Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis.

BACKGROUND: Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups. METHODS: An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed. RESULTS: Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group. CONCLUSION: This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.

Mapping timely access to emergency and essential surgical services: The Malaysian experience.

BACKGROUND: Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia. METHODS: The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping. RESULTS: There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region. CONCLUSION: There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.

Clinical activity and outcomes during Geelong's general surgery response to the coronavirus disease 2019 pandemic.

BACKGROUND: The response to the coronavirus disease 2019 pandemic has required conserving capacity and resources to avoid the health sector being overwhelmed. This paper describes Geelong's general surgical response, surgical activity, outcomes and the effect on surgical training. METHODS: Data collected from surgical audits; hospital databases and patient's medical records were used to compare the first 7 weeks of our new service delivery (30 March to 17 May 2020) to the corresponding 7 weeks in 2019 (1 April 2019 to 19 May 2019). All surgical cases, morbidity and mortality were discussed at weekly surgical audit meetings conducted by videoconference. Treatment performance indicators were tested by chi-squared test for proportions, and by Student's t-test or Mann-Whitney test for continuous variables. RESULTS: Elective general surgery decreased by 45.9% but an essential service was maintained by substantially increasing our public in private operating to perform 81 cases. Despite a 30% decrease in emergency department presentations, general surgery admissions decreased only 6.1% while emergency operations increased 13.9%. We used telehealth to conduct 81.3% of outpatient appointments and 61.8% of pre-operative anaesthetic reviews. No significant differences were found for overall surgical outcomes, including appendicectomy (perforation rates) and laparotomy (length of stay and morbidity). Operative exposure for trainees was maintained. CONCLUSION: Geelong was able to provide a safe and effective general surgery service during the first 7 weeks of the coronavirus disease 2019 pandemic. There are some valuable lessons which could be adopted elsewhere in the event of a surge or second wave of cases.

How will increasing surgical volume affect mortality in the Pacific, Papua New Guinea and Timor Leste?

BACKGROUND: Nine South Pacific nations, Papua New Guinea and Timor Leste, have collaborated to report and publish their surgical metrics as recommended by the Lancet Commission on Global Surgery (LCoGS). Currently, these countries experience about 750 postoperative deaths per year, representing 1% of crude mortality in the region. Given that more than 400 000 annual procedures are needed in the nine nations to reach the LCoGS target of 5000/100 000, we aimed to calculate the potential contribution of perioperative mortality to national mortality where these procedures are performed. METHODS: We utilized reported surgical metrics with current rates for surgical volume (SV) and perioperative mortality (POMR), as well as World Bank/WHO mortality statistics, to predict the likely impact of surgical scale-up to recommended targets by 2030. We tested correlations between SV and POMR in countries from our region using Pearson's r statistic. Funnel plots were used to evaluate the dataset for outliers. RESULTS: Surgical scale up would result in perioperative mortality contributing on average to 3.3% of all national crude mortality. This prediction assumes POMR stays the same, which is challenging to predict. In our region countries that achieved the LCoGS target (n = 5) had a lower POMR than countries that did not (n = 8). CONCLUSIONS: Surgical volumes in the South Pacific region must increase to meet the LCoGS target. Postoperative mortality as a proportion of all mortality may increase with the surgical scale up, however, the overall number of premature deaths is expected to reduce with better access to timely and safe surgical care.

Impact of public-private partnership on a regional colonoscopy service.

BACKGROUND: A public-private partnership for endoscopy was introduced in Geelong where there was no capacity for public hospital endoscopy lists to expand. This paper presents the impact of this partnership on colonoscopy services. METHODS: Data were collated from prospectively maintained databases. Wait-times to outpatient appointments, colonoscopy and follow-up were analysed between July 2015 and June 2017 allowing for a 12-month period of analysis before and after the initiation of the contract. Data are presented as medians (interquartile range). RESULTS: A total of 1300 colonoscopies were done between July 2015 and June 2016 compared to 2114 colonoscopies (P < 0.01) after the initiation of the public-private contract; 1073 (51%) colonoscopies were done on private contract. Prior to public-private contract, 41% patients waited more than 120 days from first presentation to healthcare services to diagnostic colonoscopy, this decreased to 19% after. Improvements were seen in both the waiting time for outpatient consultation (reduced from 92 days (39-136) prior to July 2016 to 73 days (32-122); P < 0.01) after) and the time taken from consultation to colonoscopy (from 125 days (70-207) to 36 days (21-159); P < 0.01) for category 1 patients. CONCLUSION: Wait-times for both specialist outpatient assessment and colonoscopy have been significantly reduced through the introduction of a unique public-private partnership in the Greater Geelong area, resulting in more timely access for public patients and improved compliance with new guidelines.

