Dr Morris and colleagues have combined Hospital Episode Statistics (HES) and Cancer Registry data for England between 1998 and 2004 and come to the conclusion that variation in abdomino-perineal excision of rectum (APE) rates derived from this methodology mandate direct and immediate intervention in UK rectal cancer surgery (Gut 2008;57:1690–7). Indeed the authors’ press release states that this evidence serves notice on the profession as to an unacceptable level of variation in the use of APE, leading to the predictable media headline “Rectal surgeons using wrong op.”1

While impressed by the media savvy of Dr Morris and colleagues, we are appalled by the naivety of their statements on the use of APE and anterior resection (AR) as clinical techniques and the evidence base they advance to enforce detailed intervention in UK clinical practice. APE and AR are complementary and not competing procedures, determined by tumour height and anal sphincter function, “case-mix” factors entirely absent from this analysis. The authors make no mention of the almost universal use of loop ileostomy with attendant morbidity in low anterior resection, the problem of loop ileostomies that are …