Novel application of the Clavien-Dindo classification system and the comprehensive complications index® in microvascular free tissue transfer to the head and neck

Complication Trajectories in Total Pharyngolaryngectomy: Comprehensive Complication Index Analysis

BACKGROUND

Understanding the trajectory of complications following total pharyngolaryngectomy (TPL) with free jejunal transfer (FJT) is crucial for enhancing patient management and improving surgical outcomes. However, the traditional Clavien-Dindo classification captures only the highest grade of complication and is unable to capture the progression of complications, limiting its utility for longitudinal assessments. This study utilized the comprehensive complication index (CCI) to provide a continuous evaluation of complications over time.

METHODS

This retrospective observational study included patients who underwent TPL with FJT between 2018 and 2023. Daily postoperative complications were tracked using the CCI, calculated from postoperative day 1 to day 30. A group-based trajectory model was employed to classify patterns of change in daily CCI. The predictive power of early CCI for a subsequent serious complication course was evaluated using receiver operating characteristic curve analysis.

RESULTS

The trajectory modeling for a total of 161 eligible patients identified three distinct complication trajectories: no complication (n = 80), moderate (n = 66), and severe (n = 15). Initial CCI values were predictive of the severe complication course: a cutoff value of 8.7 for the CCI on postoperative day 2 provided an area under the curve of 0.926 with 86.7% sensitivity and 93.8% specificity.

CONCLUSIONS

Complication trajectories after TPL with FJT can be effectively categorized using the CCI, providing insights beyond the traditional grading systems. Early identification of the severe complication course allows for targeted interventions that may improve patient outcomes.

LEVEL OF EVIDENCE: 3

Utilizing machine learning approaches to investigate the relationship between cystatin C and serious complications in esophageal cancer patients after esophagectomy

BACKGROUND

The purpose of this study is to investigate the relationship between preoperative cystatin C levels and the risk of serious postoperative complications in esophageal cancer (EC) patients, utilizing advanced machine learning (ML) methodologies.

METHODS

We conducted an observational cohort study, involving 524 EC patients from December 2014 to July 2022. ML models, including logistic regression (LR) and multilayer perceptron (MLP), were applied to investigate the relationship between cystatin C and the serious postoperative complications. The predictive value of cystatin C was evaluated using receiver operating characteristic (ROC) analysis. Based on a restricted cubic spline (RCS) method, the potential nonlinear association was scrutinized.

RESULTS

The morbidity of serious postoperative complications was 8.78%. Bleeding volume, operating time, NRS2002 score, PONS score, and cystatin C were significantly associated with serious postoperative complications. The MLP model demonstrated superior predictive accuracy (AUC = 0.775, 95% CI: 0.701-0.849) compared to the LR model (AUC = 0.714, 95% CI: 0.630-0.798) and cystatin C alone (AUC = 0.612, 95% CI: 0.526-0.699). High cystatin C level independently predicted serious postoperative complications in EC patients. A positive and linear association was found between cystatin C and serious complications.

CONCLUSION

This research uncovers a notable correlation between cystatin C and the severe complications in EC patients after esophagectomy. Employing ML techniques offers a robust method for forecasting patient outcomes and emphasizes the potential of cystatin C as a predictive biomarker in medical practice.

Segmental Mandibulectomy and Mandibular Reconstruction with Fibula-Free Flap Using a 3D Template

INTRODUCTION

The present study evaluates the influence of virtual surgical planning with a preoperative 3D resin model on aesthetic and functional outcomes in patients treated by segmental mandibulectomy and reconstruction with fibula-free flap for oral cancer.

METHODS

All consecutive patients who underwent segmental mandibulectomy and mandibular reconstruction with a fibula-free flap using a 3D template at our department from January 2021 to January 2023 were included in the study. "Patients control" were patients treated by reconstruction with a fibula-free flap without using a 3D template. Three-dimensional modeling was performed by converting from preoperative computed tomography to a stereolithography format to obtain the resin 3D models. Qualitative analysis of anatomical and aesthetic results consisted of the evaluation of the patients' aesthetic and functional satisfaction and the symmetry of the mandibular contour observed at clinical examination. Quantitative analysis was based on the assessment of the accuracy and precision of the reconstruction by comparing preoperative and postoperative computed tomograms as objective indicators.

