Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey

Validation of the Clavien-Dindo classification and Comprehensive Complication Index as measures of morbidity following total hip and knee arthroplasty

Aims

The Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI) have been validated primarily among general surgical procedures. To date, the validity of these measures has not been assessed in patients undergoing arthroplasty.

Methods

This retrospective cohort study included patients undergoing primary total hip and knee arthroplasty between April 2013 and December 2019. Complications within 90 days of surgery were graded using the CD classification and converted to CCI. Validity was established by assessing the association between both measures and discharge to inpatient rehabilitation, length of stay, and costs.

Results

Among 2,884 patients, 414 (14.4%) had an in-hospital complication and 643 (22.3%) had a complication within 90 days. Each increase in CD grade was associated with USD$1,895.48 (95% CI 1,734.77 to 2,056.18) of additional costs, an additional 1.24 days' length of stay (95% CI 1.15 to 1.33), and 43% (95% CI 26 to 62%) greater odds of discharge to inpatient rehabilitation. Each ten-unit increase in CCI score was associated with USD$1,698.55 (95% CI 1,561.8 to 1,835.3) higher costs, an additional 1.09 days' length of stay (95% CI 1.02 to 1.17), and 33% (95% CI 19% to 49%) greater odds of discharge to inpatient rehabilitation.

Conclusion

Both the CD classification and CCI appear valid and applicable to patients undergoing total joint replacement.

Surgical complications: errors and adverse events

Complications are a recognized hazard of surgery. The term is confusing; it has multiple meanings, including surgical error and adverse surgical outcomes. I propose the latter two terms are used. Grading of 'complications' is difficult but made easier by grading errors and outcomes separately, though they are not always linked. The exact grades are not established.Error avoidance requires efforts at a personal (surgeon) level, including training, learning and preparation, and at a systems level. Understanding human factors is important.The perspective of patients about adverse outcomes is not well understood. There is evidence that, unsurprisingly, patient perspectives may be different to surgeon perspectives. There are a range of surgeon responses to error and adverse outcomes; many are negative. These need to be understood better in order to protect patients and surgeons in the immediate aftermath and in the potentially prolonged 'recovery time', both for patients and surgeons.Level of evidence: V.

New scoring system combining computed tomography body composition analysis and inflammatory-nutritional indicators to predict postoperative complications in stage II-III colon cancer

BACKGROUND AND AIM

Postoperative complications are important clinical outcomes for colon cancer patients. This study aimed to investigate the predictive value of inflammatory-nutritional indicators combined with computed tomography body composition on postoperative complications in patients with stage II-III colon cancer.

METHODS

We retrospectively collected data from patients with stage II-III colon cancer admitted to our hospital from 2017 to 2021, including 198 patients in the training cohort and 50 patients in the validation cohort. Inflammatory-nutritional indicators and body composition were included in the univariate and multivariate analyses. Binary regression was used to develop a nomogram and evaluate its predictive value.

RESULTS

In the multivariate analysis, the monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), nutritional risk score (NRS), skeletal muscle index (SMI), and visceral fat index (VFI) were independent risk factors for postoperative complications of stage II-III colon cancer. In the training cohort, the area under the receiver operating characteristic curve of the predictive model was 0.825 (95% confidence interval [CI] 0.764-0.886). In the validation cohort, it was 0.901 (95% CI 0.816-0.986). The calibration curve showed that the prediction results were in good agreement with the observational results. Decision curve analysis showed that colon cancer patients could benefit from the predictive model.

CONCLUSIONS

A nomogram combining MLR, SII, NRS, SMI, and VFI with good accuracy and reliability in predicting postoperative complications in patients with stage II-III colon cancer was established, which can help guide treatment decisions.

How Women Perceive Severity of Complications after Pelvic Floor Repair?

Background: The Clavien-Dindo classification, used to describe postoperative complications, does not take into account patient perception of severity. Our main objective was to assess women’s perception of postoperative pelvic floor repair complications and compare it to the classification of Clavien-Dindo. Methods: Women and surgeons participating in the VIGI-MESH registry concerning pelvic floor repair surgery were invited to quote their perception of complication severity through a survey based on 30 clinical vignettes. For each vignette, four grades of severity were proposed: “not serious”, “a little serious”, “serious”, “very serious”. Results: Among the 1146 registered women, we received 529 responses (46.2%) and 70 of the 141 surgeons (49.6%) returned a completed questionnaire. A total of 25 of the 30 vignettes were considered classifiable according to the Clavien-Dindo classification. The women’s classification was concordant with Clavien-Dindo for 52.0% (13/25) of the classifiable vignettes. The women’s and surgeons’ responses were discordant for 20 of the 30 clinical vignettes (66.7%). Loss of autonomy (self-catheterization, long-term medication use) or occurrence of sequelae (organ damage or severe persistent pain) were perceived by women as more serious than Clavien-Dindo classification or than surgeons’ perceptions. Conclusions: Women’s perception of pelvic floor repair surgery seems different from the Clavien-Dindo classification. Lack of repair and long-term disability seem to be two major factors in favor of perception of the surgical complication as serious.

