Complication Grading in Surgery

  • Roxane D. Staiger
  • Diana Vetter
  • Pierre-Alain Clavien
Chapter

Abstract

Reliable reporting of postoperative complications is essential for the assessment and comparison of surgical quality. Postoperative mortality has drastically decreased over the past decades; therefore, focus has shifted toward nonlethal endpoints. Standardized methodologies of complication grading are of paramount importance for such quality assessments. Inconsistent definitions of morbidity and surgical complications have been replaced by various intra- and postoperative complication grading systems. This chapter summarizes, compares, and discusses the most influential and widely used complication classifications and indexes of the past two decades. Additionally, it provides a small outlook into the future of outcome research and on prospective approaches of quality improvement in surgery.

Keywords

Complication Morbidity Complication grading Outcome research 

Notes

Acknowledgments

Research Grant from the Olga Mayenfisch Foundation to Roxane D. Staiger, MD.

Research Grant from the Liver and Gastrointestinal Disease (LGID) foundation to Pierre-Alain Clavien, MD, PhD.

References

  1. 1.
    Clavien PA, et al. Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. Ann Surg. 1992;216(6):618–26.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Pearse R, et al. Mortality after surgery in Europe reply. Lancet. 2013;381(9864):370–1.CrossRefPubMedGoogle Scholar
  3. 3.
    Vonlanthen R, Clavien PA. What factors affect mortality after surgery? Lancet. 2012;380(9847):1034–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Whooley BP, et al. Analysis of reduced death and complication rates after esophageal resection. Ann Surg. 2001;233(3):338–44.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Newman MF, Fleisher LA, Fink MP. Perioperative medicine : managing for outcome. Philadelphia: Saunders Elsevier. xix; 2008. p. 723.Google Scholar
  6. 6.
    Brennan MF, Radzyner M, Rubin DM. Outcome – more than just operative mortality. J Surg Oncol. 2009;99(8):470–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364(22):2128–37.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Feldman L, et al. Measuring postoperative complications in general surgery patients using an outcomes-based strategy: comparison with complications presented at morbidity and mortality rounds. Surgery. 1997;122(4):711–9; discussion 719–20.CrossRefPubMedGoogle Scholar
  9. 9.
    Pomposelli JJ, et al. Surgical complication outcome (SCOUT) score: a new method to evaluate quality of care in vascular surgery. J Vasc Surg. 1997;25(6):1007–14; discussion 1014–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Gumbs AA, et al. Laparoscopic vs. open resection of noninvasive intraductal pancreatic mucinous neoplasms. J Gastrointest Surg. 2008;12(4):707–12.CrossRefPubMedGoogle Scholar
  11. 11.
    Beck-Schimmer B, et al. A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile anesthetic. Ann Surg. 2008;248(6):909–18.CrossRefPubMedGoogle Scholar
  12. 12.
    Trede M, Schwall G, Saeger HD. Survival after Pancreatoduodenectomy – 118 consecutive resections without an operative mortality. Ann Surg. 1990;211(4):447–58.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Seiler CA, et al. Randomized prospective trial of pylorus-preserving vs. classic duodenopancreatectomy (Whipple procedure): initial clinical results. J Gastrointest Surg. 2000;4(5):443–52.CrossRefPubMedGoogle Scholar
  14. 14.
    DeOliveira ML, et al. Assessment of complications after pancreatic surgery – a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg. 2006;244(6):931–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Martin RC 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg. 2002;235(6):803–13.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Strasberg SM, et al. Proposal for definition and severity, grading of pancreatic anastomosis failure and pancreatic occlusion failure. Surgery. 2007;141(4):420–6.CrossRefPubMedGoogle Scholar
  17. 17.
