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In the last few decades, improvements in surgical technique, pre-operative radiotherapy and oncological knowledge have dramatically reduced the incidence of abdominoperineal resection with permanent end colostomy (Miles' operation [1]) for low rectal cancer. Nowadays less than 5% of patients suffering from rectal cancer will undergo that operation [2], but even for these unfortunate patients the handicap of a permanent abdominal colostomy could be overcome. The restitutio ad integrum of the anorectal function has been a major challenge for colorectal surgeons since the first attempts by Chittenden in 1930 [3].

However, after some pioneering studies by Margottini [4] (direct perineal colostomy without continence mechanisms) and Beche [5] (direct perineal colostomy with a retrocolic sling using the anterior levator fascia), the first comprehensive report of total anorectal reconstruction following Miles' operation was published in 1976 by Simonsen et al. [6] who reported a series of 24 cancer patients with perineal colostomy and a neo-anal sphincter with an unstim-ulated graciloplasty according to the technique described by Pickrell et al. [7] for faecal incontinence.

This study did not, however, stimulate further attempts and in the next ten years only one paper [8] on this topic appeared in the medical literature (published in Chinese), reporting a similar rate of success (73%).

The greatest experience in the field was gained by Cavina et al. [9] who, in the mid-1980s, reawakened surgeons' interest in this operation and markedly modified the surgical technique. He first introduced the concept of temporary external muscle electros-timulation with the aim of preventing muscle atrophy and used both gracilis muscles, the first as a pub-orectalis sling, the other as a neo-anal sphincter. But the excellent results reported by Cavina did not overcome the scepticism of general surgeons about this operation and no other surgeons outside Italy repeated Cavina's experience for many years. The gracilis muscle is, in fact, unable to function as an anal sphincter because it cannot sustain prolonged contraction without developing fatigue and, if not stimulated for a long time, it becomes atrophic.

A strong push towards wider and more reliable application of a dynamic neo-anal sphincter using the gracilis muscle in total anorectal reconstruction came from the outstanding works by Williams et al. [10] and Baeten et al. [11] who, in the early 1990s, applied chronic low-frequency electrostimulation by an implantable pulse generator (IPG), to convert an easily fatigable muscle (like the gracilis muscle) into a fatigue-resistant one, inducing a structural and metabolic transformation of its type II muscle fibres into type I. After their initial enthusiastic reports, several colorectal surgeons around the world started to convert end abdominal colostomies to total anorectal reconstruction after Miles using the electrostimulated gracilis as a neo-sphincter, albeit with variable success [12-18].

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