The perineal colostomy could be performed at the time of the Miles' operation but this is not recommended because of the risk of local recurrence. A minimum period of 2 years of oncological follow-up should be long enough to exclude patients at risk for local recurrences and to overcome the effects of adjuvant chemotherapy. Failure to follow this obvious rule can lead to a high failure rate, as recently reported by Ho and Seow-Choen .
The fashioning of a perineal colostomy a few years after the Miles' operation has other advantages because the abdominal colostomy can be mobilised, leaving a ring of skin around the stoma reversed to the perineum so that a skin-to-skin suture can be performed. Furthermore the exact perineal site for the neo-anus could be indicated by the patient himself during a pre-operative visit. Finally this choice will select only those patients strongly motivated to dispense with abdominal colostomy.
Even the graciloplasty can be performed simultaneously with the perineal colostomy or after healing of the suture. The need to reduce the number of operations for this procedure must be balanced against the increased risk of very fearsome infective complications. Even a simple infection at the site of the elec-
trostimulator or electrode implant is difficult to manage and often requires removal of the expensive device. For this reason some Authors implant the electrodes and pulse generator only after the graciloplasty has healed .
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