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Comparative Study
, 240 (2), 205-13

Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey

Comparative Study

Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey

Daniel Dindo et al. Ann Surg.


Objective: Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.

Patients and methods: A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.

Results: The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.

Conclusions: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.


FIGURE 1. Length of hospital stay related to the types of complications. A statistically significant correlation was noted between the respective grades of complications and the length of hospital stay (P < 0.0001; Spearman rank correlation test). When more than 1 complication occurred in a patient, only the most severe was taken into account in this analysis. Grade 0 means no complication; grade V means death of a patient due to a complication. (□), Operation Type A; (formula image), Operation Type B; (▪), Operation Type C; (▥), overall.
FIGURE 2. Percent of patients presenting a complication for each grade of complications. A significant correlation was observed between the number of patients presenting the respective complication and the types of surgery (P < 0.0001; Spearman rank correlation test). In other words, in each complication grade, complications occurred more frequently in complex surgical procedures. Operation Type A (□) < Operation Type B (formula image) < Operation Type C (▪).

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