Objective: The American College of Surgeons adopted a 5 tiered grading system for surgical complications in esophageal and gastric cancer surgery. We adopted the ACS guidelines to develop a 5 tiered grading system for colorectal surgery.The present study is a retrospective report of colorectal surgery complications based on the ACS modified guidelines in a large cohort of patients.
Methods: A computerized search of all colon and rectal resections between January 1999 and December 2004 was obtained. Demographic details, co-morbidities, surgical procedure, and all post-operative complications were documented from the patients' hospital and outpatient clinic charts. All complications were graded from 1 to 5. Grade 1 included patients with minor complications that did not require medical or surgical intervention e.g. wound infection. Grade 2 included patients with complications that required medical treatment or prolonged hospital stay e.g. pneumonia. Grade 3 included patients that required invasive non-surgical intervention e.g. CT guided drainage. Grade 4 included patients with complications that necessitated surgery and grade 5 was perioperative mortality. (Table 1)
Results: 408 patients were included with an average age of 62. Elective surgery was performed in 75.7% of the patients while 24.3% required emergency surgery. 239 patients (58.6%) did not have any kind of complication. Grade 1 and 2 complications, requiring observation or medical treatment only, were recorded in 191 patients (46.8%). In 54 patients (13.2%) Grade 3-5 complications recorded. The three leading complications were surgical wound infection (8.8%), intra-abdominal abscess (8.6%) and the need for blood transfusion (6.1%). The rate of complication was significantly lower following laparoscopic procedures p<0.0001, and significantly higher following emergency procedures p<0.001.
Conclusions: This retrospective analysis of colorectal surgery complications according to a novel grading system is simple. Therefore, we adopted this reporting system in our institution and we will further test it prospectively. We advocate its use in order to create a uniform reporting system for colorectal surgery associated complications.
Table 1: grading of colorectal surgery complications

Grade	Description	N(%)
1	Observation only	87(35.5%)
2	Medical treatment only	104(42.5%)
3	Invasive non-surgical intervention	23(9.4%)
4	Surgical intervention	24(9.8%)
5	Death	7(2.8%)
Total		245