Journal of Surgical Oncology | 2019
Origin of PSAM procedure in surgical oncology
Abstract
The origin of my proposal of posterior sagittal anorectal mobilization (PSAM) technique is old and starts in 1988 with the first European Course of Alberto Peña on Tratamiento Quirurgico de las Malformaciones Ano‐rectales”, which took place at the Hospital Infantil “La Paz”, Madrid (from 2nd to 4th March, 1988). Between 1988 and 2001, this experience changed my ideas about perineal approaches of my patients. I operated, in this period, 50 cases of different types of anorectal malformations (ARM), but I also had the opportunity to start sagittal posterior approaches in cases of urogenital sinus and in perineal teratomas. Perineal sagittal approaches (posterior sagittal anorectoplasty and posterior sagittal anorectal mobilization) allow complete anatomic exposure of the perineum and lower pelvis. In 2004, I was referent Author of the preliminary paper: “Feasibility of perineal sagittal approaches in patients without anorectal malformations”. The aim of this study was to describe a series of patients operated using a perineal sagittal approach at the Gaslini Children’s Hospital from January 1997 to December 2001. All of these patients were without ARM. Indications included retrorectal abscesses (two), iatrogenic anal canal stenosis (one), postinflammatory anal canal stenosis (one), internal anal sphincter neurogenic achalasia (one), female pseudohermaphroditism (one), benign sacrococcygeal teratomas (two), malignant sacrococcygeal teratoma (one), and perineal rhabdomyosarcoma (one). However, the definitive description of my technique was in 2018 on JSO, as a specific procedure in surgical oncology (for this reason, I chose “Journal of Surgical Oncology”). In this procedure, I developed a deep posterior sagittal dissection, including sagittal section of levator ani, that is able to mobilize in any direction the anorectal canal, rectum, and distal colon, in order to obtain radical resection of different tumors. The procedure is explained using intraoperative photos and very understanding drawings. I definitively indicated this technique that I started to develop since 1988 as posterior sagittal anorectal mobilization (PSAM). Obviously, I had never read Pinter’s paper of 1996 and 2007 before the submission of mine. The study of Pinter presents different technical aspects, and different aims. The authors try to determine, using human material and experimental animals (dog animals not strictly experimental), whether the posterior sagittal approach with perirectal dissection in patients with an intact anorectum is a suitable procedure, without impairment of fecal continence. This interesting study in dogs and children is finalized to the physiological effects of perirectal dissection with possible denervation. The authors write shortly about the technical surgical aspects in children with urogenital anomalies as: “perirectal dissection in a circumferential manner around the rectum and anus. They treated cases of vaginal fistula or urogenital sinus, but no tumors. I think that Pinter’s study it is not a proposal of a new technique in pediatric surgical oncology. The authors conclude that this type of dissection does not impair fecal continence. Exceedingly different procedures are those described by Keramidas et al. The authors mobilized the rectum with the use of a perirectal sling. They describe the procedure in the following way: “A sling is placed around the rectum permitting its lateral traction.” Moreover, as it is evident in fig. 1 and in technical description on prostatic utricle cyst excision, their technique is different from PSAM. The authors also write: “The anus remained in its normal position. Total excision of tumor was successfully carried out by separation from the sacrum creating a plane between the mass and the periosteum.” Furthermore, they do not perform a real total posterior anorectal mobilization, the anorectal canal is not dissected from the perineum (see fig. 1). In this way, the exposition is really limited for a massive tumors radical resection. Probably this could be the reason why their case with “presacral sarcoma died 1 year after the operation from generalized disease.” In conclusion, only PSAM with complete mobilization of anorectal canal and rectum is suitable for the best possible exposition for pelvic‐perineal tumors; in some cases, it needs to be associated with combined laparotomy. Yours sincerely, Professor Giuseppe Martucciello