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      Assessment of Clavien-Dindo classification in patients >75 years undergoing nephrectomy/nephroureterectomy

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          Abstract

          Introduction:

          There is a paucity of a standardized post-operative complications grading system in urology especially in the elderly population. Studies show satisfactory survival and oncological outcomes albeit with a slight increase in post-operative morbidity compared to younger patients. The Clavien-Dindo classification for post-operative complications is established as a valid system worldwide and applicable in many fields of surgery.

          Purpose:

          Retrospective assessment of post-operative complications in patients >75 years who underwent open/laparoscopic nephrectomy/nephroureterectomy for renal diseases and grading the post-operative complications according to the Clavien-Dindo classification.

          Materials and Methods:

          Retrospective review of case notes was performed in patients >75 years who underwent a laparoscopic/open nephrectomy/nephroureterectomy between 2000 and 2008. Post-operative complications were graded according to the Clavien-Dindo classification.

          Results:

          A total of 54 patients >75 years underwent nephrectomy/nephroureterectomy. 29 patients had laparoscopy and 25 had open surgery. Fifty one patients had a malignancy and 3 had benign diseases. Grade I, II, IIIa, IIIb and IVa were 25.6%, 41.1%, 7.7%, 7.7% and 17.9% respectively. No significant difference was noted in the 2 groups

          Conclusions:

          We believe that in elderly patients, laparoscopic surgery can be offered safely without significantly increasing the surgical risks. The Clavien-Dindo classification is easy to use and effectively applied to categorize post-operative complications associated with nephrectomy/nephroureterectomy in elderly population. However, this system needs slight modification to incorporate intra-operative complications and large studies are needed to validate and standardize this classification for all urological procedures.

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          Most cited references 26

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          Proposed classification of complications of surgery with examples of utility in cholecystectomy.

          Lack of uniform reporting of negative outcomes makes interpretation of surgical literature difficult. We attempt to define and classify negative outcomes by differentiating complications, sequelae, and failures. Complications and sequelae result from procedures, adding new problems to the underlying disease. However, complications are unexpected events not intrinsic to the procedure, whereas sequelae are inherent to the procedure. Failures are events in which the purpose of the procedure is not fulfilled. We propose a classification of complications based on four grades: Grade I complications are alterations from the ideal postoperative course, non-life-threatening, and with no lasting disability. Complications of this grade necessitate only bedside procedures and do not significantly extend hospital stay. Grade II complications are potentially life-threatening but without residual disability. Within grade II complications a subdivision is made according to the requirement for invasive procedures. Grade III complications are those with residual disability, including organ resection or persistence of life-threatening conditions. Finally, grade IV complications are deaths as a result of complications. To illustrate the relevance of the classification, we reviewed 650 cases of elective cholecystectomy. Risk factors for development of complications were determined, and the classification was also used to analyze the value of a modified APACHE II as a preoperative prognostic score. Both supported the relevance of the proposed classification. The advantages of such a classification are (1) increased uniformity in reporting results, (2) the ability to compare results of two distinct time periods in a single center, (3) the ability to compare results of surgery between different centers, (4) the ability to compare results of surgical versus nonsurgical measures, (5) the ability to perform adequate metaanalysis, (6) the ability to identify objective preoperative risk factors, and (7) the ability to establish preoperative prognostic scores.
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            Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard.

            A classification (modified Clavien system) has been proposed to grade perioperative complications. We reviewed our experience with percutaneous nephrolithotomy (PNL), grading the complications according to this new classification. A total of 811 PNLs were performed between 2003 and 2006, and charts were retrospectively reviewed focusing on complications observed. According to the modified Clavien classification system, perioperative complications were stratified into five grades. Grade 1 defined all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside intervention. Grade 2 complications required specific medication, including antibiotics and blood transfusion. Grade 3 complications necessitated surgical, endoscopic, or radiologic intervention (3a without general anesthesia, 3b under general anesthesia). Neighboring organ injuries and organ failures were classified as grade 4, and death was considered a grade 5 complication. Kidney stones treated with PNL were also classified as simple and complex and complication rates were compared. A total of 255 perioperative complications were observed in 237 (29.2%) patients. There were 33 grade 1 (4%), 132 grade 2 (16.3%), 54 grade 3a (6.6%), 23 grade 3b (2.8%), 9 grade 4a (1.1%), and 3 grade 4b (0.3%) complications, and 1 death (0.1%). Most complications were related to bleeding and urine leakage. Grade 2 and 3a complications were significantly more common in patients with complex renal stones. A graded classification scheme for reporting the complications of PNL may be useful for monitoring and reporting outcomes. However, minor modifications concerning auxiliary treatments are needed and further studies are awaited.
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              Systematic classification of morbidity and mortality after thoracic surgery.

              Objective reporting of postoperative complications is the foundation of surgical quality assurance. We developed a system to identify both presence and severity of thoracic morbidity and mortality, and evaluated its feasibility and utility over the first two years of its implementation. The system was based on the Clavien-Dindo classification, in which the severity of a complication is proportional to the effort to treat it. Definitions were developed by peer review and questionnaire. All patients undergoing thoracic surgery (January 2008 to December 2009) were prospectively evaluated. A total of 953 patients (mean age 61 years; range, 14 to 95) underwent thoracic surgery (total # cases 1260), of which 369 patients had at least one complication (29.3% procedures). Grades I and II include minor complications requiring no therapy or pharmacologic intervention only. Grades III and IV are major complications that require surgical intervention or life support. Grade V complications result in patient death. Grades I, II, III, and IV complications comprised 4.9%, 63.9%, 21.1%, and 7.8% of all complications; overall mortality rate (grade V) was 2.2%. The most common complications were prolonged air leak (18.8%) and atrial fibrillation (18.2%) after pulmonary resection, and atrial fibrillation (11.5%) after esophagectomy-gastrectomy. Prolonged air leak led to a major complication (13%), readmission (17%), or prolonged hospital stay (29%) to a greater extent than atrial fibrillation (3%, 2%, and 7%, respectively). This standardized classification system for identifying presence and severity of thoracic surgical complications is feasible, facilitates objective comparison, identifies burden of illness of individual complications, and provides an effective method for continuous surgical quality assessment. 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Urol Ann
                Urol Ann
                UA
                Urology Annals
                Medknow Publications & Media Pvt Ltd (India )
                0974-7796
                0974-7834
                Jan-Mar 2013
                : 5
                : 1
                : 18-22
                Affiliations
                [1 ]Department of Urology, St James's University Hospital, Leeds, United Kingdom
                [2 ]Department of Urology, University Hospital of North Tees and Hartlepool, United Kingdom
                [3 ]Department of Urology, Hull and East Yorkshire Hospitals NHS Trust, Castlehill Hospital, United Kingdom
                [4 ]Department of Urology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, United Kingdom
                Author notes
                Address for correspondence: Mr. Chandra Shekhar Biyani, Consultant Urological Surgeon, Department of Urology, Pinderfields General Hospital, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, WF1 4DG, West Yorkshire, United Kingdom. E-mail: shekharbiyani@ 123456hotmail.com
                Article
                UA-5-18
                10.4103/0974-7796.106959
                3643316
                23662003
                Copyright: © Urology Annals

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Original Article

                Urology

                clavien-dindo, elderly, nephrectomy

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