[Research Updates: Standardized Reporting and Evaluation Instruments for Postoperative Complications]

Postoperative complications are important indicators for evaluating surgical outcomes, and mortality and the incidence of various specific complications are often used to measure the efficacy of surgical and perioperative management strategies. With the progress of medical technology, there has been a dramatic decline in mortality and the incidence of complications. As a result, reporting and evaluation in the traditional methods no longer meets the actual needs of the world. There has arisen an urgent need for an instrument of standardized reporting and evaluation. The instrument should be aligned with the actual circumstances and should represent the patient's overall burden of postoperative complications. We herein reviewed the latest research findings on Clavien-Dindo Classification (CDC) system and comprehensive complication index (CCI), two instruments of standardized reporting and evaluation of postoperative complications, and discussed the space for improvement and prospects of application of CDC and CCI.

Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis

BACKGROUND

The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications.

OBJECTIVE

The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a comprehensive cancer center.

PATIENTS

Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study.

MAIN OUTCOME MEASURES

Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d).

RESULTS

Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories.

LIMITATIONS

The study was limited by its retrospective design and generalizability.

CONCLUSIONS

The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521.

EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS

ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.

Are patients knowledgeable of medical errors and medical complications? A cross-sectional study at a tertiary hospital, Riyadh

Background

Basic understanding of medical errors and medical complications is essential to ensure patient safety. Our aim in this study was to assess whether patients have sufficient knowledge of medical errors and medical complications and to identify the factors that influence their knowledge.

Methods

A cross-sectional study was conducted with 400 patients with a scheduled appointment at King Abdulaziz Medical City from 2019 to 2020. A self-administered validated questionnaire was developed by the coinvestigators. The first section focused on demographic information, and the second contained 17 scenarios to assess the knowledge of the patients. The data were analyzed with Chi-square test and logistic regression.

Results

The sample size realized as 346 (n = 346), with the majority (n = 198, 57%) female, and the mean age 39.5 ± 11 years. The mean scores for the medical errors and complications were 5.5 ± 2.10 and 4.8 ± 2.3, respectively. The participants with secondary education were less likely to have sufficient knowledge of both medical complications (OR 0.52, P = 0.016) and errors (OR 0.52, P = 0.016). In terms of age, the older participants, the 38-47 year age group, were less likely to be knowledgeable about medical complications compared to the younger age groups (OR 0.92, P = 0.046).

Conclusion

The patients had a higher level of knowledge about medical errors compared to medical complications. The level of education and the employment status significantly predicted the knowledge of both medical errors and complications.

Comparison of the Clavien-Dindo and Comprehensive Complication Index systems for grading of surgical complications after colorectal resections

INTRODUCTION

Postoperative complications are associated with prolonged hospital stay and a rise in costs of treatment. The Comprehensive Complication Index (CCI) was developed as a scoring system that does not only take the most severe complication into account but all complications after surgery. Our aim was to compare the Clavien-Dindo scoring system with the CCI in predicting length of hospital stay (LOHS) and in-hospital costs after colorectal resections.

METHODS

Complications occurring after surgical procedures, performed between October 2012 and September 2013, were prospectively recorded. During this period 164 patients developed complication(s). Only patients that underwent a colorectal resection were included. Multivariable linear regression analysis was performed to find independent predictors of in-hospital costs and LOHS.

RESULTS

64 patients (age (range): 69 (10-91) years, M/F: 36/28) were retained. 46 (71.9%) patients had a Clavien-Dindo score ≥ IIIb. Median (IQR) CCI was 40 (30.2-53.9). Mean (±SD) in-hospitals costs for all patients were €12,920 ± €10,229. The adjusted difference (95% CI, p-value) in in-hospital costs for minor and major (Clavien-Dindo ≥ IIIb) complications was 10,021 (€4283 to €15,759, p = 0.001). A 10 point increase in CCI increased in-hospital costs by €2040. Multivariable analysis retained CCI > 40 as the only independent risk factor for increased in-hospital costs (Standard Beta Coeffic (p-value): 8063 (p = 0.022).

CONCLUSION

CCI is a better predictor of in-hospital costs than Clavien-Dindo score to classify complications after colorectal resections, as it captures all complications. Further research is warranted to extrapolate our findings to other sub-specialities of surgery.

Reporting and grading of complications after mid-urethral sling surgeries: Could the "Clavien-Dindo Classification" be adopted?

Background:

To construct a modified model for reporting and grading of postoperative complications after the mid-urethral sling (MUS) procedure based on the Clavien-Dindo classification. In addition, complications of three different types of MUS were compared.

Materials and methods:

A PubMed search for postoperative complication after MUS was carried out for the period between January 1990 and July 2018. Reported complications were stratified in a plate form designed in accordance with grades of the Clavien-Dindo classification. Then, the proposed model was applied on reported complications in 160 females who underwent three different procedures of MUS (transvaginal tape [TVT], transobturator tape [TOT], and autologous fascial sling) with a minimum follow-up of 24 months.

Results:

The mean ± SD age at time of surgery was 46 ± 7 years. TVT was carried out in 75 (47%) patients, TOT in 40 (25%), and fascial sling in 45 (28%). The total number of complications was 62 in 43 (26.8%) patients. The vast majority of complications were Grade I and Grade II 19 (12%) and 21 (13%) out of 160 patients, respectively. Transient postoperative voiding difficulty (Grade II) and de novo urgency (Grade II) were the most prevalent complications in the fascial sling method (15.4% for each), whereas transient thigh pain (Grade II) was the most frequently reported complication after TOT (10%). Life-threatening vascular injury (Grade IV-a) was a serious complication in TVT cases.