Global Surgery System Strengthening: It Is All About the Right Metrics.

Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. This article discusses the definition, validity, feasibility, relevance, and progress with each of these metrics. The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.

Colorectal multidisciplinary meetings: how do they affect the timeliness of treatment?

BACKGROUND: The aim of this study is to determine whether multidisciplinary team (MDT) meetings alter the length of time to treatment (LOTT) for patients with colorectal cancer. METHODS: We conducted a retrospective audit of all patients with colorectal cancer from the Geelong Hospital (TGH) mandatory colorectal database from 1 January 2006 to 3 February 2011. To be included, patients had to have had elective surgical intervention for primary colorectal adenocarcinoma. A comparison of historical controls was conducted between patients discussed in MDT meetings and those managed prior to the introduction of MDT meetings (3 October 2006) to determine the LOTT in days from definitive diagnosis (colonoscopy) to definitive management (surgery, radiotherapy or chemotherapy). RESULTS: In total, the median LOTT for the historical control and MDT era patient populations were 19.5 and 20 days, respectively. Within the MDT era, we noticed significantly longer times to treatment for patients with rectal cancer who were seen in an MDT meeting prior to definitive management than patients who did not have an intervening MDT meeting (P < 0.001). With a difference of 7.5 days, the clinical significance of these findings remains contentious. However, it is worthwhile recognizing this trend in patients who are exhibiting symptoms due to near obstruction or significant bleeding. The LOTT for colon cancer patients remained unchanged. CONCLUSION: The introduction of MDT meetings to TGH has prolonged the LOTT for patients with rectal cancer. These findings pave the way for further revision of the efficiency of MDT meeting at TGH.

Measuring the Burden of Surgical Disease Averted by Emergency and Essential Surgical Care in a District Hospital in Papua New Guinea.

BACKGROUND: Timely access to emergency and essential surgical care (EESC) and anaesthesia in low- and middle-income countries (LMICs) prevents premature death, minimises lifelong disability and reduces their economic impact on families and communities. Papua New Guinea is one of the poorest countries in the Pacific region, and provides much of its surgical care at a district hospital level. We aimed to evaluate the surgical capacity of a district hospital in PNG and estimate the effectiveness of surgical interventions provided. METHODS: We performed a prospective study to calculate the number of DALYs averted for 465 patients treated with surgical care over a 3-month period (Sep-Nov 2013) in Alotau Hospital, Milne Bay Province, PNG (pop 210,000). Data were also collected on infrastructure, workforce, interventions provided and equipment available using the World Health Organization's Integrated Management of Emergency and Essential Surgical Care Toolkit, a survey to assess EESC and surgical capacity. We also performed a retrospective one-year audit of surgical, obstetric and anaesthetic care to provide context with regards to annual disease burden treated and surgical activity. RESULTS: EESC was provided by 11 Surgeons/Anaesthetists/Obstetricians (SAO) providers, equating to 5.7 per 100,000 population (including 4 nurse anaesthetists). They performed 783/100,000 procedures annually. Over the 3-month prospective study period, 4954 DALYs were averted by 465 surgical interventions, 52 % of which were elective. This equates to 18,330 DALYs averted annually or, approximately 18 % of the published but estimated disease burden in the Province in the 2013 Global Burden of Disease Study. The overall peri-operative mortality rate was 1.29 %, with 0.41 % for elective procedures and 2.25 % for emergencies. CONCLUSIONS: Much of the burden of surgical disease in Papua New Guinea presenting to Alotau General Hospital serving Milne Bay Province can be effectively treated by a small team providing emergency and essential surgical care. This is despite a relatively low surgical volume and limited numbers of trained surgical anaesthesia obstetric providers, and likely underservicing. The ability of surgical care to avert disease in Papua New Guinea highlights its importance to public health in LMICs.

Laparoscopic or open appendicectomy for suspected appendicitis in pregnancy and evaluation of foetal outcome in Australia.