RESULTS

Seven patients (five males and two females, mean age of 65.1 years) were included in the study. All patients showed a symmetric mandibular contour based on the clinical examination. After recovery, six patients (85.7%) considered themselves aesthetically satisfied. The quantitative analysis (assessed in six/seven patients) showed that the mean difference between preoperative and postoperative intercondylar distance, intergonial angle distance, anteroposterior dimension, and gonial angle improved in the 3D template-assisted group.

CONCLUSION

The 3D-printed template for mandibular reconstruction with microvascular fibula-free flap can improve aesthetic outcomes in comparison with standard approaches.

The Postsurgical Clavien–Dindo Classification in Minor Surgery Can Improve Perception and Communication (Investigation on Blepharoplasty)

The postsurgical Clavien–Dindo classification in minor surgery can improve perception and communication (Investigation on Blepharoplasty). Background: Minor surgery lacks a standardized postoperative complication classification. This leads to the presentation of inaccurate postsurgical complication rates and makes comparisons challenging, especially for patients seeking information. This study aims to evaluate a standardized five-step complication grading system (Clavien–Dindo Classification, CDC) on the example of blepharoplasty, which is the most performed minor aesthetic surgery worldwide. Methods: A retrospective observational exploratory study of patients (N = 344) who received a bilateral upper eyelid blepharoplasty under local anesthesia from the same surgical staff was performed. Data were retrieved from the electronic patient record: the CDC grading and the surgeon-reported complications (N = 128) at the first follow-up on day 7. In addition, a telephone survey with patients (N = 261) after 6 months was performed, which consisted of 7 complication-related yes/no questions. Results: Based on the CDC, 41.6% of patients were classified as having no complications, and 58.4% had one. Furthermore, 1 patient (0.3%) received a revision under general anesthesia (CDC IIIb), 18 patients (5.2%) were re-operated under local anesthesia (CDC IIIa), 23 patients (6.7%) required pharmacological intervention (CDC II), and 159 patients (46.2%) had a complication from the normal postoperative course and received supportive treatment (CDC I). Moreover, 90.5% of the mentioned complications accounted for Grade I and II; 94% of the patients subjectively experienced no complications; 51% of patients were pleased with the surgery even though a complication occurred according to the CDC; 34% of complications escaped the awareness of the surgeon. Conclusions: Grade I and II complications occurred frequently. Complications escaped the perception of the patients and surgeons. The classification identifies a wide variety of postsurgical complications and allows a standardized comparison in minor surgery objectively. Potential: The CDC in minor procedures can improve the (institutional) preoperative communication with patients regarding potential postoperative expectations. Furthermore, the classification can be a useful tool to detect complication-related costs, identify insurance-related requests, and support evidence in medicolegal disputes. The example of blepharoplasty can be translated to various other and even less invasive procedures.

Classification of cochlear implant complications using a modified Clavien-Dindo classification

OBJECTIVES

Cochlear implantation (CI) surgery is a highly effective procedure for severe to profound hearing loss, with a low complication rate. There are currently multiple grading systems for CI surgery complications, making comparison of outcomes difficult. We propose a modification to the Clavien-Dindo classification of complications, and use this modified classification to analyse our complications.

METHODS

Complications were classified as: I - Self-limiting complications requiring no treatment or simple pharmacological therapies; II - Complications requiring pharmacological interventions other than those permitted under the criteria for Grade I, or non-invasive radiological imaging; IIIa - Complications necessitating surgical, radiological or endoscopic intervention, but excluding implant explantation and/or reimplantation. IIIb - Complications necessitating implant explantation and/or reimplantation.