Conclusions:

Postoperative complications of the MUS could be graded according to Clavien's classification. The vast majority of complications were Graded I or II. TVT can cause serious life-threatening complications.

Experience with PlasmaJet™ in debulking surgery in 87 patients with advanced-stage ovarian cancer

OBJECTIVE

The aim was to evaluate the effectiveness and safety of PlasmaJet™ in cytoreductive surgery in patients with advanced-stage ovarian cancer.

METHODS

All patients between September 2013 and January 2018 undergoing surgical cytoreduction for advanced-stage ovarian cancer with the help of PlasmaJet™ were identified and analyzed retrospectively.

RESULTS

Eighty-seven patients diagnosed with advanced-stage ovarian cancer underwent surgery with PlasmaJet™. Primary debulking surgery was performed in 15 cases. Fifty-seven patients underwent interval debulking after neoadjuvant chemotherapy. Secondary and tertiary debulking was done in, respectively, 11 and three patients, and one patient underwent quaternary debulking using PlasmaJet™. In all 87 patients but one, complete resection of all macroscopic disease was obtained. PlasmaJet™ was used to remove carcinomatosis on the peritoneum, bowel serosa, intestinal mesentery, and lesions in the upper abdomen (diaphragm and liver surface). No damage to the bladder or ureter was noted in relation to the use of PlasmaJet™. Three patients developed a bowel leakage postoperatively. In one of these patients, PlasmaJet™ was used to treat tumoral implants in the affected region.

CONCLUSIONS

Our series suggests that the use of PlasmaJet™ is efficient and safe in obtaining complete resection of all macroscopic tumoral lesions in advanced-stage ovarian cancer.

Do Patients Accurately Represent Their Experiences After Hip and Knee Replacements?

Background

To investigate discrepancies, if any, between the complications that patients report on the patient-reported outcome measures (PROMs) questionnaire and what is formally recorded in their medical records.

Methodology

A retrospective analysis of PROMs-reported complications was performed at a single elective center for all patients who had an elective primary total knee or hip replacement between April 2016 and March 2017. Corresponding patient medical records were then analyzed to correlate the PROMs with any documentation of postoperative complications, which similar to the PROMs data were categorized into wound complications, urinary complications, readmission, and further operative procedures.

Results

A set of 54 complete patient records were compared to the corresponding PROMs data. The combined overall positive predictive value was 0.47 while the overall negative predictive value was 0.91. Concordance between patients and the medical records was 70.4% for wound complication, 66.7% for urinary complications, 83.3% for readmission, and 96.3% for reoperation.

Conclusion

PROMs data are becoming increasingly important in auditing and planning healthcare provision. This study highlights a significant level of discrepancy between the PROMs-reported complication rates and those documented in the medical records. There is a visible disparity between patient perception and the medical definition of postoperative complications. Further patient education and empowerment are required in preparation for arthroplasty.

Standardizing Postoperative Complications-Validating the Clavien-Dindo Complications Classification in Cardiac Surgery

Cardiac surgery lacks a method for quantifying postoperative morbidities. The Clavien-Dindo Complications Classification (CDCC) and the Comprehensive Complication Index (CCI) were successfully implemented as outcome reporting methods in other surgical specialties. This study aims to validate these complication scales in cardiac surgery. Between 2010 and 2019, we prospectively collected data on 41,218 adult patients (73% men, mean age 67 ± 11 years) undergoing cardiac surgery at 6 university hospitals. Complications were graded using the CDCC based on the complication's treatment invasiveness with adaptations for common treatments in cardiac surgery. CCI were calculated, representing multiple complications on a scale of 0 (no complication) to 100 (death). Associations with predictors of poor outcome were assessed using mixed-effects models accounting for center as a random effect. CDCC grade was 0 in 23.0%, I in 11.4%, II in 35.3%, IIIa in 6.4%, IIIb in 2.6%, IVa in 16.1%, IVb in 2.1%, and V in 3.1%. Median CCI was 23 (9, 40). A change from lowest to highest observed CDCC grade was associated with an increase in the Society of Thoracic Surgeons mortality score from 1.1% to 4.7%, surgery duration from 177 to 233 minutes, and hospital stay from 5.2 to 17 days (all P < 0.0001). The CCI also increased with greater procedure complexity (P < 0.0001). Increase in CDCC/CCI is associated with greater comorbidities, surgery durations, lengths of stay, and procedure complexity, accurately reflecting the nuances of the adult cardiac surgery postoperative course. These have great potential for uniform outcome reporting and quality improvement initiatives.

Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study

OBJECTIVE

The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications.

BACKGROUND

Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population.

METHODS

Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting.

RESULTS

In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery.

CONCLUSIONS

Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.

Severity of Postoperative Complications From the Perspective of the Patient

Background:

Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.

Objective:

To assess patient-rated complication severity and determine concordance with existing grading systems.

Methods:

A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.

Results:

One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.

Conclusion:

Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

[Applicability of the Clavien-Dindo classification in the evaluation of postoperative complications at the Surgery Department of the National Hospital Center of Nouakchott: observational study of 834 cases]

Introduction

Postoperative complications are common; some are transient, others may be serious, but they are all important to patients. One of the most important gaps in surgical research is the lack of consensus over the preferred result, the type of measurement or of evaluation.

Methods

We conducted a retrospective study of postoperative complications at the Surgery Department of the National Hospital Center of Nouakchott. Eight hundred thirty-four patients underwent surgery over a seven-month period (1 January 2017-31 July 2017). The demographic and clinical parameters were studied and analyzed statistically using SPSS software 20.

