extended clavien-dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax,...

18
Surg Today (2016) 46:668–685 DOI 10.1007/s00595-015-1236-x 1 3 ORIGINAL ARTICLE Extended Clavien‑Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria Hiroshi Katayama 1 · Yukinori Kurokawa 2 · Kenichi Nakamura 1 · Hiroyuki Ito 3 · Yukihide Kanemitsu 4 · Norikazu Masuda 5 · Yasuhiro Tsubosa 6 · Toyomi Satoh 7 · Akira Yokomizo 8 · Haruhiko Fukuda 1 · Mitsuru Sasako 9 Received: 24 April 2015 / Accepted: 14 June 2015 / Published online: 20 August 2015 © The Author(s) 2015. This article is published with open access at Springerlink.com commonly in their fields and defined more detailed grading criteria for each complication in accordance with the gen- eral grading rules of the Clavien-Dindo classification. Results We listed 72 surgical complications experienced commonly in surgical trials, focusing on 17 gastroentero- logic complications, 13 infectious complications, six tho- racic complications, and several other complications. The grading criteria were defined simply and were optimized for surgical complications. Conclusions The JCOG postoperative complications cri- teria (JCOG PC criteria) aim to standardize the terms used to define adverse events (AEs) and provide detailed grading guidelines based on the Clavien-Dindo classification. We believe that the JCOG PC criteria will allow for more pre- cise comparisons of the frequency of postoperative compli- cations among trials across many different surgical fields. Keywords JCOG postoperative complications criteria (JCOG PC criteria) · Clavien-Dindo classification · Postoperative complications Introduction The evaluation of postoperative complications in surgi- cal trials is as important as the assessment of toxicities in chemotherapy trials. Prior to the proposal of a therapy-ori- ented classification scheme, by Clavien PA et al. in 1992 [1], there were no accepted definitions for the grading of surgical complications in clinical practice. This framework proposed by Clavien et al. was not used widely, because there was no system for the grading of severity of surgical complications [2] and no uniform definition of these events. For instance, some surgeons included a body tempera- ture greater than 38 °C on two consecutive days as being Abstract Purpose Prior to publication of the Clavien-Dindo clas- sification in 2004, there were no grading definitions for surgical complications in either clinical practice or surgical trials. This report establishes supplementary criteria for this classification to standardize the evaluation of postoperative complications in clinical trials. Methods The Japan Clinical Oncology Group (JCOG) commissioned a committee. Members from nine surgi- cal study groups (gastric, esophageal, colorectal, lung, breast, gynecologic, urologic, bone and soft tissue, and brain) specified postoperative complications experienced * Mitsuru Sasako [email protected] 1 Japan Clinical Oncology Group Data Center/Operations Office, Center for Research Administration and Support, National Cancer Center, Tokyo, Japan 2 Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Japan 3 Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan 4 Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan 5 Department of Surgery, Breast Oncology, National Hospital Organization, Osaka National Hospital, Osaka, Japan 6 Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan 7 Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan 8 Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan 9 Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan

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Page 1: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

Surg Today (2016) 46:668–685DOI 10.1007/s00595-015-1236-x

1 3

ORIGINAL ARTICLE

Extended Clavien‑Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria

Hiroshi Katayama1 · Yukinori Kurokawa2 · Kenichi Nakamura1 · Hiroyuki Ito3 · Yukihide Kanemitsu4 · Norikazu Masuda5 · Yasuhiro Tsubosa6 · Toyomi Satoh7 · Akira Yokomizo8 · Haruhiko Fukuda1 · Mitsuru Sasako9

Received: 24 April 2015 / Accepted: 14 June 2015 / Published online: 20 August 2015 © The Author(s) 2015. This article is published with open access at Springerlink.com

commonly in their fields and defined more detailed grading criteria for each complication in accordance with the gen-eral grading rules of the Clavien-Dindo classification.Results We listed 72 surgical complications experienced commonly in surgical trials, focusing on 17 gastroentero-logic complications, 13 infectious complications, six tho-racic complications, and several other complications. The grading criteria were defined simply and were optimized for surgical complications.Conclusions The JCOG postoperative complications cri-teria (JCOG PC criteria) aim to standardize the terms used to define adverse events (AEs) and provide detailed grading guidelines based on the Clavien-Dindo classification. We believe that the JCOG PC criteria will allow for more pre-cise comparisons of the frequency of postoperative compli-cations among trials across many different surgical fields.

