What Is a Surgical Complication? (2008)

Quality assessment programs have been well-established tools in industry for decades. A unique focus on quality assessment significantly contributed to the economic success of Japan in the early 1950s, and this philosophy of steadily improving quality by continuous measurement of specific outcome variables reached the Western world only many years later. In medicine, these principles have been adopted very slowly and are still incomplete in many areas, possibly because of a lack of true competition among health care providers. Competition remains the most obvious driving force for the development of quality assessment programs. Thus, rising costs associated with constrained resources in most health care systems over the past decade, together with evidence of variations in clinical practice, have triggered growing interest in measuring our work. In the United States, large databases, such as the National Surgical Quality Improvement Program (NSQIP) established in 1991 to study surgical performance in Veteran Affairs Hospitals, have been established to record surgical outcome, to rate hospital quality, and to benchmark performance. The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery. However, the definition of complications in surgery still lacks standardization, hampering the interpretation of surgical performance and quality assessment. In 1992, we and our colleagues defined ‘‘negative outcome’’ by differentiating among complications, failure to cure, and sequelae [1, 2]. Complications were defined as ‘‘any deviation from the normal postoperative course’’ and a classification of complications by severity was proposed [1]. Complications were differentiated from sequelae, which cover conditions that are inherent in the procedure, and that thus will inevitably occur (such as scar formation or the inability to walk after an amputation). Similarly, diseases or conditions that remain unchanged after surgery are not complications, but rather a failure to cure. For example, early recurrence of inguinal hernia or incompletely resected malignant tumors, while clearly reflecting a negative outcome, are better covered under the term ‘‘failure to cure.’’ Twelve years later, while gaining experience with the routine use of the three categories of negative outcome (complications, sequelae, and failure to cure), as well as the classification of complications in our surgical practice [1– 3], we introduced a revised system to grade surgical complications [4]. It was validated through a large cohort of patients and an international survey. The basic principle of the classification remained unchanged; i.e., it was based on the therapy needed to correct the complication. In the modified system, we eliminated the length of hospital stay as a criterion measuring the severity of a complication. We also took into greater account complications requiring an ICU stay or an intermediate care stay and those dealing with the central nervous system, and we gave special emphasis to long-term disability resulting form a complication [4]. This novel therapy-oriented five-scale classification appears to be used more and more, according to reports in the surgical literature [5–14]. The definition of surgical complications is a challenging task. Many surgeons would argue that the surgeon’s intuition is an appropriate guide to defining what a complication might be. The appropriateness of the surgeon’s intuition for risk assessment has recently been emphasized in this journal [15]. However, the value of the D. Dindo P.-A. Clavien (&) Department of Surgery, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland e-mail: clavien@chir.uzh.ch