Results

The study involved 834 patients, of whom 426 (51.1%) were men. The average age of patients was 34.81 years (1-90 years). Four hundred thirty-two (51.2%) patients underwent emergency surgery. The sex ratio (M/F) was 1.04. Arab-Berbers race accounted for 77.8%. Appendicular disease accounted for 41.12%, hepatobiliary disease accounted for 17.76%, and abdominal wall disease accounted for 16.1%). Thyroid disease accounted for 5.6%. One hundred eighty-three (21.94%) patients developed postoperative complications, including 4 (2.1%) deaths. Clavien-Dindo grade II was the most represented with 82.5% of complications and accounted for 17.91% of all operated patients. Surgical site infection accounted for 62.8% of all complications.

Conclusion

This study shows that the Clavien-Dindo classification can be applied to patients who have undergone elective surgery and emergency surgery. We think that the lack of follow-up and the lack of means to fight the infection and the non-rigorous respect of asepsis and antisepsis procedures would play an important role.

The Assessment of Complications After Major Abdominal Surgery: A Comparison of Two Scales

BACKGROUND

An accurate and reproducible method for the evaluation of postoperative morbidity is essential for a valid assessment of the outcomes of surgery. However, there is still no consensus on reporting of complications. The Clavien-Dindo classification (CDC) of complications is a validated system which reports only the most severe complication. The Comprehensive Complication Index (CCI) is a novel scale designed to capture the overall burden of complications. The aim of our study is to validate and compare the CDC and the CCI in the setting of high-risk surgical patients in whom multiple complications are common.

METHODS

A prospective, observational study analyzed 206 high-risk adult patients undergoing major abdominal surgery. Each postoperative complication was recorded until discharge or readmission within 30 days. The severity of complications was graded with the CDC, and the CCI was calculated subsequently. Correlations of the CDC and the CCI with hospitalization indicators and functional activity on discharge were assessed and compared.

RESULTS

A total of 424 complications occurred in 125 (60.7%) patients. The median CCI for the cohort was 20.9 (0-44.9). CD grade II was the most frequent among patients with complications (62/125; 49.6%). The CCI and the CDC have shown a strong correlation (r = 0.969, P < 0.01). Both scales strongly correlated with the parameters of hospitalization, but the CCI showed a stronger correlation to the intensive care unit length of stay (LOS; 0.670 versus 0.628, P < 0.001), postoperative LOS (0.652 versus 0.630, P = 0.041), and prolonged intensive care unit LOS (0.604 versus 0.555, P < 0.001). The median CCI and the highest CD grade were significantly different respective to the functional activity on discharge (P < 0.001).

CONCLUSIONS

The CDC and the CCI are the effective methods for reporting of complications after major abdominal surgery. The CCI is a more accurate scale for use in high-risk patients and correlates better with the postoperative LOS.

A Comparison Between the Comprehensive Complication Index and the Clavien-Dindo Grading as a Measure of Postoperative Outcome in Patients Undergoing Gastrointestinal Surgery-A Prospective Study

BACKGROUND

The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD to assess which of the two was a better measure of postoperative outcomes.

MATERIALS AND METHODS

Between June 2015 and December 2016, we recorded the complications using CD grading and CCI in 1000 consecutive patients in our gastrointestinal and hepatopancreaticobiliary surgery unit. The outcome variables studied were postoperative length of hospital stay (LOS), postoperative intensive care unit (ICU) stay, and time to normal activity. The results were expressed as strength of correlation and predictive accuracy of the outcome variables.

RESULTS

There were 600 males and 400 female patients, with a mean age of 50.3 y. A total of 788 (78.8%) elective and 212(21.2%) emergency procedures were performed. The overall 90-day/in-hospital mortality was 7.9%. Both CD and CCI showed a good correlation with LOS (r = 0.58; P = 0.001, r = 0.57; P = 0.001), ICU stay (r = 0.62; P = 0.002, r = 0.62; P = 0.001), and time to normal activity (r = 0.48; P = 0.01; r = 0.49; P = 0.01). The accuracy of CCI to predict the LOS (area under the curve [AUC] = 0.89; P < 0.001), ICU stay (AUC = 0.85; P < 0.001), and time to normal activity (AUC = 0.76; P < 0.001) was comparable to that of CD (AUC = 0.90; P < 0.001, AUC = 0.87; P < 0.001, AUC = 0.77; P < 0.001).

CONCLUSIONS

Both CD and CCI were equally accurate in measuring the postoperative outcomes and in their ability to predict the same in patients undergoing gastrointestinal and hepatopancreaticobiliary surgeries. Considering the relative ease of determination of CD, it remains a more commonly used measure for assessing the severity of complications and outcomes compared to CCI.

The Comprehensive Complication Index CCI: A proposed modification to optimize short-term complication reporting after cystectomy and urinary diversion

OBJECTIVE

To optimize complication reporting in patients undergoing cystectomy and urinary diversion (UD) using the Comprehensive Complication Index (CCI). The original CCI ranging from 0 (no complications) to 100 (death) integrates all complications weighted by severity over time in a single formula. However, due to the large number of complications after cystectomy and UD, the CCI may exceed the upper limit.

