Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4

Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature.

The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification.

Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

/pdf/classification-of-surgical-complications-a-new-proposal-with-h643vehuw5.pdf

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Background and Aims:The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the co

The Clavien-Dindo classification of surgical complications: five-year experience.

The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). Conclusions Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

/pdf/a-surgical-safety-checklist-to-reduce-morbidity-and-pw0mo35zs1.pdf

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Harmon S. Jordan, ScD, Karima A. Kendall, PhD, Linda J. Lux, Roycelynn Mentor-Marcel, PhD, MPH, Laura C. Morgan, MA, Michael G. Trisolini, PhD, MBA, Janusz Wnek, PhD

Jeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN,

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society

2013 AHA/ACC/TOS Guideline for the Management of Overweight

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(03)13640-9.pdf

Obesity in general elective surgery

Background The dramatic shortage of kidney donors has triggered interest in other sources of organs, such as donors without a heartbeat. Accumulating evidence suggests that the short-term survival of cadaveric kidneys from such donors is similar to that of cadaveric kidneys from donors with a heartbeat. However, no data from large, matched studies with long-term follow-up are available. We conducted a matched, single-center study of kidney transplants obtained from donors without a heartbeat and those from donors with a heartbeat, with a 15-year follow-up period. Methods Between 1985 and 2000, 122 kidney transplantations involving donors without a heartbeat were performed at the University of Zurich, in Switzerland. Outcomes of these procedures were compared with those of 122 transplantations of kidneys from donors with a heartbeat. The recipients were matched according to age, sex, number of transplantations, and calendar period of transplantation. Results The characteristics of the recipients did not di...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa020274

Kidney transplantation from donors without a heartbeat.

According to Donabedian, medical quality is determined by structure, process and outcome. In surgery, outcome is still the most frequently used indicator of surgical quality. However, there is still a lack of a precise definition of a ‘good’ or ‘bad’ surgical outcome. In 1992, it was proposed that ‘negative outcome’ should be subdivided into complication, failure to cure and sequelae . Complications were defined as ‘any deviation from the normal postoperative course’. Conditions, which are inherent to the procedure and are expected to occur (such as pain or scar formation) should be discriminated from complications and be termed ‘sequelae’. Finally, diseases that remain unchanged after surgery or reoccur (e.g. R2-resected tumour or an early recurrence of an inguinal hernia) also reflect negative outcomes, either, but constitute a failure to cure rather than a complication.

Daniel Dindo

Papers

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

The Clavien-Dindo classification of surgical complications: five-year experience.

Obesity in general elective surgery

Kidney transplantation from donors without a heartbeat.

The Clavien–Dindo Classification of Surgical Complications