JRRMMC Section of Colon and Rectal Surgery

Colorectal Patient’s Expectations Form

Name: Valencia, Cyril Justin De Torres

ASA score: 2

ECOG: 1

Procedure: Adhesiolysis, segmental ileal resection, end to end anastomosis

 Pro c e dure : 44120 - Enterectomy, resection of small intestine; single resection and anastomosis
Ris k Fac to rs : Male, Emergent, Mild systemic disease

Note : Y our R is k has be e n rounde d to one de cim al poin t.

Your Average Chance of
Out c omes R is k Risk Out c om e
S e rio us Co mplic atio n
14.4% 22.4% Be lo w Ave rag e

Any Co mplicatio n
18.8% 29.2% Be lo w Ave rag e

Pne umo nia

1.5% 3.9% Be lo w Ave rag e

Cardiac Co mplic atio n

0.5% 2.0% Be lo w Ave rag e

S urg ic al S ite Infe c tio n

9.3% 11.7% Be lo w Ave rag e

Urinary Trac t Infe c tio n

0.8% 1.5% Be lo w Ave rag e

Ve no us Thro mbo e mbo lis m

1.6% 2.9% Be lo w Ave rag e

Re nal Failure
0.5% 1.6% Be lo w Ave rag e

Re admis s io n
6.7% 11.3% Be lo w Ave rag e

Return to OR
5.7% 7.1% Be lo w Ave rag e

De ath
0.5% 3.0% Be lo w Ave rag e

Dis c harg e to Nurs ing o r Re hab Facility

3.3% 15.6% Be lo w Ave rag e

S e ps is
3.7% 4.2% Be lo w Ave rag e

Pre dic te d Le ng th o f Ho s pital S tay: 6 days

Dis c laime r: The ACS Surgical Risk Calculator estimates the chance of an unfavorable outcome
(such as a complication or death) after surgery. The risk is estimated based upon information the
patient gives to the healthcare provider about prior health history. The estimates are calculated
using data from a large number of patients who had a surgical procedure similar to the one the
patient may have. Please note the risk percentages provided to you by the Surgical Risk Calculator
are only estimates. The risk estimate only takes certain information into account. There may be
other factors that are not included in the estimate which may increase or decrease the risk of a
complication or death. These estimates are not a guarantee of results. A complication after surgery may happen even if the risk is low. This information is not intended to
replace the advice of a doctor or healthcare provider about the diagnosis, treatment, or potential outcomes. ACS is not responsible for medical decisions that may be
made based on the risk calculator estimates, since these estimates are provided for informational purposes. Patients should always consult their doctor or other health
care provider before deciding on a treatment plan.

Definitio ns
Serious Complication includes important problems that occur after surgery including: Serious Complication (Continued):
Heart complication: Includes heart attack or sudden stopping of the heart Urinary tract infection: Infection of the bladder and kidneys
Pneumonia: Infection in the lungs Wound disruption: Separation of the layers of a surgical wound
Kidney failure: Kidneys no longer function in making urine and/or clearing the
blood of toxins Any Complication also includes:
Blood clot: Clot in the legs or lungs Wound infection: An infection at or near the incision
Return to the OR: The need to go back to the operating room due to a problem Extended time on the ventilator: Ventilator assistance for breathing
after the prior surgery longer than 48 hours
Wound infection: An infection at or near the area where the surgery was Stroke: An interruption in blood flow to the brain
performed
Sepsis: Whole-body infection Discharge to Nursing or Rehab facility: Discharge to a facility other than home
Intubation: The need to put the breathing tube back in after surgery to help
breathing

The information contained in this report is privileged patient health information, and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). The ACS is not responsible for ensuring that this information is transmitted or stored in a secure environment.

© 2007 - 2021, American College of Surgeons National Surgical Quality Improvement Program. All Rights Reservered.
EXPECTATIONS POST – OP:

Medical Expected occurrence Anticipated to patient

Sepsis 10% <

Wound infection 6% =

Rectal bleeding 3% <

Urinary Retention 3% <

Small bowel 2% <

obstruction

Paralytic ileus 2% >

Surgical Expected Anticipated to

occurrence patient

Anastomotic leak 1 -24% =

Abdominal wall 1% =
abscess
 Iatrogenic Injury .006% =

Adhesions 10% >

Incisional hernia 8.3% =

Fistula 0-23 <

Reconstruction 1% >
unfeasibility

 Bleeding 1% =

Death 0-5% <

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________

This paper is thoroughly discussed to me by my attending surgeons and I hereby declare

that I understand the surgical expectations enumerated to me.

Conforme:
Patient/Relative Signature