METHODS

In an observational single-center cohort, 90-day postoperative complications in 1,313 consecutive patients undergoing cystectomy and UD from 2000 to 2017 were evaluated. Prospectively collected complications were graded according to the Clavien-Dindo classification (CDC). A modified Berne CCI was developed using an exponential function, which transforms the sum of the weights into a value between 0 and 100. The correlation between the Berne and original CCI values was depicted graphically. Finally, original CCI and Berne CCI values for each patient were extracted and compared. Predictive values of CCI scores for mortality or severe complications (CDC ≥IV) within 1 year postoperatively were investigated by use of multiple logistic regression analyses.

RESULTS

Overall complication rate was 82%, with CDC grade I to II in 56% and CDC grade IIIa to V in 27% respectively. Applying the original CCI, the upper limit was exceeded in 8 patients, with a maximal value of 119.1 (median 25.7 [interquartile range: 20.9-37.2]). The maximal value of the Berne CCI was 99.4 (21.2 [14.6-39.3]) for nondeath cases. The Berne CCI predicted the onset of death and severe complications between postoperative day 91 and 365 (both P <0.0001), whereas the original CCI was only predictive in interaction with other variables but not alone (P = 0.2772 and P = 0.0862, respectively).

CONCLUSION

The optimized Berne CCI depicts postoperative morbidity and burden within 90 days after cystectomy and UD without exceeding the upper index limit. It is specifically suited for longitudinal assessment of complications after cystectomy and UD taking into consideration every single complication and corresponding treatment. As the Berne CCI well predicted the onset of mortality and severe complications within 1 year postoperatively, this may allow a better preoperative patient counselling. It therefore warrants consideration for standardized reporting of complications after cystectomy and UD.

Vancouver Foot and Ankle WNS (Wound, Nerve, and Systemic) Classification System for Foot and Ankle Orthopedic Surgery

BACKGROUND

Adverse events require consistent recording to determine the effect of alternate treatments. This study was undertaken to evaluate the Vancouver Foot and Ankle WNS complication scale to capture complications (W: wound, N: nerve, S: systemic) to assist in outcome recording.

METHODS

Interrater reliability was tested in 2 settings: (1) between 2 blinded clinicians in a live clinical setting and (2) between 8 orthopedic surgeons using case vignettes based on a retrospective analysis of 500 foot and ankle procedures performed at the Toronto Western Hospital, Department of Orthopaedics. The intrarater reliability of the WNS scale was tested in a single rater using the case vignettes. Inter- and intrarater reliability were assessed using the Fleiss and Cohen weighted kappa ( k), respectively and 95% confidence intervals (CIs). There was adequate power over 0.8.

RESULTS

In the live clinical setting, the Cohen weighted k (95% CI) values for the W (0.935 [0.862, 1.01]), N (0.914 [0.752, 1.08]), and S (1 [1, 1]) parameters, indicating a near perfect level of agreement between raters. In the broader community of professional foot and ankle surgeons, the Fleiss k values (95% CI) had moderate agreement for the W (0.712 [0.688, 0.735]), N (0.775 [0.738, 0.811]), and high agreement for S (0.834 [0.802, 0.866]) parameters based on case vignettes. However, the Fleiss k values continued to indicate moderate to strong agreement between raters for all parameters.

CONCLUSIONS

The WNS scale provided a standardized method of measuring foot and ankle surgical complications. There was at least moderate-strong interrater agreement for all parameters measured on case vignettes and excellent concordance in the live setting.

LEVEL OF EVIDENCE

Level III, comparative series.

The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery

BACKGROUND

The comprehensive complication index (CCI) integrates all complications of the Clavien-Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC.

METHODS

Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution.

RESULTS

From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p < 0.05). The CCI demonstrated a stronger relationship with hospital stay (ρ = 0.721, p < 0.001) than did the CDC (ρ = 0.634, p < 0.001). For prolonged hospital stays (≥30 days), only the CCI showed a moderate correlation (ρ = 0.544, p = 0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time-event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed.

CONCLUSIONS

The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.

Classifying Adverse Events Following Lower Limb Orthopaedic Surgery in Children With Cerebral Palsy: Reliability of the Modified Clavien-Dindo System

BACKGROUND

The modified Clavien-Dindo (MCD) system is a reliable tool for classifying adverse events (AEs) in hip preservation surgery and has since been utilized in studies involving lower limb surgery for ambulant and nonambulant children with cerebral palsy (CP). However, the profile of AEs recorded in children with CP compared with typically developing children is different, and the reliability of the MCD in CP is unknown. This study aimed to evaluate the interrater and intrarater reliability of the MCD system for classifying AEs following lower limb surgery in children with CP.

METHODS

Eighteen raters were invited to participate, including clinicians from surgical, nursing, and physical therapy professions, and individuals with CP. Following a MCD familiarization session, participants rated 40 clinical scenarios on 2 occasions, 2 weeks apart. Fleiss' κ statistics were used to calculate interrater and intrarater reliability.

RESULTS

The overall Fleiss' κ value for interrater reliability in the first rating was 0.70 (95% confidence interval, 0.61-0.80), and increased to 0.75 (95% confidence interval, 0.66-0.84) in the second rating. The average Fleiss' κ value for intrarater reliability was 0.78 (range, 0.48 to 1.00). Grading of more severe AEs (MCD III to V) achieved near perfect agreement (κ, 0.87 to 1.00). There was a lower level of agreement for minor AEs (MCD I-II) (κ, 0.53 to 0.55). A κ score of 0 to 0.2 was deemed as poor, 0.21 to 0.4 as fair, 0.41 to 0.6 as good, 0.61 to 0.8 as very good, and 0.81 to 1.0 as almost perfect agreement.

