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Consequent to recent advances in surgical techniques and management, survival rate has increased substantially over the last 25 years, particularly in colorectal cancer patients. However, post-operative morbidity and mortality from colorectal cancer vary widely across the country. Therefore, standardised outcome measures are emphasised not only for professional accountability, but also for comparison between treatment units and regions. In a heterogeneous population, the use of crude mortality as an outcome measure for patients undergoing surgery is simply misleading. Meaningful comparisons, however, require accurate risk stratification of patients being analysed before conclusions can be reached regarding the outcomes recorded. Sub-specialised colorectal surgical units usually dedicated to more complex and high-risk operations. The need for accurate risk prediction is necessary in these units as both mortality and morbidity often are tools to justify the practice of high-risk surgery. The Acute Physiology And Chronic Health Evaluation (APACHE) is a system for classifying patients in the intensive care unit. However, APACHE score was considered too complex for general surgical use. The American Society of Anaesthesiologists (ASA) grade has been considered useful as an adjunct to informed consent and for monitoring surgical performance through time. ASA grade is simple but too subjective. The Physiological & Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and its variant Portsmouth POSSUM (P-POSSUM) were devised to predict outcomes in surgical patients in general, taking into account of the variables in the case-mix. POSSUM has two parts, which include assessment of physiological parameters and operative scores. There are 12 physiological parameters and 6 operative measures. The physiological parameters are taken at the time of surgery. Each physiological parameter or operative variable is sub-divided into three or four levels with an exponentially increasing score. However, POSSUM and P-POSSUM over-predict mortality in patients who have had colorectal surgery. Discrepancies in these models have led to the introduction of a specialty-specific POSSUM: the ColoRectal POSSUM (CR-POSSUM). CR-POSSUM only uses six physiological parameters and four operative measures for prediction of mortality. It is much simplified to allow ease of use.

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Splenic rupture is a life-threatening condition characterized by internal hemorrhage, often difficult to diagnose. Colonoscopy is a gold standard routine diagnostic test to investigate patients with gastrointestinal symptoms as well as to those on the screening program for colorectal cancer. Splenic injury is seldomly discussed during consent for colonoscopy, as opposed to colonic perforation, as its prevalence accounts for less than 0.1%. A 66-year-old Caucasian woman with no history of collagen disorder was electively admitted for routine colonoscopy for surveillance of adenoma. She was admitted following the procedure for re-dosing of warfarin, which was stopped prior to the colonoscopy. The patient was found collapsed on the ward the following day with clinical shock and anemia. Computed tomography demonstrated grade 4 splenic rupture. Immediate blood transfusion and splenectomy was required. Splenic rupture following routine colonoscopy is extremely rare. Awareness of it on this occasion saved the patient's life. Despite it being a rare association, the seriousness warrants inclusion in all information leaflets concerning colonoscopy and during its consent.

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BACKGROUND: The clinical effectiveness of pus swabs for microbiological analysis during incision and drainage of perianal abscess is controversial. Its cost implication is often overlooked. The present study aimed to determine if submission of pus swabs can be avoided without a negative effect on outcome. METHODS: All consecutive cases of incision and drainage of perianal abscess between January 2004 and 2008 were retrospectively reviewed. Patient demographics, microbiological results, and clinical outcome with a follow-up of 6 months were assessed. RESULTS: A review of patient records revealed 235 cases (59 F:176 M; age range: 6-99 years; median: 37 years). In 38 cases no swabs were taken; in 28 cases (12%), 106 cases (45%), and 16 cases (7%) swabs contained skin flora organisms, coliform/Bacteroides, and sterile, respectively. Within 6 months follow-up, 185 of the abscesses had healed, leaving 39 cases of fistula (25 cases had setons remained in situ for their fistulas at 6 months follow-up) and 11 patients were lost from follow-up. Fistulas were not associated with coliform/Bacteroides found on microbiological analysis (P > 0.05). In only 4 cases (1.7%) were the swab results mentioned in follow-up reports. CONCLUSIONS: Surgeons tend not to review microbiological results at patient follow-up. Furthermore, the preliminary findings suggest that microbiological results have no correlation with presence of fistulas or prognosis. Randomized controlled trials are warranted to assess whether abandoning submission of pus swabs will affect clinical effectiveness of treatment in patients with perianal abscess.

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