Keywords JCOG postoperative complications criteria (JCOG PC criteria) · Clavien-Dindo classification · Postoperative complications

Introduction

The evaluation of postoperative complications in surgi-cal trials is as important as the assessment of toxicities in chemotherapy trials. Prior to the proposal of a therapy-ori-ented classification scheme, by Clavien PA et al. in 1992 [1], there were no accepted definitions for the grading of surgical complications in clinical practice. This framework proposed by Clavien et al. was not used widely, because there was no system for the grading of severity of surgical complications [2] and no uniform definition of these events. For instance, some surgeons included a body tempera-ture greater than 38 °C on two consecutive days as being

Abstract Purpose Prior to publication of the Clavien-Dindo clas-sification in 2004, there were no grading definitions for surgical complications in either clinical practice or surgical trials. This report establishes supplementary criteria for this classification to standardize the evaluation of postoperative complications in clinical trials.Methods The Japan Clinical Oncology Group (JCOG) commissioned a committee. Members from nine surgi-cal study groups (gastric, esophageal, colorectal, lung, breast, gynecologic, urologic, bone and soft tissue, and brain) specified postoperative complications experienced

* Mitsuru Sasako [email protected]

1 Japan Clinical Oncology Group Data Center/Operations Office, Center for Research Administration and Support, National Cancer Center, Tokyo, Japan

2 Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Japan

3 Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan

4 Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan

5 Department of Surgery, Breast Oncology, National Hospital Organization, Osaka National Hospital, Osaka, Japan

6 Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan

7 Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan

8 Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

9 Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan

Page 2: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

669Surg Today (2016) 46:668–685

1 3

“high”, whereas others included intraoperative complica-tions, postoperative complications (within 30 days), and late events such as dumping syndrome. Few randomized controlled trials (RCTs) [3] have used this classification system, with individual parochial definitions of surgical complications being used in most surgical RCTs [4–6].

In cancer clinical trials, adverse events (AEs) are evalu-ated in accordance with the Common Terminology Criteria for Adverse Events (CTCAE), which is far from exhaustive in terms of surgical complications; thus, some surgeons are not comfortable using grading definitions. The Clavien-Dindo classification, published in 2004 [7] defined a sim-ple classification of postoperative complications, which has been adopted widely in clinical practice. Although this clas-sification categorizes postoperative complications broadly into four major groups, it is often desirable to more clearly define the common AEs to avoid the use of different or less precise terms for the same AEs occurring in different clini-cal trials. More detailed grading criteria for common AEs would also be helpful for surgeons. Therefore, our aim was to establish supplementary criteria for the Clavien-Dindo classification to standardize the evaluation of postoperative complications.

Methods

The Japan Clinical Oncology Group (JCOG) commis-sioned a committee to establish more precise criteria for the grading of surgical complications. The committee com-prised members from nine JCOG study groups (gastric, esophageal, colorectal, lung, breast, gynecologic, urologic, bone and soft tissue, and brain) who have extensive expe-rience with surgical trials. These groups established the JCOG postoperative complications criteria (JCOG PC cri-teria). Members identified the postoperative complications experienced commonly in their fields and defined detailed grades for each complication in accordance with the gen-eral grading rules of the Clavien-Dindo classification. The JCOG PC criteria were reviewed and approved by the JCOG Executive Committee and published on the JCOG website in October, 2011 (in Japanese) [8].

Results

The JCOG PC criteria included 72 surgical AEs experi-enced commonly in surgical trials, including 17 gastroen-terological complications, 13 infectious complications, six thoracic complications, and several other complications (Table 1). If no applicable AE terms are found in the JCOG PC criteria, ‘other (specify)’ should be chosen. In such cases, the appropriate AE term should be used, and the

overall grading should be performed in accordance with the general rules of the Clavien-Dindo classification. Because the grading definitions follow the general rules of the Cla-vien-Dindo classification, surgeons can use these original rules to grade AEs, and can also refer to the more detailed definitions in the JCOG PC criteria if necessary. Table 2 lists the differences between CTCAE, the Clavien-Dindo classification, and the JCOG PC criteria.

Discussion

Until Clavien PA et al. published their original classifica-tion in 1992, there were no established criteria or frame-work available to standardize surgical complications in surgical trials. In 2003, the US National Cancer Institute-Common Toxicity Criteria (NCI-CTC) version 2.0 [9] were revised and renamed the CTCAE version 3.0 [10]. This system has been used widely to evaluate and define the toxicity of chemotherapy or radiotherapy. While terms and definitions for AEs occurring as a result of intraopera-tive and postoperative complications were not included in the NCI-CTC version 2.0, some surgical AE terms were incorporated in the CTCAE version 3.0. Nevertheless, the CTCAE version 3.0 failed to include many surgical com-plications and surgeons were frequently unable to objec-tively classify complications using its grading definitions.

