’ at 5-year followup. Furthermore, the VAS pain score was significantly lower at 5-year follow-up (28.6) compared with baseline (63.3), indicating a relief of pain symptoms after surgery. All in all, we must conclude that elective sigmoid resection has an important impact on improvement of QoL in patients with recurrent diverticulitis and/or ongoing complaints after an episode of left-sided diverticulitis. As discussed in our paper, the complication rate of surgery, and especially the anastomotic leakage rate, in the DIRECT study was higher compared with previous literature (11% vs 4%). All patients with anastomotic leakage underwent reoperation with a protective stoma. These (re)interventions also resulted in hernia operations on the long term; however, these rates were comparable with previous literature (14%). We agree with Cerdán-Santacruz et al that these complications (short and long term) should not be taken lightly, especially in a benign disease such as diverticular disease, and should be discussed with patients before performing surgery. We must, however, emphasize that despite these complications, QoL was still higher in the operative group, strengthening our conclusion that elective surgery has an important impact on improvement of QoL. Thus, our conclusion remains that surgeons should counsel patients for elective sigmoidectomy in case of recurrent diverticulitis and/or ongoing complaints after an episode of left-sided diverticulitis weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.