RESULTS

1053 patients were recorded as having had at least one cochlear implant inserted with 114 complications reported in 90 patients. The 114 complications were classified into the proposed classification with 18 (15.7%) as Grade I, 36 (31.5%) as Grade II, 17 (14.9%) as Grade IIIa and 43 (34.2%) as Grade IIIb.

DISCUSSION

We found a low complication rate, and were able to use the modified Clavien-Dindo classification system to analyse our data. We would strongly advocate for a uniform reporting system and propose this modification of a widely used system.

Proposed Prediction Model and Nomogram for Systemic Complications in Patients Undergoing Free Flap Head and Neck Reconstruction

Postoperative complications in head and neck surgery are well-known, but a predictive model to guide clinicians in free flap reconstructions has not been established. This retrospective single-center observational study assessed 131 patients who underwent ablative surgery and received free flap reconstruction. Primary endpoint was the occurrence of systemic complications (PSC). Secondary endpoint was the generation of a nomogram of complications according to the CDC classification. In the ordinal regression model, postoperative administration of furosemide [1.36 (0.63–2.11), p < 0.0001], blood loss [0.001 (0.0004–0.0020), p = 0.004], postoperative nadir hemoglobin [−0.03 (−0.07–0.01), p = 0.108], smoking [0.72 (0.02–1.44), p = 0.043], and type of flap reconstruction [1.01 (0.21–1.84), p = 0.014] as predictors. A nomogram with acceptable discrimination was proposed (Somer's delta: 0.52). Application of this nomogram in clinical practice could help identify potentially modifiable risk factors and thus reduce the incidence of postoperative complications in patients undergoing microvascular reconstruction of the head and neck.

Assessment of Surgical Complications With Respect to the Surgical Indication: Proposal for a Novel Index

Introduction: The Clavien–Dindo classification is a broadly accepted surgical complications classification system, grading complications by the extent of therapy necessary to resolve them. A drawback of the method is that it does not consider why the patient was operated on primarily.

Methods: We designed a novel index based on Clavien–Dindo but with respect to the surgical indication. We surveyed an international panel of otolaryngologists who filled out a questionnaire with 32 real case-inspired scenarios. Each case was graded for the surgical complication, surgical indication, and a subjective rating whether the complication was acceptable or not.

Results: Seventy-seven otolaryngologists responded to the survey. Mean subjective rating and surgical complication grading for each scenario showed an inverse correlation (r² = 0.147, p = 0.044). When grading the surgical complication with respect to the surgical indication, the correlation with the subjective rating increased dramatically (r² = 0.307, p = 0.0022).

Conclusion: We describe a novel index grading surgical complications with respect to the surgical indication. In our survey, most respondents judged a complication as acceptable or not according to its grade but kept in mind the surgical indication. This subjective judgment could be quantified with our novel index.

Modified Clavien-Dindo Classification and Outcome Prediction in Free Flap Reconstruction among Patients with Head and Neck Cancer

Because of limitations caused by unique complications of free flap reconstruction, the Clavien–Dindo classification was modified to include grade “IIIc” for “partial or total free flap failure.” From 2013 to 2018, 116 patients who had undergone free flap reconstruction for head and neck cancer with grade III or higher postoperative complications were grouped using the “Modified” Clavien–Dindo classification. Alcoholism displayed significant predictive effects between grade IIIb and IIIc (72.7% vs. 50%, p = 0.028). Significant differences were observed between grade IIIb and IIIc in the duration of hospital stay (23.1 ± 10.1 vs. 28.6 ± 11.9 days, p = 0.015), duration of intensive care unit stay (6.0 ± 3.4 vs. 8.7 ± 4.3 days, p = 0.001), reoperation times during the current hospitalization (1.4 ± 0.8 vs. 2.0 ± 1.0 times, p < 0.001), and wound infection rate (29.9% vs. 62.5%, p = 0.002). The severity levels were significantly positively correlated with reoperation times during the current hospitalization (p < 0.001), ICU stay (p = 0.001), and hospital stay (p < 0.001). The modified Clavien–Dindo classification with grade IIIc describes the perioperative complications of head and neck free flap reconstruction to predict clinical outcomes based on severity.