CONCLUSIONS

The MCD System demonstrates a very good interrater and intrarater reliability following lower limb surgery in children with CP. The MCD can be used by clinicians from different health care professions with a high level of reliability. The MCD may improve standardization of AE recording with a view to accurate audits and improved clarity in outcome studies for CP.

LEVEL OF EVIDENCE

Level II-diagnostic.

Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis

OBJECTIVE

We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare its outcomes with those of open right hepatectomy (ORH) in hepatocellular carcinoma (HCC) patients with liver cirrhosis.

BACKGROUND

Laparoscopic liver resection has been reported as a safe and effective approach for the management of liver cancer; however, its outcomes have not been evaluated in a large cohort of HCC patients with liver cirrhosis.

METHODS

We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n = 37) or ORH (n = 115) between June 2008 and July 2015 at the Asan Medical Center in Seoul, Korea. We performed 1:1 propensity score matching between the LRH and ORH groups. Subsequently, 33 patients were included in each group.

RESULTS

There was no statistically significant difference between the LRH and ORH groups regarding the rate of complications (P = 0.053). However, the mean comprehensive complication index, which accounts for the severity of complications, was significantly lower in the LRH group (0.63 vs 4.42; P = 0.025). There were no significant differences between the LRH and ORH groups regarding 2-year disease-free survival rate or 2-year overall survival rate (P = 0.645 and P = 0.090, respectively).

CONCLUSIONS

Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Impact of postoperative complications on readmission and long-term survival in patients following surgery for colorectal cancer

PURPOSE

It is well known that specific postoperative complications such as stroke influence readmissions and overall survival (OS) after surgery for colorectal cancer (CRC). Whether overall hospital morbidity is associated with increased risk of readmission and poorer long-term survival is unknown. New tools are available to accurately quantify overall morbidity, such as the comprehensive complication index (CCI). The aim is to evaluate the impact of complications on readmission and overall survival (OS) in patients operated for colorectal cancer.

METHODS

Postoperative complications of patients undergoing surgery for CRC were assessed over a 5-year period using the Clavien-Dindo classification, and overall morbidity was assessed by using the CCI. Individual scores were analyzed regarding their association with readmission and OS by using the multivariate logistic and Cox proportional-hazards regression analysis, respectively.

RESULTS

Two hundred eighty-four patients were operated for CRC, of which 22 (8%) were readmitted. One hundred five patients (37%) developed at least one postoperative complication during the hospital stay. While single complications or the use of severe complication only (grade ≥IIIb) was not associated with readmission, overall morbidity (CCI) predicted readmission (OR 1.02 (95% CI 1.0-1.04), p = 0.044). Similarly, morbidity assessed by the CCI had a significant negative predictive value on OS, e.g., patients with a CCI of 20 were 22% more likely to die within a 5-year follow-up, when compared to patients with a CCI of 10 (p = 0.022).

CONCLUSIONS

Overall combined morbidity as assessed by the CCI leads to more frequent readmission, and is associated with poorer long-term survival after surgery for CRC.

Using the Comprehensive Complication Index to Assess the Impact of Neoadjuvant Chemoradiotherapy on Complication Severity After Esophagectomy for Cancer

Background

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with esophageal or junctional cancer has become a standard of care. The comprehensive complication index (CCI) has recently been developed and accounts for all postoperative complications. Hence, CCI better reflects the burden of all combined postoperative complications in surgical patients than the Clavien–Dindo score alone, which incorporates only the most severe complication. This study was designed to evaluate the severity of complications in patients treated with nCRT followed by esophagectomy versus in patients who underwent esophagectomy alone using the comprehensive complication index.

Study-design

All patients included in the CROSS trial—a randomized, clinical trial on the value of nCRT followed by esophagectomy—were included. Complications were assessed and graded using the Clavien–Dindo classification. CCI was derived from these scores, using the CCI calculator available online (www.assessurgery.com). CCI of patients who underwent nCRT followed by surgery was compared with the CCI of patients who underwent surgery alone.

Results

In both groups 161 patients were included. The median (and interquartile range) CCI of patients with nCRT and surgery was 26.22 (17.28–42.43) versus 25.74 (8.66–43.01) in patients who underwent surgery alone (p = 0.58). There also was no difference in CCI between subgroups of patients with anastomotic leakage, pulmonary complications, cardiac complications, thromboembolic events, chyle leakage, and wound infections.

Conclusions

Neoadjuvant chemoradiotherapy according to CROSS did not have a negative impact on postoperative complication severity expressed by CCI compared with patients who underwent surgery alone for potentially curable esophageal or junctional cancer.