    DeLong MR, et al. Publication bias and the under-reporting of complications in the literature: have we dug our own pay-for-performance grave? Plast Reconstr Surg. 2014;134(4S-1):42–3.CrossRefGoogle Scholar
  18. 18.
    Johnston L. Healthcare administration: concept, methodologies, tools and applications: Medical Information Science Reference; 2015.Google Scholar
  19. 19.
    Bruce J, et al. The measurement and monitoring of surgical adverse events. Health Technol Assess. 2001;5(22):1–194.CrossRefPubMedGoogle Scholar
  20. 20.
    Horton R. Surgical research or comic opera: questions, but few answers. Lancet. 1996;347(9007):984–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111(5):518–26.PubMedGoogle Scholar
  22. 22.
    Pillai SB, et al. Complexity- and risk-adjusted model for measuring surgical outcome. Br J Surg. 1999;86(12):1567–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Veen MR, et al. Recording and classification of complications in a surgical practice. Eur J Surg. 1999;165(5):421–4; discussion 425.CrossRefPubMedGoogle Scholar
  24. 24.
    Strasberg SM, Linehan DC, Hawkins WG. The accordion severity grading system of surgical complications. Ann Surg. 2009;250(2):177–86.CrossRefPubMedGoogle Scholar
  25. 25.
    Slankamenac K, et al. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Clavien PA, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96.CrossRefPubMedGoogle Scholar
  28. 28.
    Chun YS, et al. Systemic chemotherapy and two-stage hepatectomy for extensive bilateral colorectal liver metastases: perioperative safety and survival. J Gastrointest Surg. 2007;11(11):1498–504; discussion 1504–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Permpongkosol S, et al. Complications of 2,775 urological laparoscopic procedures: 1993 to 2005. J Urol. 2007;177(2):580–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Sundaram CP, et al. Complications after a 5-year experience with laparoscopic donor nephrectomy: the Indiana University experience. Surg Endosc. 2007;21(5):724–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Seely AJ, et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg. 2010;90(3):936–42; discussion 942.CrossRefPubMedGoogle Scholar
  33. 33.
    Petrowsky H, et al. Effects of pentoxifylline on liver regeneration: a double-blinded, randomized, controlled trial in 101 patients undergoing major liver resection. Ann Surg. 2010;252(5):813–22.CrossRefPubMedGoogle Scholar
  34. 34.
    Oberkofler CE, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256(5):819–26; discussion 826–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Vonlanthen R, et al. The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg. 2011;254(6):907–13.CrossRefPubMedGoogle Scholar
  36. 36.
    Porembka MR, et al. Quantitative weighting of postoperative complications based on the accordion severity grading system: demonstration of potential impact using the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(3):286–98.CrossRefPubMedGoogle Scholar
  37. 37.
    Kazaryan AM, Rosok BI, Edwin B. Morbidity assessment in surgery: refinement proposal based on a concept of perioperative adverse events. ISRN Surg. 2013;2013:625093.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kim YW, et al. Long-term outcomes of laparoscopy-assisted distal gastrectomy for early gastric cancer: result of a randomized controlled trial (COACT 0301). Surg Endosc. 2013;27(11):4267–76.CrossRefPubMedGoogle Scholar
  39. 39.
    Agadzhanov VG, Shulutko AM, Kazaryan AM. Minilaparotomy for treatment of choledocholithiasis. J Visc Surg. 2013;150(2):129–35.CrossRefPubMedGoogle Scholar
  40. 40.
    Vollmer CM, et al. Establishing a quantitative benchmark for morbidity in Pancreatoduodenectomy using ACS-NSQIP, the accordion severity grading system, and the postoperative morbidity index. Ann Surg. 2015;261(3):527–36.CrossRefPubMedGoogle Scholar
  41. 41.
    Reddy S, et al. Timed stair climbing is the single strongest predictor of perioperative complications in patients undergoing abdominal surgery. J Am Coll Surg. 2016;222(4):559–66.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Strasberg SM, Hall BL. Postoperative morbidity index: a quantitative measure of severity of postoperative complications. J Am Coll Surg. 2011;213(5):616–26.CrossRefPubMedGoogle Scholar
