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Transanal Endoscopic Microsurgery or Total Mesorectal Excision: Not an Anagram!

We read the article by Leijtens et al. [1] with a great interest, as this is a relevant topic in rectal cancer. Although we wish to congratulate the authors for their work, we would also like to add a word of caution. The article by Leijtens et al. [1] was a retrospective, multicenter, observational study reviewing the role of transanal endoscopic microsurgery (TEM) from 1994 to 2010. One of the major advantages of such a design is the opportunity to provide longterm follow-up data on recurrence, overall, and disease-specific survival rates [2]. However, the authors drew their conclusions based on data obtained from less than 3-year follow-up; therefore, the year of their publication, namely, 2018 remains unclear. Although we support the authors’ strategy to perform TEM as a diagnostic tool in case of false-negative endoscopic biopsies of large tubulo-villous adenomas, we wish to express a concern regarding the violation of the total mesorectal excision (TME) plane. In fact, full-thickness local excision may not be necessary to establish an accurate diagnosis, which can be accomplished by endoscopic submucosal dissection [3]. Although we agree with the authors’ suggestion that TEM can be a valuable instrument to palliate symptoms in old frail patients with rectal cancer, we respectfully disagree with the authors’ conclusion that TEM can be a definitive procedure not followed by TME when the intent is cure in patients with resectable rectal cancer. In fact, reliable data suggest that transanal excision (such as TEM is) may result in higher risk for cancer-related death [4].