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Colorectal cancer screening, diagnosis, staging and treatment have developed and improved significantly over the last three decades with an overall 5-year survival now approaching 60% 1. Currently the number of colorectal cancer survivors in the UK is approximately 250,000 with a predicted increase to over 600,000 in the next 3 decades, due to rising cancer incidence and better outcomes 2,3. This article is protected by copyright. All rights reserved.

Publication of surgical activity and mortality was first introduced in the United Kingdom (UK) in 2004 for adult cardiac surgery. The Kennedy Inquiry into paediatric cardiac deaths at the Bristol Royal Infirmary [1] motivated this initiative. The Freedom of Information Act in 2005 and the Francis Report [2] which appeared in 2012 led to the NHS Commissioning Board’s document “Everybody Counts” [3]. Aimed to improve surgical care and promote patient safety, these reports underlined the need for greater transparency and informed patient decision-making. They recommended the publication of surgical “activity, clinical quality measures and survival rates from national audits for every practicing consultant” in nine surgical specialties and in interventional cardiology. Adjusted 90-day mortality rates are currently available online for all colorectal cancer surgeons in England [4], but the introduction of surgeon-specific outcome data (SSD) has raised concerns, not least because of the variable quality of such dataand the statistical methods employed to analyse them [5], but also over the value of these results for informing patient and clinician choice. While good evidence exists that surgeons support the publication of outcome data [6], there is a potential for this to influence a surgeon’s practice adversely, for example in avoiding elective surgery for high-risk patients. Alternative reporting methods may provide a more sensitive quality assessment of treatment by reflecting the multidisciplinary approach to perioperative care rather than that provided by the individual surgeon.

Optimal treatment for low rectal cancer is total mesorectal excision, with most patients suitable for low colo-rectal or colo-anal anastomosis. A colon pouch has early functional benefits, although long-term function, especially evacuation, might mitigate against its routine use. The aim of this study was to assess evacuation and continence in patients with a colon pouch, and to examine the impact of possible risk factors.In 1998, all 102 surviving patients with a colon pouch, whose stoma had been closed for more than one year, were sent a postal questionnaire. A composite incontinence score was calculated from questions on urgency, use of a pad, incontinence of gas, liquid or faeces; and a composite evacuation score from questions on medication taken to evacuate, straining, the need and number of times returned to evacuate.The response rate was 90% (50 M, 42 F), with a median age of 68 years (IQR 60-78) and median follow-up of 2.6 years (IQR 1.7-3.9). The anastomosis was 3 cm or less from the anus in 45/92 (49%), and incontinence scores were worse in this group (P = 0.001). There were significantly higher incontinence scores in females (P = 0.014). Age, preoperative radiotherapy, part of colon used for anastomosis, postoperative leak and length of follow-up had no demonstrable effect on either score.Gender and anastomotic height were the only variables which influenced incontinence. Ninety percent of patients reported that their bowel function did not affect their overall wellbeing, and none would have preferred to have a stoma.