BACKGROUND: Recent data suggest that laparoscopic appendicectomy (LA) in pregnancy is associated with higher rates of foetal loss when compared to open appendicectomy (OA). However, the influence of gestational age and maternal age, both recognized risk factors for foetal loss, was not assessed. METHOD: This was a multicentre retrospective review of all pregnant patients who underwent appendicectomy for suspected appendicitis from 2000 to 2012 across seven hospitals in Australia. Perioperative data and foetal outcome were evaluated. RESULTS: Data on 218 patients from the seven hospitals were included in the analysis. A total of 125 underwent LA and 93 OA. There were seven (5.6%) foetal losses in the LA group, six of which occurred in the first trimester, and none in the OA group. After matching using propensity scores, the estimated risk difference was 5.1% (95% confidence interval (CI): 1.4%, 9.8%). First trimester patients were more likely to undergo LA (84%), while those in the third were more likely to undergo OA (85%). Preterm delivery rates (6.8% LA versus 8.6% OA; CI: -12.6%, 5.3%) and hospital length of stay (3.7 days LA versus 4.5 days OA; CI: -1.3, 0.2 days) were similar. CONCLUSION: This is the largest published dataset investigating the outcome after LA versus OA while adjusting for gestational and maternal age. OA appears to be a safer approach for pregnant patients with suspected appendicitis.

Surgical capacity building in Timor-Leste: a review of the first 15 years of the Royal Australasian College of Surgeons-led Australian Aid programme.

BACKGROUND: Timor-Leste suffered a destructive withdrawal by the Indonesian military in 1999, leaving only 20 Timorese-based doctors and no practising specialists for a population of 700 000 that has now grown to 1.2 million. METHODS: This article assesses the outcomes and impact of Royal Australasian College of Surgeons (RACS) specialist medical support from 2001 to 2015. Three programmes were designed collaboratively with the Timor-Leste Ministry of Health and Australian Aid. The RACS team began to provide 24/7 resident surgical and anaesthesia services in the capital, Dili, from July 2001. The arrival of the Chinese and Cuban Medical Teams provided a medical workforce, and the Cubans initiated undergraduate medical training for about 1000 nationals both in Cuba and in Timor-Leste, whilst RACS focused on specialist medical training. RESULTS: Australian Aid provided AUD$20 million through three continuous programmes over 15 years. In the first 10 years over 10 000 operations were performed. Initially only 10% of operations were done by trainees but this reached 77% by 2010. Twenty-one nurse anaesthetists were trained in-country, sufficient to cover the needs of each hospital. Seven Timorese doctors gained specialist qualifications (five surgery, one ophthalmology and one anaesthesia) from regional medical schools in Papua New Guinea, Fiji, Indonesia and Malaysia. They introduced local specialist and family medicine diploma programmes for the Cuban graduates. CONCLUSIONS: Timor-Leste has developed increasing levels of surgical and anaesthetic self-sufficiency through multi-level collaboration between the Ministry of Health, Universidade Nacional de Timor Lorosa'e, and sustained, consistent support from external donors including Australian Aid, Cuba and RACS.

Cautery versus scalpel for abdominal skin incisions: a double blind, randomized crossover trial of scar cosmesis.

BACKGROUND: The purpose of this study was to determine whether there is any difference in cosmetic outcome between using cutting diathermy and using a scalpel to make abdominal skin incisions. METHOD: This was a prospective, randomized, double-blind crossover study. The primary end point was wound cosmesis as judged by the patient. In each case, one-half of the skin incision was made using diathermy, and one-half using a scalpel blade. Patients were contacted at 6 months post-operatively, and were asked which half of the wound looked better to them. A panel of 18 surgeons was also shown photographs of the wounds taken after 6 months, and were asked the same question. RESULTS: Of the 31 patients with complete follow-up, 11 (35%) reported no difference between the two halves of the wound. Nine (29%) preferred the half incised with diathermy, and 11 (35%) preferred the half incised with the scalpel (P = 0.82, chi-squared test). Twenty-four patients consented to having their wound photographed. There was no difference in the surgeons' preference between the diathermy and scalpel halves of the incision (P = 0.35, signed-rank test). CONCLUSION: We found the use of cutting diathermy to make abdominal skin incisions to be cosmetically equivalent to cutting with the scalpel. As previous studies have not shown adverse wound outcomes using this technique, and considering the safety concerns for theatre staff when the scalpel is used, the routine use of cutting diathermy for skin incisions in abdominal surgery is justified.

Colorectal preOperative Surgical Score (CrOSS) for mortality in major colorectal surgery.

