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In Clinical Values of Preoperative Use of Antibiotics in Transanal Endoscopic Microsurgery article, the authors investigated prospectively with the aim to compare two groups of patients who underwent Transanal Endoscopic Microsurgery (TEM) with or without preoperative administration of antibiotics.Citation1 The prophylactic antibiotic treatment showed better patient's laboratory inflammation markers, in first and third postoperative day in comparison with control group.Citation1
Gerhard Buess, in 1983, proposed for the first time the TEM equipment for transanal excision of sessile adenomas or T1 rectal cancer.Citation2 By this instrumentation it is possible to perform rectal lesions excisions at different depths in the rectal wall based on the tumor staging,Citation1,3 passing from submucosal resection or full thickness excision up to the Endoluminal Loco-Regional Resection (ELRR)Citation1,4,5. Recently TEM instrumentation was proposed to perform also Transanal Total Mesorectal Excision (TATME) that allows to resect the entire rectum and mesorectum.Citation6
Although rectal excision by TEM could be considered such as a Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure, we do not forget that rectal ampulla is a very contaminated field so particular carefulness should be referred to infection or sepsis development.
Albeit, in Europe and in USA the preoperative prophylactic antibiotic administration, together with the pre- and postoperative rectal lumen irrigation with povidone-iodine are treadmill,Citation3,7,8 they are not widely accepted as reported in the Chen's et al.Citation1. In fact, according to “Application of Antimicrobial Drugs Guide for Perioperative Prevention” published in Chinese Medical Association Surgery Branch in 2006,Citation9 TEM procedure does not need for prophylactic administration of antibiotics.
In our opinion, preoperative antibiotics administration should be mandatory. Another important issue is that the prophylactic antibiotic administration should coverage for both aerobic and anaerobic bacteria as well as gram-positive and gram-negative. In the Chen's et al. article, only a cephalosporin antibiotic was administered,Citation1 anyway in our opinion the best prophylactic antibiotics administration in case of TEM procedures includes the association of cephalosporin and metronidazole.
On the other hand, postoperative administration should be based on the depth of the excision of the lesion (submucosal resection or full thickness excision or ELRRCitation1,4,5) and based on the closure or not of the rectal wall. In fact, as reported in literature some authors consider the closure of the defect of the rectal wall after TEM excision as well as an essential step of the procedure, but in contrast, other authors do not consider this step mandatory in all cases.Citation3,10 Moreover, another important aspect, that can influence the chose to administer or not the antibiotics therapy postoperatively, could be the neoadjuvant chemo-radiotherapy (n-CRT).Citation3 In the Chen's et al. article, patients who underwent to n-CRT are not reported,Citation1 even if, recently, it is possible to observe a fast increase of association of neoadjuvant therapy and transanal procedures (with TEM or other platforms).Citation3,7,8 The impact of the n-CRT on postoperative outcomes in these patients is still debated, anyway the use of this therapy should be considered during the evaluation of the antibiotics management strategy.
In conclusion, despite in the Chen's et al.,Citation1 the significant differences observed between the two groups in terms of laboratory inflammation markers do not reflect a direct clinical implication, because postoperative complications, such as dehiscence, fever or sepsis were not observed, their paper, in our opinion, it is very important, due to could be the first one of a series of papers, with the aim to change the current antibiotics management guidelines proposed by the Chinese Medical Association Surgery Branch.Citation9
DISCLOSURES
Author has no conflicts of interest or financial ties to disclose.
REFERENCES
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- National Comprehensive Cancer Network. (NCCN). Clinical practice guidelines in oncology. Rectal Cancer, Version 1. 2017. Accessed 23 NOV. 2016.
- Bignell MB, Ramwell A, Evans JR, et al. Complications of transanal endoscopic microsurgery (TEMS): a prospective audit. Colorectal Dis. 2010;12(7 Online):e99–e103.