In 2009, the CTCAE version 4.0 [11] was released, with considerably more surgical AE terms, but several common surgical complications were still not included. For exam-ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading definitions were not clinically optimized for some surgical AEs. For example, the grading defini-tion of pancreatic fistula in this version of the CTCAE is suitable for pancreatitis, but not for pancreatic fistula after pancreatectomy. Such inappropriate definitions have made surgeons reluctant to use the CTCAE version 4.0 in surgi-cal trials.

In 2004, the Clavien-Dindo classification was modified to allow for the grading of life-threatening complications and long-term disability caused by a complication. This revised version defines five grades of severity (Grade I, II, IIIa, IIIb, IVa, IVb, and V) and the suffix “d” (for “disabil-ity”) is used to denote any postoperative impairment [7]. This refined Clavien-Dindo classification has been used increasingly in clinical practice and also in clinical trials involving surgical procedures, because it is simple, repro-ducible, and flexible [12]. Rather than providing specific grading criteria for each AE, the Clavien-Dindo classifica-tion provides broad-based but general criteria that can be used uniformly for all kinds of surgical AEs. However, sev-eral issues have emerged since this classification became

Page 3: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

670 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

Lis

t of

surg

ical

adv

erse

eve

nt (

AE

) te

rms

and

grad

ings

Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

AE

term

Any

dev

iatio

n fr

om th

e no

rmal

pos

tope

rativ

e co

urse

with

out t

he n

eed

for

phar

mac

olog

ical

tr

eatm

ent o

r su

rgic

al,

endo

scop

ic, o

r ra

dio-

logi

cal i

nter

vent

ions

. A

llow

ed th

erap

eutic

re

gim

ens

incl

ude

drug

s su

ch a

s an

tiem

etic

s,

antip

yret

ics,

ana

lges

ics,

di

uret

ics,

ele

ctro

lyte

s,

and

phys

ioth

erap

y. T

his

grad

e al

so in

clud

es

wou

nd in

fect

ions

op

ened

at t

he b

edsi

de

Req

uire

men

t for

ph

arm

acol

ogic

al

trea

tmen

t with

dr

ugs

othe

r th

an

thos

e al

low

ed f

or

grad

e I

com

plic

a-tio

nsB

lood

tran

sfus

ions

an

d to

tal p

aren

-te

ral n

utri

tion

are

also

incl

uded

Req

uire

men

t for

su

rgic

al, e

ndos

copi

c or

rad

iolo

gica

l int

er-

vent

ion

not u

nder

ge

nera

l ane

sthe

sia

Req

uire

men

t fo

r su

rgic

al,

endo

scop

ic o

r ra

diol

ogic

al

inte

rven

tion

unde

r ge

nera

l an

esth

esia

Lif

e-th

reat

enin

g co

mpl

icat

ions

(i

nclu

ding

CN

S co

mpl

icat

ions

)*

requ

irin

g IC

/IC

U

man

agem

ent.

Sing

le o

rgan

dys

-fu

nctio

n (i

nclu

ding

di

alys

is)

Lif

e-th

reat

enin

g co

m-

plic

atio

ns (

incl

udin

g C

NS

com

plic

atio

ns)*

re

quir

ing

IC/I

CU

m

anag

emen

t. M

ul-

tiple

org

an d

ysfu

nc-

tion

Dea

th

of th

e pa

tient

If th

e pa

tient

suf

fers

fr

om a

com

plic

a-tio

n at

the

time

of

disc

harg

e, th

e su

f-fix

“d”

(fo

r “d

is-

abili

ty”)

is a

dded

to

the

resp

ectiv

e gr

ade

of c

ompl

i-ca

tion.

Thi

s la

bel

indi

cate

s th

e ne

ed

for

a fo

llow

-up

to

fully

eva

luat

e th

e co

mpl

icat

ion

Stro

keC

linic

al o

bser

vatio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

ticoa

gu-

lant

ther

apy)

Rad

iolo

gica

l int

erve

n-tio

n w

ithou

t gen

eral

an

esth

esia

(e.

g.,

intr

acer

ebro

vasc

ular

tr

eatm

ent)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

drai

nage

, su

rgic

al c

lippi

ng,

cere

brov

ascu

lar

bypa

ss, c

arot

id

enda

rter

ecto

my)

IC/I

CU

man

agem

ent

indi

cate

dIC

/IC

U m

anag

emen

t in

dica

ted;

ass

oci-

ated

with

res

pira

tory

fa

ilure

Dea

thPe

rsis

tent

hem

i-pl

egia

Rec

urre

nt

lary

ngea

l ne

rve

pals

y

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Asp

irat

ion;

med

i-ca

l man

agem

ent

indi

cate

d (e

.g.,

antib

iotic

s)

