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Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids − a clear classification is needed

of the study group and of these 12 patients. Specifically there is no mention of whether patients underwent laparoscopic, laparoscopic converted to open or open surgery or previous abdominal surgery. There is no information on operator experience, the accuracy of using a visual assessment tool for blood loss, and any variation in blood transfusion criteria and postoperative management across centres. Many of the above factors contribute to the degree of blood loss intra-operatively and without details of the use of blood products it is difficult to speculate on the potential to create an immunosuppressed environment contributing to tumour recurrence for example. While there is no statistical significance between stage and degree of blood loss one cannot ignore the observation that patients with the greatest blood loss had more preoperative irradiation and, together with the greater incidence of postoperative complications, this might suggest that blood loss was more a surrogate marker of poorer tumour biology and need for radicality of surgery rather than an indicator of recurrence. Several reports point to a relationship between increased blood loss and postoperative complications and long-term survival [2]. It would therefore be of interest to know what particular types of postoperative complication are being referred to in patients with increased blood loss, as infective complications have been noted to be associated with poorer long-term disease-free and overall survival in patients undergoing liver resection for colorectal metastasis [3]. Furthermore the use of the Dindo Clavien classification of complications would have added to the study, by permitting an assessment of the impact of bleeding on complications. Nevertheless we concur with the authors that blood loss is an important marker of quality of surgery and impacts on the outcome of oncological surgery.