Clavien-Dindo Classification of Surgical Complications:

Interactive tutorial

Harry ClaireauxSlides modified from those by Dr. Stephen Chapman

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

What we will cover

• Outline of the Clavien-Dindo classification

• 8 short examples – open to the floor

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

• Measure of morbidity

• Any deviation from the normal postoperative course (grades I-V)

• Classification via therapeutic consequence

• Grade allocated to each complication identifiedIn the OAKS study please record the highest single grade per patient

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Clavien-Dindo classification of surgical complications

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Definitions

I• Deviation from normal postoperative course without need for

pharmacological, surgical, endoscopic or radiological interventions.• There are some “allowed therapeutic regimens” e.g. antiemetics,

antipyretics, diuretics & electrolytes.• Wound infections opened at bedside are classified here.

II• Requiring pharmacological intervention (beyond grade 1).• Blood transfusions and total parenteral nutrition are classified here.

IIIa • Requiring surgical, endoscopic or radiological intervention • Without general anaesthesia

IIIb • Requiring surgical, endoscopic or radiological intervention• With general anaesthesia

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Definitions cont.

IVa• Life-threatening complication requiring intensive management

• Includes CNS complications (brain haemorrhage & stroke but not TIA)

• Single organ dysfunction (including dialysis)

IVb• Life-threatening complication requiring intensive management

• Includes CNS complications (brain haemorrhage & stroke but not TIA)

• Multi-organ dysfunction

V • Death of patient

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

What you will see on

On to the cases…Inclusion & exclusion criteria

• Included:– Adult patients undergoing gastrointestinal resection / anastomosis or liver resection– Elective & emergency

• Excluded:– Appendicectomy– Cholecystectomy– Simple hernia repair (without resection)– Urological indication– Gynaecological indication– Vascular indication (but include bowel resection for mesenteric ischaemia)

• Refer to the protocol

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 1: A 52 year old man underwent gastrectomy for malignancy. Six days

post-operatively he had left sided facial and limb weakness. His CT head scan showed no acute changes. He was not thrombolysed. Several hours later the weakness resolved spontaneously. A diagnosis of

transient ischaemic attack was made and aspirin 75mg OD was started.

Eligible for OAKS?Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 2: A 65 year old man underwent elective hepatectomy for resection

of hepatocellular carcinoma (HCC). Following surgery he experienced significant post-operative nausea and vomiting (PONV). The symptoms settled with adequate anti-emetic therapy. He also developed a wound infection requiring

antibiotics according to local policy. Eligible for OAKS?

Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 3: A 69 year old lady underwent laparoscopic cholecystectomy for cholecystitis. Shortly after the operation, she developed severe abdominal pain and fever. A bile leak was confirmed and fixed during emergency laparotomy. She recovered with no further

complications.

Eligible for OAKS?Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 4: A 52 year old man underwent elective left hemicolectomy for malignancy. In the days following the procedure he developed

pneumonia and was started on empirical antibiotic therapy. His breathing continued to deteriorate, leading to critical care escalation with eventual ventilatory support. He recovered

following a prolonged stay in critical care.

Eligible for OAKS?Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 5: A 59 year old man underwent living donor liver transplantation.

His post-operative course was uncomplicated, apart from moderate nausea and vomiting requiring anti-emetic therapy.

Eligible for OAKS?Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 6: A 41 year old lady underwent anterior resection for a rectal

tumour. On the first post-operative night she spiked a temperature and was given intravenous paracetamol. On day 2

he was hypokalaemic and was administered oral potassium supplementation.

Eligible for OAKS?

Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 7: A 61 year old man underwent femoral-popliteal bypass for

worsening arterial insufficiency. Post-operatively, he suffered an acute myocardial infarction leading to cardiac arrest.

Resuscitation attempts were unsuccessful and the patient was pronounced dead shortly after.

Eligible for OAKS?

Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Example 8: A 34 year old man underwent laparoscopic appendicectomy for

acute appendicitis. Post-operatively, he developed an intra-abdominal collection requiring drainage in theatre. Two days

later he developed a temperature. Nitrites were identified in his urine, following which antibiotics were commenced

Eligible for OAKS?

Classification?

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England

Take home points…

• Clavien-Dindo is a classification of morbidity via therapeutic consequence

• Secondary outcome measure for OAKS Audit

• Input the highest grade complication for each patient on

• Please complete e-learning to consolidate your knowledge

Protocol Launch Meeting and Research Skills CourseSeptember 16th 2015, RCS England