  43. 43.
    Beilan J, et al. The postoperative morbidity index: a quantitative weighing of postoperative complications applied to urological procedures. BMC Urol. 2014;14:1.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Muangkaew P, et al. Outcomes of simultaneous major liver resection and colorectal surgery for colorectal liver metastases. J Gastrointest Surg. 2016;20(3):554–63.CrossRefPubMedGoogle Scholar
  45. 45.
    Datta J, Vollmer CM Jr. Advances in surgical management of pancreatic diseases. Gastroenterol Clin N Am. 2016;45(1):129–44.CrossRefGoogle Scholar
  46. 46.
    Ratti F, et al. Impact of totally laparoscopic combined management of colorectal cancer with synchronous hepatic metastases on severity of complications: a propensity-score-based analysis. Surg Endosc. 2016;30(11):4934–45.CrossRefPubMedGoogle Scholar
  47. 47.
    Meffert H, Bolz J. Internationales Marketing-Management. 1998; S.76 ff.76 ff.Google Scholar
  48. 48.
    Welge MK, Holtbrügge D. Internationales Management: Theorien, Funktionen, Fallstudien. 2006; S.100 ff.100 ff.Google Scholar
  49. 49.
    Zentes J, Swoboda B, Schramm-Klein H. Internationales Marketing. 2006;S.180.180.Google Scholar
  50. 50.
    Slankamenac K, et al. The comprehensive complication index a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg. 2014;260(5):757–63.CrossRefPubMedGoogle Scholar
  51. 51.
    Fretland AA, et al. Open versus laparoscopic liver resection for colorectal liver metastases (the Oslo-CoMet study): study protocol for a randomized controlled trial. Trials. 2015;16:73.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Machado MAC, et al. The laparoscopic Glissonian approach is safe and efficient when compared with standard laparoscopic liver resection: Results of an observational study over 7 years. Surgery. 2016;160(3):643–51.CrossRefPubMedGoogle Scholar
  53. 53.
    Marsman EM, et al. Pancreatoduodenectomy with colon resection for cancer: a nationwide retrospective analysis. Surgery. 2016;160(1):145–52.CrossRefPubMedGoogle Scholar
  54. 54.
    Rössler F, et al.. Defining benchmarks for major liver surgery: a multicenter analysis of 5202 living liver donors. Annals of Surgery, 9000. Publish Ahead of Print.Google Scholar
  55. 55.
    Rosenthal R, et al. Reporting of adverse events in surgical trials: critical appraisal of current practice. World J Surg. 2015;39(1):80–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Shackleton CR, et al. Morbidity in live liver donors: standards-based adverse event reporting further refined. Arch Surg. 2005;140(9):888–95; discussion 895–6.CrossRefPubMedGoogle Scholar
  57. 57.
    Satava RM. Identification and reduction of surgical error using simulation. Minim Invasive Ther Allied Technol. 2005;14(4):257–61.CrossRefPubMedGoogle Scholar
  58. 58.
    Kaafarani HM, et al. Derivation and validation of a novel severity classification for intraoperative adverse events. J Am Coll Surg. 2014;218(6):1120–8.CrossRefPubMedGoogle Scholar
  59. 59.
    Rosenthal R, et al. Definition and classification of intraoperative complications (CLASSIC): Delphi study and pilot evaluation. World J Surg. 2015;39(7):1663–71.CrossRefPubMedGoogle Scholar
  60. 60.
    McClusky DA, Smith CD. Design and development of a surgical skills simulation curriculum. World J Surg. 2008;32(2):171–81.CrossRefPubMedGoogle Scholar
  61. 61.
    Rassweiler JJ, Teber D, Frede T. Complications of laparoscopic pyeloplasty. World J Urol. 2008;26(6):539–47.CrossRefPubMedGoogle Scholar
  62. 62.
    Kinaci E, et al. Is the classification of intraoperative complications (CLASSIC) related to postoperative course? Int J Surg. 2016;29:171–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Roxane D. Staiger
    • 1
  • Diana Vetter
    • 1
  • Pierre-Alain Clavien
    • 1
  1. 1.Department of Surgery and TransplantationUniversity Hospital of ZurichZurichSwitzerland

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