Cultural adaptation and the Clavien-Dindo surgical complications classification translated to Brazilian Portuguese

ABSTRACT Objective: to generate a translated and validated version of the Clavien-Dindo Classification of Surgical Complications (CDC) to Brazilian Portuguese (CDC-BR). Methods: the process of translation and adaptation followed the guideline of Beaton et al., 2000. We divided 76 participating surgeons, in different levels of experience, from the Department Surgery of the Hospital de Clínicas de Porto Alegre, into two groups: Group I applied the original version (CDC, n=36);r Group II used the modified version (CDC-BR, n=40). Each group classified 15 clinical cases of surgical complications. We compared performance between the groups (Mann-Whitney test) relating to the level of experience of the surgeon (Kruskal-Wallis test), considering p value <0.05 as significant. Results: the performance of the Group II (CDC-BR) was higher, with 85% accuracy, compared with 79% of Group I (CDC), p-value =0.012. The performance of the groups as for surgeons experience displayed p=0.171 for Group I, p=0.528 for Group II, and p=0.135 for overall performance. Conclusion: we produced a translated and validated version of the CDC for Brazilian Portuguese. The instrument will be a useful tool in the production of evidence on surgical outcomes.

The impact of complications on quality of life following colorectal surgery: a prospective cohort study to evaluate the Clavien-Dindo classification system

AIM

This prospective cohort study was performed to evaluate the impact of complications on quality of life (QOL) in colorectal surgery. The Clavien-Dindo complication classification (CDCC) is promising, but has not been evaluated by relating the classification to patient-reported outcome measures.

METHOD

Patients undergoing colorectal surgery were evaluated prospectively 12 months postoperatively using the WHOQOL-BREF questionnaire. Patient data were prospectively recorded and complications were classified using the CDCC. Postoperative QOL in patients with minor and severe complications and patients without complications was compared using a general linear model. Relationships between CDCC and QOL were examined using correlations and multivariate regression.

RESULTS

Of 218 patients, 130 (59.6%) had complications. In patients with severe complications there was a greater decrease in overall QOL (P = 0.043), QOL-physical (P < 0.001) and QOL-psychological (P = 0.013) domains in the first six postoperative weeks, whereas patients with minor complications had QOL scores comparable to those of patients without complications. QOL recovered to preoperative levels in all groups at 12 months. Change in QOL at 6 weeks was significantly correlated with CDCC grade, especially in the physical domain (Spearman's rho -0.287, P < 0.001). The presence of severe complications was an independent predictor of overall QOL, QOL-physical and QOL-psychological at 6 weeks.

CONCLUSION

Severe complications are associated with reduced postoperative QOL at 6 weeks, but QOL recovers after 12 months. CDCC grade negatively correlates with change in QOL in the early postoperative period. These findings support the theoretical framework of the CDCC.

Differences in early complications between circular and linear stapled gastrojejunostomy in laparoscopic gastric bypass

BACKGROUND

Laparoscopic gastric bypass (LGBP) is the most common bariatric procedure worldwide. The gastrojejunostomy can be stapled with a circular or linear stapler, each with their own specific advantages. We have evaluated differences in postoperative complications between the two techniques.

METHODS

We studied operative data and postoperative complications in 560 patients (79.8 % females, median age 42, BMI 42.5) operated with LGBP between 2008 and 2012 at our center. The gastrojejunostomy was initially performed using a circular stapler (CS) in 288 patients and later by linear stapler (LS) in 272. Complications, operative time, and length of stay were retrieved from our database. The risk of developing a port site infection was evaluated with multivariate logistic regression.

RESULTS

Port site infections were more common with CS than LS, 5.2 and 0.4 %, respectively (p < 0.01). Multivariate analysis demonstrated CS to be an independent risk factor for port site infections (OR 16.3 (2.09-126), p < 0.01), as well as for stomal ulcers (OR 10.1, 1.15-89, p = 0.04). Major postoperative complications remained unchanged (anastomotic leak 1.0 vs. 1.1 %, abscess 0.7 vs. 0.4 %), while operative time and length of stay were found to be shorter using the LS (122 vs. 83 min, p < 0.001 and 4 vs. 3 days, p < 0.001).

CONCLUSIONS

The linear stapled technique yielded lower incidence of port site infections, probably by avoiding the passage of a contaminated circular stapler through the abdominal wall. No difference in major complications was seen, but operative time was shorter using a linear stapler instead of a circular stapler.

The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials

OBJECTIVE

To test whether the newly developed comprehensive complication index (CCI) is more sensitive than traditional endpoints for detecting between-group differences in randomized controlled trials (RCTs).

BACKGROUND

A major challenge in RCTs is the choice of optimal endpoints to detect treatment effects. Mortality is no longer a sufficient marker in studies, and morbidity is often poorly defined. The CCI, integrating all complications including their severity in a linear scale ranging from 0 (no complication) to 100 (death), is a new tool, which may be more sensitive than other traditional endpoints to detect treatment effects on postoperative morbidity.

METHODS

The CCI was tested in 3 published RCTs from European centers evaluating pancreas, esophageal and colon resections. To compare the sensitivity of the CCI with traditional morbidity endpoints, for example, presence of any (yes/no) or only the most severe complications, all postoperative events were assessed, and the CCI calculated. Treatment effects and sample size calculations were compared using the CCI and traditional endpoints.

RESULTS

Although RCTs failed to show between-group differences using any or most severe complications, the CCI revealed significant differences between treatment groups in 2 RCTs-after pancreas (P=0.009) and esophageal surgery (P=0.014). The CCI in the RCT on colon resections confirmed the absence of between-group differences (P=0.39). The required sample sizes in trials are up to 9 times lower for the CCI than for traditional morbidity endpoints.

CONCLUSIONS

This study demonstrates superiority of the CCI to traditional endpoints. The CCI may serve as an appealing endpoint for future RCTs and may reduce the sample size.