Seve

re a

spir

atio

n;

food

inta

ke a

lmos

t im

poss

ible

; med

ical

in

terv

entio

n un

der

loca

l ane

sthe

sia

indi

cate

d (e

.g.,

voca

l cor

d in

ject

ion,

tr

ache

al p

unct

ure)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (i

nclu

ding

tra-

cheo

stom

y un

der

seda

tion)

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thH

oars

enes

s, d

iffi-

culty

in s

peak

ing;

co

mm

unic

atio

n th

roug

h w

rit-

ing

nece

ssar

y;

disc

harg

ed w

ith

trac

heos

tom

y

Upp

er e

xtre

m-

ity p

ares

the-

sia

Clin

ical

obs

erva

tion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

edSu

rgic

al in

terv

entio

n w

ithou

t gen

eral

an

esth

esia

indi

cate

d (e

.g.,

nerv

e bl

ock)

––

––

Pers

iste

nt b

rach

ial

pare

sthe

sia

Pare

sthe

sia

in

rese

cted

par

t (P

hant

om

pain

)

Clin

ical

obs

erva

tion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

edSu

rgic

al in

terv

entio

n w

ithou

t gen

eral

an

esth

esia

indi

cate

d (e

.g.,

nerv

e bl

ock)

––

––

Pers

iste

nt p

hant

om

pain

Page 4: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

671Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Isch

emic

hea

rt

dise

ase

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

ticoa

gu-

lant

ther

apy)

Car

diac

cat

hete

riza

-tio

n in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (c

oron

ary

arte

ry

bypa

ss)

Hea

rt f

ailu

re a

ssoc

i-at

ed w

ith lo

w

card

iac

outp

ut

synd

rom

e; I

C/

ICU

man

agem

ent

indi

cate

d

Hea

rt f

ailu

re a

ssoc

i-at

ed w

ith lo

w c

ardi

ac

outp

ut s

yndr

ome

and

rena

l fai

lure

; IC

/IC

U m

anag

emen

t in

dica

ted

Dea

thPe

rsis

tent

hea

rt

failu

re f

ollo

win

g m

yoca

rdia

l inf

arc-

tion

Peri

card

ial

effu

sion

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d (d

rain

age

only

th

roug

h ex

istin

g dr

ain-

age

tube

)

Med

ical

man

age-

men

t ind

icat

edIm

age-

guid

ed d

rain

pl

acem

ent/p

ara-

cent

esis

incl

udin

g dr

ain

repl

acem

ent

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (f

enes

trat

ion)

Car

diac

tam

pona

de;

IC/I

CU

man

age-

men

t ind

icat

ed

Car

diac

tam

pona

de

and

rena

l fai

lure

; IC

/IC

U m

anag

emen

t in

dica

ted

Dea

th–

Bra

dyar

rhyt

h-m

iaC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., at

ropi

ne, β

ag

onis

ts)

Med

ical

inte

rven

-tio

n un

der

loca

l an

esth

esia

indi

cate

d (e

.g.,

pace

mak

er

impl

anta

tion)

–H

eart

fai

lure

ass

oci-

ated

with

low

ca

rdia

c ou

tput

sy

ndro

me;

IC

/IC

U m

anag

emen

t in

dica

ted

Hea

rt f

ailu

re a

ssoc

i-at

ed w

ith lo

w c

ardi

ac

outp

ut s

yndr

ome

and

rena

l fai

lure

; IC

/IC

U m

anag

emen

t in

dica

ted

Dea

th–

Supr

aven

tric

u-la

r ar

rhyt

h-m

ia

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tiarr

hyth

-m

ic d

rugs

)

Med

ical

inte

rven

-tio

n un

der

loca

l an

esth

esia

indi

cate

d (e

.g.,

cath

eter

abl

a-tio

n, s

ynch

roni

zed

card

iove

rsio

n)

–H

eart

fai

lure

ass

oci-

ated

with

low

ca

rdia

c ou

tput

sy

ndro

me;

IC

/IC

U m

anag

emen

t in

dica

ted

Hea

rt f

ailu

re a

ssoc

i-at

ed w

ith lo

w c

ardi

ac

outp

ut s

yndr

ome

and

rena

l fai

lure

; IC

/IC

U m

anag

emen

t in

dica

ted

Dea

th–

Ven

tric

ular

ar

rhyt

hmia

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tiarr

hyth

-m

ic d

rugs

)

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

cath

eter

abl

atio

n,

exte

rnal

defi

brill

ator

, pa

cem

aker

impl

anta

-tio

n)

–H

eart

fai

lure

ass

oci-

ated

with

low

ca

rdia

c ou

tput

sy

ndro

me;