BACKGROUND: Colorectal surgery carries a significant mortality risk, with reported rates of 1-6% for elective surgery and up to 22% in the emergency setting. Both clinicians and patients will benefit from being able to predict the likelihood of death before surgery. Recently, we have described and validated two risk stratification models for colorectal surgery, the Barwon Health 2012 and Association Française de Chirurgie models. However, these models are not suitable for assessment at patient's bedside. The purpose of this study is to develop a simplified preoperative model capable of predicting mortality following colorectal surgery. METHODS: The new model is termed Colorectal preOperative Surgical Score (CrOSS). The development and internal validation of CrOSS was performed using a prospectively maintained colorectal database. External validation was performed using retrospective data. Univariate and multivariate analyses were performed in model development. Calibration and discrimination were used for model validation. RESULTS: There were 474 and 389 consecutive colorectal surgeries at Geelong Hospital and Western Hospital. Overall mortality rates were 5.16% and 1.03%, respectively. Significant predictors for mortality were as follows: age ≥70, urgent operation, albumin ≤30 g/L and congestive heart failure (receiver operating characteristic (ROC) = 0.870, calibration P-value = 0.937). The predicted risk of mortality was stratified according to the risk profile of 0.39-66.51%. When validated externally, CrOSS predicted mortality accurately (ROC = 0.847, calibration P-value = 0.199). CONCLUSIONS: A robust and simple preoperative model has been created to risk-stratify patients for colorectal surgery. This was successfully validated at another tertiary hospital.

Recalibration and validation of a preoperative risk prediction model for mortality in major colorectal surgery.

BACKGROUND: In 2009, Barwon Health designed a risk stratification model for mortality in major colorectal surgery with the use of only preoperative risk factors. The Barwon Health 2009 model was shown to predict mortality reliably, and it was comparable to other models, such as the original, POSSUM. However, the Barwon Health 2009 model was never validated with data other than those used to develop the model. OBJECTIVE: The aim of this study was to perform temporal and external validation of the Barwon Health 2009 model and to compare it with other published models. DESIGN: : The temporal validation was a prospective observational study, whereas the external validation was a retrospective observational study. The discrimination and calibration of the models were assessed by using the area under receiver operator characteristic and χ test of Hosmer-Lemeshow goodness-of-fi technique. SETTINGS: This is a multi-institutional study. Data were collected from 2008 to 2010. RESULTS: There were 474 major colorectal cases at Geelong Hospital (temporal validation) and 389 cases at Western Hospital (external validation). The overall mortality rate was 5.10% and 1.03%. In the comparison of the 2 demographics, Geelong Hospital had a higher proportion of patients who were older and had higher ASA scores and comorbidity counts, whereas Western Hospital surgeons were operating on a higher number of urgent cases. Despite the differences, the Barwon Health 2009 model was able to discriminate mortality reliably (area under receiver operator characteristic = 0.753) but had poor model calibration (p < 0.001) on temporal validation. Hence, the model was recalibrated to predict mortality accurately(area under receiver operator characteristic = 0.772; p = 0.83), and this was successfully validated at Western Hospital (area under receiver operator characteristic = 0.788; p = 0.24). CONCLUSIONS: We have developed a model that can accurately predict mortality after major colorectal surgery by using only data that are available preoperatively. After recalibration, the model was successfully validated in a second hospital.

Does an Acute Surgical Model increase the rate of negative appendicectomy or perforated appendicitis?

INTRODUCTION: The clinical outcomes from suspected appendicitis depend on balancing the rate of negative appendicectomy (NA) with perforated appendicitis (PA). An Acute Surgical Model (ASM) was introduced at Geelong Hospital (GH) in 2011 involving a dedicated emergency general surgery theatre list every business day giving greater access to theatre for general surgeons. The aim of this study was to evaluate the effect of the ASM at GH on the management of appendicitis, in particular the NA and PA rates. METHODS: Data for 357 patients undergoing emergency appendicectomy was collected prospectively over 1 year (2011) and compared with a historical control group of 351 patients (2010). The data was analysed for patient demographics, preoperative diagnostic radiology and outcomes including NA and PA rates and complications. The negative appendicectomy rates were compared with contemporary studies. RESULTS: There was no difference between the two groups in rates of negative appendicectomy 21% (ASM; 73/357) versus 21% (Control; 73/351) P = 0.98, or perforated appendicitis 17% (ASM; 61/357) versus 13% (Control; 47/351) P = 0.18. The introduction of the ASM corresponded to a significantly lower proportion of emergency appendicectomies overnight (4% [16/357] versus 12% [44/351] P = 0.005). There was no significant difference in the use of preoperative diagnostic radiology or complications. Matched contemporary studies had a NA rate of 26%. CONCLUSION: The introduction of the ASM at GH has not significantly altered the rate of NA or PA. The NA rate at GH is comparable to other published UK and Australian series.

Medical student participation in a surgical outpatient clinic: a randomized controlled trial.

