Dear Editor: We found the article from Dr. Jiang et al. concerning their experience with antiperistaltic cecoproctostomy after subtotal colectomy (the so-called Sarli procedure) for slow-transit constipation, published in the December issue of Int J Colorectal Dis to be of great interest. In recent years, this procedure has been proposed as an alternative to total colectomy and ileo-rectal anastomosis (TC-IRA) as the treatment of colonic inertia, with varying results. Dr. Jiang et al. report the results of this procedure in 17 patients and compare them to those achieved in 20 patients undergoing TC-IRA, concluding that the former seems to be superior, affording the patients a better quality of life. Although the inevitable bias associated with the retrospective nature of the study, the (small) size of the sample and the (short) length of follow-up do not allow for definitive conclusions, we congratulate the authors for their preliminary results, which match those we achieved in our series [1]. Nevertheless, we believe that readers should benefit from some clarification concerning both patient selection and surgical technique, since often it is the details that determine the results of a surgical procedure. We believe that careful patient selection has a determining role in achieving good results after surgery for constipation. In particular, considering patients who are candidates for surgery for colonic inertia, an adequate preoperative work up should involve a multidisciplinary approach, including psychiatrists as well as gastroenterologists, nutritionists and surgeons. Dr Jiang et al. maintain that ten patients with severe colonic inertia finally did not undergo surgery (which accounts for the 59% of those finally undergoing the Sarli procedure), but it is not clear why these potential candidates were withdrawn. In particular, although the authors cite the absence of severe psychiatric diseases as a condition to undergo surgery (it is listed as the last of seven exclusion criteria) it is not clear who assessed (and how) the psychiatric status of the patients and how many patients were excluded from surgery owing to psychiatric disorders. This issue is not idle: in their experience with cecorectal anastomosis performed in 14 patients treated from 1986, Dr. Iannelli et al. [2] report a lower success rate of the Sarli procedure compared to TC-IRA. It is worth mentioning that roughly 60% of their patients underwent surgery although having psychiatric disorders needing treatment. We believe that this feature may partially explain the unusually high rate of patients complaining of postoperative abdominal pain associated with bloating (50%), the low self-assessed satisfaction rate and, in one patient with a pre-existing psychiatric disorder, the development of a very disabling diarrhea (30 bowel movements a day). A meticulous application of the surgical technique is also a key to success. In particular, the issue of the cecal stump size should be addressed. Although the technique we described in our preliminary report involved a resection of the ascending colon 10 to 15 cm from the ileo-cecal junction, we are now slightly changing our attitude. After one patient had cecum distension 6 months postoperatively, we decided to modify the procedure, by shortening the cecal stump to 8 cm maximum length. After this technical Int J Colorectal Dis (2009) 24:1117–1118 DOI 10.1007/s00384-009-0668-4