IC

/IC

U m

anag

emen

t in

dica

ted

Hea

rt f

ailu

re a

ssoc

i-at

ed w

ith lo

w c

ardi

ac

outp

ut s

yndr

ome

and

rena

l fai

lure

; IC

/IC

U m

anag

emen

t in

dica

ted

Dea

th–

Ate

lect

asis

/sp

utum

ex

cret

ion

dif-

ficul

ty

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d, e

xcep

t for

ne

buliz

ers,

exp

ecto

rant

s,

or lu

ng p

hysi

othe

rapy

(e

.g.,

post

ural

dra

inag

e)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Bro

ncho

scop

ic a

spir

a-tio

n or

sur

gica

l in

terv

entio

n in

di-

cate

d (e

.g.,

trac

heal

pu

nctu

re)

with

out

gene

ral a

nest

hesi

a

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (i

nclu

ding

tra-

cheo

stom

y un

der

seda

tion)

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

trac

heos

tom

y

Page 5: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

672 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Tra

chea

l fis

tula

, bro

n-ch

ial fi

stul

a

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

–Pr

oced

ure

unde

r lo

cal

anes

thes

ia in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

tube

dra

inag

e,

open

dra

inag

e

Pulm

onar

y fis

tula

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d (d

rain

age

only

th

roug

h ex

istin

g dr

ain-

age

tube

)

–Pr

oced

ure

unde

r lo

cal

anes

thes

ia in

dica

ted

(e.g

., ch

est t

ube

drai

nage

, ple

u-ro

desi

s) in

clud

ing

drai

n re

plac

emen

t in

dica

ted.

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (C

losu

re f

or

pleu

ropa

ren-

chym

al d

efec

ts,

pleu

rode

sis)

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

tube

dra

inag

e,

open

dra

inag

e

Chy

loth

orax

Obs

erva

tion

of c

hy-

lous

dra

inag

e flu

id o

r th

orac

ente

sis

fluid

onl

y (d

rain

age

only

thro

ugh

exis

ting

drai

nage

tube

)

Fat-

rest

rict

ed d

iet,

intr

aven

ous

nutr

i-tio

n in

dica

ted

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

thor

acic

du

ct li

gatio

n)

––

Dea

thPe

rsis

tent

res

-pi

rato

ry d

istr

ess,

m

alnu

triti

on

Pleu

ral e

ffus

ion

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d (d

rain

age

only

th

roug

h ex

istin

g dr

ain-

age

tube

)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., di

uret

ics)

Imag

e-gu

ided

dra

in

plac

emen

t/tho

ra-

cent

esis

incl

udin

g dr

ain

repl

acem

ent

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Mul

tiple

org

an f

ailu

reD

eath

Pers

iste

nt r

espi

ra-

tory

dis

tres

s

Lun

g to

rsio

n–

––

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

deto

rsio

n,

lobe

ctom

y)

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

th–

Asc

ites

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d (d

rain

age

only

th

roug

h ex

istin

g dr

ain-

age

tube

)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., di

uret

ics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

Dea

thPe

rsis

tent

abd

omi-

nal f

ulln

ess

Page 6: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

673Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Dia

rrhe

aIn

test

inal

flui

d ex

cre-

tion ≥

2000

ml/d

ay;

inte

rven

tion

not i

ndi-

cate

d

Inte

stin

al

fluid

exc

re-

tion ≥

2000

ml/

day

asso

ciat

ed

with

deh

ydra

tion

or e

lect

roly

te

abno

rmal

ity;

intr

aven

ous

fluid

s in

dica

ted

––

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thSi

gnifi

cant

am

ount

of

per

sist

ent

inte

stin

al fl

uid

excr

etio

n

Dys

phag

iaC

linic

al o

bser

vatio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Ent

eral

/intr

ave-

nous

nut

ritio

n (I

nclu

ding

TPN

) in

dica

ted

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

trac

heal

pun

ctur

e,

endo

scop

ic g

astr

os-

tom

y)

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

Dea

thG

astr

osto

my

Inte

stin

al

fistu

laC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

(dra

inag

e on

ly

thro

ugh

exis

ting

drai

n-ag

e tu

be)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (c

olos

tom

y)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

re

nal d

isor

ders

in

dica

ting

dial

ysis

)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

ent

eroc

u-ta

neou

s fis

tula

Inte

stin

al

isch

emia

/ne

cros

is

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Rad

iolo

gica

l int

erve

n-tio

n/en

dosc

opic

/su

rgic

al in

terv

en-

tion

with

out g

ener

al

anes

thes

ia in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

inte

stin

al

rese

ctio

n)

At l

east

one

org

an

failu

re (

e.g.

