Pierre A. Clavien

Bio: Pierre A. Clavien is an academic researcher from University of Zurich. The author has contributed to research in topics: Liver transplantation & Transplantation. The author has an hindex of 16, co-authored 30 publications receiving 6957 citations.

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

Abstract: 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

Are There Better Guidelines for Allocation in Liver Transplantation? A Novel Score Targeting Justice and Utility in the Model for End-Stage Liver Disease Era

Abstract: Objectives:To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.Background:The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

ALPPS: from human to mice highlighting accelerated and novel mechanisms of liver regeneration.

Abstract: OBJECTIVES: To develop a reproducible animal model mimicking a novel 2-staged hepatectomy (ALPPS: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy) and explore the underlying mechanisms. BACKGROUND: ALPPS combines portal vein ligation (PVL) with liver transection (step I), followed by resection of the deportalized liver (step II) within 2 weeks after the first surgery. This approach induces accelerated hypertrophy of the liver remnant to enable resection of massive tumor load. To explore the underlying mechanisms, we designed the first animal model of ALPPS in mice. METHODS: The ALPPS group received 90% PVL combined with parenchyma transection. Controls underwent either transection or PVL alone. Regeneration was assessed by liver weight and proliferation-associated molecules. PVL-treated mice were subjected to splenic, renal, or pulmonary ablation instead of hepatic transection. Plasma from ALPPS-treated mice was injected into mice after PVL. Gene expression of auxiliary mitogens in mouse liver was compared to patients after ALPPS or PVL. RESULTS: The hypertrophy of the remnant liver after ALPPS doubled relative to PVL, whereas mice with transection alone disclosed minimal signs of regeneration. Markers of hepatocyte proliferation were 10-fold higher after ALPPS, when compared with controls. Injury to other organs or ALPPS-plasma injection combined with PVL induced liver hypertrophy similar to ALPPS. Early initiators of regeneration were significantly upregulated in human and mice. CONCLUSIONS: ALPPS in mice induces an unprecedented degree of liver regeneration, comparable with humans. Circulating factors in combination with PVL seem to mediate enhanced liver regeneration, associated with ALPPS.

Severity grading of surgical complications.

Abstract: In 1992, we published an article entitled “Proposed classification of complications of surgery with examples of utility in cholecystectomy.” This article grew out of discussions regarding the state of reporting complications in the surgical literature. Several problems were noted. First, there was no uniform definition of a surgical complication. Also, severity grading of complications was usually absent. Finally, when present, the severity grading was subjective rather than based on objective criteria. The authors of this editorial set out to remedy this shortcoming in outcome reporting, and subdivided negative events into complications, sequelae and failures to cure, defined the term “complication,” and established a severity scale of complications based on objective criteria. The key concept of this scale was that the objective severity of a complication could be either defined by the treatment it provoked to reverse it, or death. Furthermore, the length of hospital stay was another criterion in the lower grades of complication, while complications with permanent disability were given their own grade. After more than 10 years of routine use of this system, one of us (P.A.C.) along with his team in Zurich published a new version of the original classification. Modifications mostly focused on the manner of reporting life threatening and permanently disabling complications. The classification was tested on a cohort of 6336 patients, who underwent elective general surgery. Personal judgment and interobserver variation were also analyzed through an international survey, with questionnaires sent to 10 surgical centers worldwide. The new system proposed 5 grades of severity, of which levels III and IV were subdivided into IIIa, IIIb and IVa, IVb, respectively. The length of stay was eliminated as a criterion, since it is not an objective marker for poor outcome, especially in an international classification, where many factors, independent of postoperative events, may influence the duration of hospitalization. This revision received an enthusiastic response from surgeons; it has been used in more than 250 studies since its introduction in 2004, with over 100 citations in 2008. The original classification was cited 31 times in the same year. This system of grading complications was selected by an international group of experts in outcome of surgical procedures (The Safe Surgery Saves Life Study Group) as one of the standard composite endpoints in evaluating and improving the safety of surgery. Among other attempts at grading complications according to severity, Martin et al published an extensive review of surgical complication reported in the literature in 2002. The grading system used in the original article published in 1992, was described as part of their analysis. Although their proposed grading system was virtually identical to the initially described system of 1992, somewhat confusingly, some authors have referred to this subsequently as the “(Memorial Sloan Kettering Cancer Center) grading system.” However, in considering the impact of the 1992 system it has to be taken into account–and to put it in perspective it received 10 citations in 2008. That brings us to the 2 articles published in this issue of Annals of Surgery and the unusual situation of having the 2 lead authors of somewhat competing articles coauthor an editorial. The reason for this being that the concepts advanced in the 2 articles are much more alike than different reflecting the desire of the coauthors for a consensus. The proposal for getting to this point is described below. The article from Washington University in St. Louis focuses exclusively on how the 3 classifications have functioned in the published literature as vehicles for reporting complications in surgical studies. Its goal was solely to assess and then to modify the classifications used so that it fits the needs of surgical authors. It identified 129 articles with more than 44,000 patients up to June 2007 that used the classifications and analyzed these articles for 20 specific variables. The central observations were that the number of patients and the number of complications reported in these studies spanned a very large numerical range (10–2775 patients and 3–720 complications), and that 59% of authors contracted the classifications to fit their study. However, the cut points were highly variable and so the number of grades in the subsequent classifications was also quite variable. This led to the central proposal in this article to create an expandable classification (hence “Accordion Classification”) which would have a contracted 4 level form and an expanded 6 level

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

Abstract: 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

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Abstract: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

The Brisbane 2000 terminology of liver anatomy and resections.

Abstract: Background The Scientific Committee of the IHPBA, meeting in December 1998, created a Terminology Committee to deal with the confusion in nomenclature of hepatic anatomy and liver resections. A terminology was sought which was anatomically correct, in which anatomical and surgical terms agreed, and which was consistent, self-explanatory, linguistically correct, translatable, precise and concise. Discussion After 18 months the International Committee presented a terminology that was accepted by the IHPBA at the recent World Congress in Brisbane. The purpose of this paper is to present that terminology.

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

Abstract: 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 i