Although some specialties will not undertake surgery in people with reversible risk, e.g. smoking or obesity, this is often not possible in patients coming for cancer interventions due to the short time frame. Risk should however be predicted and minimized by optimization of the preoperative health status e.g. stopping smoking [7] and excess alcohol intake [8] for at least 4 weeks prior to surgery, when time allows. We would routinely ensure that anyone with significant cardiac comorbidity undergoes examination using stress echocardiography, and if necessary, angiographic evaluation. Those people with compromised respiratory function would also have appropriate assessment of their respiratory capacity in order to ensure the anesthetist is fully informed regarding any limitation and, when possible, to improve function. Other comorbidities such as renal function should be assessed and all factors taken into consideration when planning whether to operate, what operation to perform and what risk of mortality and morbidity to state when taking consent.

In order to improve risk prediction and allow comparison between populations, the Physiological & Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) was devised. It uses 12 physiological and six surgical parameters in order to calculate the risk of intervention. An adaptation for colorectal surgery, the ColoRectal POSSUM (CR-POSSUM) use only six physiological parameters and four operative measures for prediction of morbidity [9]. Their accuracy is limited but their major disadvantage is that they require intraoperative data for their calculation. The use of cardiopulmonary exercise (CPEx) testing provides a combined assessment of cardiac and respiratory fitness following exercise and will provide the team and, more importantly the patient, with an objective assessment of the risk of intervention. Swart and Carlisle [10] have used CPEx testing and risk assessment preoperatively and identified factors which independently influence subsequent year on year mortality. They showed that attending a consultant lead preoperative clinic and admission to a perioperative critical care unit reduce adverse outcomes [11]. A 6 min walking test has been well validated [12] for the prediction of risk and is a relatively straight forward assessment. That and other approaches such as comorbidity measurement and frailty testing [13] have the potential to impact on outcome by altering the approach to surgery or choice of operation, but to date have been routinely used in very few centers.

Sir David Cuthbertson (1900–1989), a biochemist working in Glasgow during the 1920s, was one of the first scientists to uncover the link between the physiological (neuro-hormonal) stress response and the negative impact it can have on outcomes. We have built on that principle by providing explicit preoperative information including goal setting, which facilitates postoperative recovery, pain control and discharge [14]. A clear explanation of expectations prior to and during hospitalization facilitates adherence to the care pathway, allowing patients to feel part of and to expedite their recovery. The knowledge of targets including nutrition, mobilization and other tasks provides encouragement and positive reinforcement, leading to earlier recovery and discharge[5]. Our standard approach to this is the provision of written and oral information 1–2 weeks preoperatively by a dedicated preadmission nurse for all patients undergoing elective rectal resection. This usually takes 30—40 min and is performed with a family member or friend present in order to aid discharge planning. It will be scheduled earlier and with medical assessment when patients have certain comorbidities in order to correctly identify them, thus allowing time for optimization if possible.