, pu

lmon

ary

diso

rder

s in

dica

t-in

g m

echa

nica

l ve

ntila

tion

or r

enal

di

sord

ers

indi

cat-

ing

dial

ysis

)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thH

ome

ente

ral/i

ntra

-ve

nous

nut

ritio

n

Gas

tric

tube

ne

cros

isO

bser

vatio

n of

a s

mal

l fis

tula

with

ora

l con

tras

t st

udy

or d

rain

age

imag

ing

(dra

inag

e on

ly

thro

ugh

exis

ting

drai

n-ag

e tu

be)

Med

ical

man

age-

men

t (e.

g., a

nti-

biot

ics)

, ent

eral

/in

trav

enou

s nu

tri-

tion

indi

cate

d

Rad

iolo

gica

l int

erve

n-tio

n/en

dosc

opic

/el

ectiv

e su

rgic

al

inte

rven

tion

with

out

gene

ral a

nest

hesi

a in

dica

ted,

incl

udin

g dr

ain

repl

acem

ent

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

th

Page 7: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

674 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Refl

ux

esop

hagi

tisC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

-ag

emen

t (e.

g.,

PPI,

pan

crea

tic

enzy

me

inac

tiva-

tors

) or

ent

eral

/in

trav

enou

s nu

tri-

tion

indi

cate

d

–In

terv

entio

n un

der

gene

ral a

nest

he-

sia

indi

cate

d

––

Dea

thPe

rsis

tent

hea

rtbu

rn

Ileu

s (p

aral

ytic

)C

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; med

ical

man

age-

men

t not

indi

cate

d ex

cept

for

laxa

tives

and

in

trav

enou

s nu

triti

on

Med

ical

man

age-

men

t bey

ond

laxa

tives

, NG

tu

be p

lace

men

t, or

in

trav

enou

s nu

tri-

tion

man

agem

ent

indi

cate

d

Nas

oent

eric

tube

pl

acem

ent

Tre

atm

ent f

or il

eus

unde

r ge

nera

l an

esth

esia

(w

ith

or w

ithou

t int

esti-

nal r

esec

tion)

Ext

ensi

ve in

test

inal

ne

cros

is, a

t lea

st

one

orga

n fa

ilure

(e

.g.,

pulm

onar

y di

sord

ers

requ

irin

g m

echa

nica

l ven

ti-la

tion

or n

ephr

opa-

thy

indi

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thH

ome

intr

aven

ous

nutr

ition

Panc

reat

ic

fistu

laO

n or

aft

er p

osto

pera

tive

day

3, d

rain

age

fluid

am

ylas

e le

vel ≥

3 tim

es th

e up

per

limit

of in

stitu

tiona

l cri

teri

a,

but i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

, en

tera

l/int

rave

-no

us n

utri

tion

indi

cate

d

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual p

ancr

eatic

ps

eudo

cyst

on

CT,

oc

casi

onal

fev

er,

or a

bdom

inal

pai

n

Inte

stin

al

obst

ruct

ion

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; m

edic

al m

anag

e-m

ent n

ot in

dica

ted

exce

pt f

or la

xativ

es a

nd

intr

aven

ous

nutr

ition

Med

ical

man

age-

men

t bey

ond

laxa

tives

, NG

tu

be p

lace

men

t, or

in

trav

enou

s nu

tri-

tion

man

agem

ent

indi

cate

d

Nas

oent

eric

tube

pl

acem

ent

Tre

atm

ent f

or il

eus

unde

r ge

nera

l an

esth

esia

(w

ith

or w

ithou

t int

esti-

nal r

esec

tion)

Ext

ensi

ve in

test

inal

ne

cros

is, a

t lea

st

one

orga

n fa

ilure

(e

.g.,

pulm

onar

y di

sord

ers

requ

irin

g m

echa

nica

l ven

ti-la

tion

or n

ephr

opa-

thy

indi

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thH

ome

intr

aven

ous

nutr

ition

Del

ayed

gas

tric

em

ptyi

ngC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t (e.

g., p

eri-

stal

sis

stim

ulat

-in

g dr

ugs)

, NG

tu

be p

lace

men

t, en

tera

l/int

rave

-no

us n

utri

tion

indi

cate

d

–In

terv

entio

n un

der

gene

ral a

nest

he-

sia

indi

cate

d

––

Dea

thPe

rsis

tent

pos

tpra

n-di

al n

ause

a

Page 8: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

675Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Dum

ping

sy

ndro

me

Clin

ical

obs

erva

tion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed–

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

Dea

thPe

rsis

tent

dum

ping

sy

mpt

om

Bili

ary

fistu

laC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

(dra

inag

e on

ly

thro

ugh

exis

ting

drai

n-ag

e tu

be)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual p

seud

ocys

t on

CT;

occ

asio

nal

feve

r or

abd

omi-

nal p

ain

Cho

lecy

stiti

sC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; med

ical

man

age-

men

t not

indi

cate

d ex

cept

for

cho

lago

gues

Med

ical

man

age-

men

t bey

ond

chol

agog

ues

indi

cate

d

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

Perc

utan

eous

tran

-sh

epat

ic g

allb

ladd

er

drai

nage

)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (c

hole

cyst

ec-

tom

y)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thO

ccas

iona

l fev

er o

r ab

dom

inal

pai

n

Gas

troi

ntes

tinal

an

asto

mot

ic

leak

Onl

y sm

all fi

stul

a ob

serv

ed o

n or

al c

on-

tras

t stu

dy o

r dr

aina

ge

imag

ing

(dra

inag

e on

ly

thro

ugh

exis

ting

drai

n-ag

e tu

be)

