To the Editor, We thank Hompes et al. for their comments on and for the interesting questions that have been raised about our article [1]. In the literature few topics are as confusing as local excision for the treatment of rectal cancer. In fact, the term ‘‘local excision’’ includes different exeresis techniques with respect to the tumor-free mucosa margins, the depth of excision into the rectal wall, and the extent of perirectal fat removal. In order to avoid performing different treatments, we have standardized the operation, as described in our article. In our opinion, the extent of tissue removal is the main technical factor in improving the results. Therefore, our results cannot be compared with those reported by Stipa and Bach [2, 3] for several reasons. Stipa et al. [2] reported the results of a nonextended resection. The multi-institutional study by Bach et al. [3] has the following biases: (1) Surprisingly, one third of the patients were preoperatively diagnosed as benign; (2) R1 excision occurred in pT1 and pT2 in 9.9 and 21.7%, respectively; (3) a full-thickness excision was performed in only 80% of pT1-2 patients; (4) international criteria for local excision were not observed in more than 70% of cases. Moreover, on average each center enrolled only 23 patients. The first question raised by Hompes et al. is about the 6.6% wound dehiscence rate reported in our study, which is substantially different from the result of Marks et al. [4] of 25.6% in the irradiated group and 0% in the nonirradiated group. Indeed, in that paper the two groups were not comparable in terms of staging. In the nonirradiated group only uT0-1 were included, while the irradiated group included mostly uT2-3 rectal tumors. Consequently, it is reasonable to speculate that patients underwent a different extent of local excision in the series by Marks et al. Again, we are strongly convinced that the favorable results of their series are related to the different surgical technique used. The key point is a wide dissection and mobilization at the level of the perirectal fascia of the cranial margin in order to facilitate tissue approximation and to avoid tension on the suture line. Furthermore, the lower suture line dehiscence rate in our series may be related to a different followup protocol. Marks et al. performed a routine follow-up study 2 and 6 weeks after surgery, including digital rectal examination and endoscopy. Instead, our protocol included follow-up endoscopy in all patients 3 months after surgery. In the early postoperative period only patients with clinical symptoms (i.e., fever, pain) underwent endoscopy. This policy is aimed at avoiding iatrogenic suture line dehiscence possibly induced by scope introduction or excess gas insufflation. Marks et al. describe and treat all wound dehiscence, including the subclinical ones, whereas we describe and cure only patients with clinical symptoms due to a partially leaking suture. If our series underestimates the suture line dehiscence rate, it is also true that not all suture line dehiscence after transanal endoscopic microsurgery (TEM) are clinically relevant and require treatment. In this respect, it is interesting to note that in the Marks et al. series [4] only one patient with suture line dehiscence required a temporary stoma. The second question posed by Hompes et al. focused on the postoperative strategy in case of pathological lymph G. Lezoche (&) Clinica di Chirurgia Generale e Metodologia Chirurgica, Ospedali Riuniti, Universita Politecnica delle Marche, Via Conca 1, Ancona 60121, Italy e-mail: lezoche@me.com