BACKGROUND: To determine the patient, doctor and student perceptions with different styles of student participation in a surgical outpatient clinic. METHODS: A randomized controlled trial was conducted in surgical outpatients. Participants included patients scheduled to see one of four specialist general surgeons, the surgeons themselves and third-year medical students undertaking their general surgery rotation at the Geelong Hospital. A total of 151 consultations were randomized to one of three consultation styles between August 2011 and August 2012. (i) 'No Student', consultation without a student being present, (ii) 'Student with Doctor', consultation where the student accompanied the doctor throughout the consultation and (iii) 'Student before Doctor', consultation where the student interviewed the patient before the doctor and examined the patient in the doctor's presence. Participants' perceptions and experience of each of the consultations was assessed in the form of written questionnaires. RESULTS: There was no difference in overall patient satisfaction with different styles of student participation (P = 0.080). Students showed a clear preference for the 'Student before Doctor' consultation style (P = 0.023). There were no differences in consultation outcomes from the doctor's perspective (P = 0.88), except time (P < 0.0001). CONCLUSION: This study supports a style of consultation where students are actively involved in patient care as it has no adverse effects on patient satisfaction and it is the preferred participation style from the student's perspective. Doctors do not feel that active student involvement interferes with their ability to deliver healthcare except that it prolongs consultation time.

Dedicated emergency theatres improve service delivery and surgeons' job satisfaction.

BACKGROUND: There are well-described benefits to separating emergency and elective surgery. Geelong Hospital lacked the resources to implement a separate acute surgical unit, but instituted daily dedicated emergency general surgery operating sessions, managed by an on-site consultant. This study aims to assess the impact of this on service delivery and surgeons' job satisfaction. METHODS: From 1 February 2011, daily half-day operating lists were allocated for general surgical emergencies. Patients treated on these lists were studied prospectively until 31 December 2011. Theatre waiting times and hospital stay were compared with the previous year. A quality-of-life questionnaire was administered to participating surgeons before the project commenced and after 6 months. RESULTS: A total of 966 patients underwent surgery during an emergency general surgery admission in the control period, and 984 underwent surgery during the study period. The median time from arrival in the emergency department (ED) to surgery was reduced from 19 (18-21) h in the control group to 18 (17-19) h in the study group (P = 0.033). The time from booking surgery to operation was reduced from 4.8 (4.3-5.4) h to 3.9 (3.5-4.3) h (P < 0.0001). For patients undergoing emergency laparotomy, the time from booking to surgery was reduced from 3.1 (2.2-4.1) to 2.4 (1.8-2.9) h, and hospital stay was reduced from 13 (11-15) to 10 (9-12) days (P = 0.0089). The surgeons' responses to the questionnaires showed improvement in job satisfaction (P < 0.0001). CONCLUSION: This intervention has improved service delivery for emergency surgery patients, and improved the participating surgeons' job satisfaction.

Preoperative risk stratification for mortality and major morbidity in major colorectal surgery.

INTRODUCTION: Risk stratification in major colorectal surgery, in general, has used preoperative, intraoperative, and postoperative variables, and has been used for purposes of comparative audit. To enable preoperative clinical use, this study aimed to stratify risk by use of preoperative risk factors only. METHODS: This is a single-institutional prospective observational study. RESULTS: There were 887 major colorectal procedures assessed. Independent risk factors for mortality were American Society of Anesthesiologists' physical status Grades III to V, age, high comorbidity count, and low surgeon case volume. For major morbidity, risk factors were American Society of Anesthesiologists' Grades III to V, urgent operation, and operation to excise the rectum. Overall, mortality was 4.51%, and major morbidity was 19.6%. The estimated risk of mortality was stratified by risk factor profile from 0.12% (95% CI, 0.02-0.93) to 42.4% (95% CI, 23.5-63.9). The risk of major morbidity was stratified from 7.22% (95% CI, 4.82-10.7) to 49.2% (95% CI, 34.2-64.4). Model discrimination was favorable to the existing risk adjustment models applied to our cohort. The Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (including Portsmouth and ColoRectal modifications), and Association of ColoProctology of Great Britain and Ireland Colorectal Cancer models (mortality: area under receiver operating characteristic (AU ROC) curves 0.87 compare 0.70-0.81, major morbidity: 0.69 compare 0.66)). CONCLUSIONS: Simple and readily available preoperative risk factors can achieve risk stratification. Risk stratification based on preoperative risk factors only possibly has comparable efficacy with those models that use preoperative, intraoperative, and postoperative risk factors.