Med

ical

man

age-

men

t (e.

g., a

ntib

i-ot

ics)

or

ente

ral/

intr

aven

ous

nutr

i-tio

n (I

nclu

ding

T

PN)

indi

cate

d

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

wou

nd o

peni

ng o

r dr

ain

repl

acem

ent

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

sutu

re,

rean

asto

mos

is,

bypa

ss, d

rain

age,

co

lost

omy)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thH

ome

ente

ral/i

ntra

-ve

nous

nut

ritio

n

Ure

teri

c in

jury

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Tra

nsur

ethr

al u

rete

ral

sten

t ins

ertio

n or

per

cuta

neou

s ne

phro

stom

y

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

Acu

te r

enal

fai

lure

, he

mod

ialy

sis

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

uret

eral

ste

nt

Ure

thra

l inj

ury

Fole

y ca

thet

er p

lace

men

tM

edic

al m

anag

e-m

ent i

ndic

ated

(e

.g.,

antib

iotic

s)

Inte

rven

tion

unde

r lo

cal o

r lu

mba

r an

esth

esia

indi

cate

d (e

.g.,

perc

utan

eous

cy

stos

tom

y)

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

Fole

y ca

thet

er

plac

emen

t

Page 9: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

676 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Post

oper

ativ

e he

mor

rhag

eC

ontr

olla

ble

with

com

-pr

essi

on o

nly

Blo

od tr

ansf

usio

n or

med

ical

man

-ag

emen

t ind

icat

ed

Surg

ical

hem

osta

sis

unde

r lo

cal a

nest

he-

sia

or e

ndos

copi

c an

d ra

diol

ogic

al

inte

rven

tion

hem

o-st

asis

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (h

emos

tasi

s)

Sing

le o

rgan

fai

lure

; st

epdo

wn

ICU

/IC

U

care

indi

cate

d

Mul

tiple

org

an f

ailu

re;

IC/I

CU

man

agem

ent

indi

cate

d

Dea

thPe

rsis

tent

ane

mia

Sero

ma

(Acc

umul

atio

n of

ser

ous

fluid

)

Bed

side

par

acen

tesi

s on

ly

(dra

inag

e on

ly th

roug

h ex

istin

g dr

aina

ge tu

be)

–Im

age-

guid

ed d

rain

pl

acem

ent/p

ara-

cent

esis

incl

udin

g dr

ain

repl

acem

ent

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thE

xuda

te le

akag

e fr

om w

ound

, oc

casi

onal

fev

er

and

infe

ctio

n,

disc

harg

ed w

ith

drai

nage

tube

Ute

rine

ana

sto-

mot

ic le

akC

linic

al o

r va

gina

l obs

er-

vatio

n on

ly; i

nter

vent

ion

not i

ndic

ated

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

–In

terv

entio

n un

der

gene

ral a

nes-

thes

ia in

dica

ted

(res

utur

ing)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

leak

age

from

ute

rova

gina

l an

asto

mos

is d

ue

to s

utur

e fa

ilure

(s

urgi

cal u

nion

of

two

diff

eren

t ana

-to

mic

al s

truc

ture

s)

Abd

omin

al

inci

sion

al

hern

ia

Clin

ical

obs

erva

tion

only

; in

terv

entio

n no

t ind

i-ca

ted

exce

pt f

or tr

uss

and

NSA

IDs

Med

ical

man

age-

men

t bey

ond

trus

s an

d N

SAID

s in

dica

ted

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (m

esh,

fas

cial

re

sutu

ring

)

Ext

ensi

ve in

test

inal

ne

cros

is, a

t lea

st

one

orga

n fa

ilure

(e

.g.,

pulm

onar

y di

sord

ers

requ

irin

g m

echa

nica

l ven

ti-la

tion

or n

ephr

opa-

thy

indi

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thIn

test

inal

pro

laps

e up

on in

crea

sed

intr

a-ab

dom

inal

pr

essu

re

Wou

nd d

ehis

-ce

nce

Clin

ical

obs

erva

tion

only

; in

terv

entio

n no

t ind

i-ca

ted

exce

pt f

or w

ound

ir

riga

tion

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

resu

turi

ng)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

resu

turi

ng)