Comprehensive complication index for NOTES procedures: results from a randomized controlled trial and comparison to published NOTES complication data

OBJECTIVE

This investigation uses the comprehensive complication index (CCI) to compare complications after natural orifice transluminal endoscopic surgery (NOTES) procedures.

BACKGROUND

NOTES procedures are developed to miniaturize surgical trauma. NOTES publications inconsistently report complications. The CCI improves reporting of complications.

METHODS

The CCI is calculated using complication data from a single center, double blind, randomized controlled trial comparing transvaginal [transvaginal cholecystectomy (TVC), N = 41] and conventional laparoscopic cholecystectomy (CLC, N = 51). Complications are assessed using the classification of surgical complications (CSC). Two different scenarios are applied to the CSC for definition of complications with an emphasis on minor complications. CSC data are fed into the free online CCI-calculator. The CCIs from complication data from other NOTES reports are calculated accordingly and compared to our results.

RESULTS

The CCI allows easy indexing of complications with or without a CSC table. For scenario I, the mean CCI of CLC versus TVC is 3.3 (± 6.3; SD) versus 3.5 (± 6.4; n.s.) and for scenario II it is 7.6 (± 6.4) versus 6.5 (± 7.0; n.s.). The difference of the mean between the two scenarios is highly significant (p < 0.000). The mean CCIs of both groups and scenarios are below the CCI of 8.7 for a grade I CSC complication. Similar calculation of CCIs from other NOTES publications yields mean CCIs below 8.7 for the surgical procedures reported.

CONCLUSION

The CCI results in a single, easily comparable complication index for surgical procedures whereas the CSC yields tabular results. A significant difference in interpretation occurs with variation in definition of complications. Average CCIs below a value of 10 describe low complication rates. Authors need to describe their definition of complications if using the CSC and the CCI. More emphasis should be given to reporting of minor complications. The use of the CCI for NOTES procedures will enable international comparison.

Fatores preditivos de complicações graves em cirurgia neonatal

OBJETIVO: investigar a incidência e gravidade das complicações pós-operatórias precoces e identificar fatores de risco para o seu desenvolvimento em recém-nascidos submetidos ao tratamento cirúrgico, sob anestesia geral. MÉTODOS: análise retrospectiva dos dados de 437 neonatos com doença crítica submetidos à cirurgia neonatal num centro cirúrgico pediátrico terciário, entre janeiro de 2000 e dezembro de 2010. A gravidade das complicações ocorridas nos primeiros 30 dias de pós-operatório foi classificada utilizando o sistema de Clavien-Dindo para complicações cirúrgicas, sendo considerados graves os graus III a V. Por análise estatística uni e multivariada avaliaram-se variáveis pré e intraoperatórias com potencial preditivo de complicações pós-operatórias graves. RESULTADOS: a incidência de, pelo menos, uma complicação grave foi 23%, com uma mediana de uma complicação por paciente 1:3. Ao todo, ocorreram 121 complicações graves. Destas, 86 necessitaram de intervenção cirúrgica, endoscópica ou radiológica (grau III), 25 puseram em risco a vida, com disfunção uni ou multi-órgão (grau IV) e dez resultaram na morte do paciente (grau V). As principais complicações foram técnicas (25%), gastrointestinais (22%) e respiratórias (21%). Foram identificados quatro fatores de risco independentes para complicações pós-operatórias graves: reoperação, operação por hérnia diafragmática congênita, prematuridade menor que 32 semanas de idade gestacional e cirurgia abdominal. CONCLUSÃO: a incidência de complicações pós-operatórias graves após cirurgias neonatais, sob anestesia geral, permaneceu elevada. As condições consideradas fatores de risco independentes para complicações graves após a cirurgia neonatal podem ajudar a definir o prognóstico pós-operatório em neonatos com doença cirúrgica e orientar as intervenções para melhoria de resultados.

The comprehensive complication index: a novel continuous scale to measure surgical morbidity

OBJECTIVE

To develop and validate a comprehensive complication index (CCI) that integrates all events with their respective severity.

BACKGROUND

Reporting of surgical complications is inconsistent and often incomplete. Most studies fail to provide information about the severity of complications, or inform only on the most severe event, ignoring events of lesser severity.

METHODS

We used an established classification of complications, adopting methods from operation risk index analysis in marketing research to develop a formula that considers all complications that may occur in a patient. The weights of each grade of complication, defined as median reference values, were obtained from 472 participants, who rated 30 different complications. Validation to assess sensitivity to treatment effects and validity of the CCI was performed by 4 different approaches, based on 1299 patients.

RESULTS

The CCI is calculated as the sum of all complications that are weighted for their severity (multiplication of the median reference values from patients and physicians). The final formula yields a continuous scale to rank the severity of any combination of complications from 0 to 100 in a single patient. The CCI was highly sensitive in detecting treatment effect differences in the context of a randomized trial (effect size detected by CCI vs conventional standardized morbidity outcomes). It also showed a negative correlation with postoperative health status (r = -0.24, P = 0.002), and high correlation with the results of patient-rated single and multiple complications on conjoint analysis (r = 0.94, P < 0.001).

CONCLUSIONS

The CCI summarizes all postoperative complications and is more sensitive than existing morbidity endpoints. It may serve as a standardized and widely applicable primary endpoint in surgical trials and other interventional fields of medicine. The CCI can be readily computed on the basis of tabulated complications according to the Clavien-Dindo classification (available at www.assessurgery.com).