Ext

ensi

ve in

test

inal

ne

cros

is, a

t lea

st

one

orga

n fa

ilure

(e

.g.,

pulm

onar

y di

sord

ers

requ

irin

g m

echa

nica

l ven

ti-la

tion

or n

ephr

opa-

thy

indi

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

sign

ifica

nt w

ound

de

hisc

ence

Page 10: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

677Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Gas

troi

ntes

tinal

an

asto

mot

ic

sten

osis

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Ent

eral

/intr

ave-

nous

nut

ritio

n (I

nclu

ding

TPN

) in

dica

ted

Bal

loon

dila

tatio

n,

sten

ting,

mag

netic

co

mpr

essi

on a

nast

o-m

osis

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

rean

asto

-m

osis

, byp

ass)

––

Dea

thFr

eque

nt o

utpa

tient

en

dosc

opic

dila

ta-

tion

Intr

aabd

omin

al

absc

ess

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on C

T, o

ccas

iona

l fe

ver

or a

bdom

i-na

l pai

n

Pelv

ic a

bsce

ssC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on C

T, o

ccas

iona

l fe

ver

or a

bdom

i-na

l pai

n

Pneu

mon

iaC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

exce

pt f

or

nebu

lizer

s, e

xpec

tora

nts,

or

lung

phy

siot

hera

py

(e.g

., po

stur

al d

rain

age)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Bro

ncho

scop

ic

aspi

ratio

n, tr

ache

al

punc

ture

Tra

cheo

stom

y un

der

gene

ral

anes

thes

ia/s

eda-

tion

or m

echa

ni-

cal v

entil

atio

n

Mec

hani

cal v

entil

a-tio

n in

dica

ted

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

res

-pi

rato

ry d

istr

ess,

oc

casi

onal

fev

er

Med

iast

initi

sC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on C

T im

ages

, oc

casi

onal

fev

er

or a

bdom

inal

pai

n

Pyot

hora

xC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on C

T im

ages

or

disc

harg

ed w

ith

tube

dra

inag

e,

open

dra

inag

e

Page 11: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

678 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Low

er

extr

emity

ly

mph

angi

tis(L

ymph

nod

e in

fect

ion)

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

-tio

n un

der

loca

l an

esth

esia

indi

cate

d (l

ymph

atic

ana

sto-

mos

is)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (l

ymph

atic

an

asto

mos

is)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

–Pe

rsis

tent

ede

ma

Infe

cted

lym

-ph

ocel

e(R

etro

peri

to-

neal

abs

cess

)

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Dra

inag

e un

der

loca

l ane

sthe

sia

or

with

out a

nest

hesi

a in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (i

ncis

ion

and

drai

nage

)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on im

agin

g st

udy,

oc

casi

onal

fev

er

or a

bdom

inal

pai

n

Infe

ctio

us

cerv

iciti

sC

linic

al o

r va

gina

l obs

er-

vatio

n on

ly; i

nter

vent

ion

not i

ndic

ated

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Dra

inag

e un

der

loca

l ane

sthe

sia

or

with

out a

nest

hesi

a in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age,

hys

ter-

ecto

my)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

infe

cted

va

gina

l dis

char

ge

Ute

rine

infe

c-tio

nC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Dila

tion

and

cure

ttage

un

der

loca

l ane

s-th

esia

or

with

out

anes

thes

ia in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age,

hys

ter-

ecto

my)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on im

agin

g st

udy,

oc

casi

onal

fev

er

or a

bdom

inal

pai

n

Ova

rian

infe

c-tio

nC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Para

cent

esis

dra

inag

e un

der

loca

l ane

sthe

-si

a in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age,

oop

ho-

rect

omy)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on im

agin

g st

udy,

oc

casi

onal

fev

er

or a

bdom

inal

pai

n

Page 12: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

679Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Vul

val i

nfec

-tio

nC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Para

cent

esis

dra

inag

e un

der

loca

l ane

sthe

-si

a in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (d

rain

age,

ski

n fla

p, o

r m

uscu

-lo

cuta

neou

s fla

p)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thR

esid

ual a

bsce

ss

on im

agin

g st

udy,

oc

casi

onal

fev

er

or a

bdom

inal

pai

n

Wou

nd in

fec-

tion

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d, e

xcep

t for

w

ound

ope

ning

and

w

ound

irri

gatio

n at

the

beds

ide

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

drai

nage

)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

drai

nage

, re

sutu

ring

)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thC

ontin

ued

outp

a-tie

nt ir

riga

tion

Impl

ant i

nfec

-tio

nC

linic

al o

bser

vatio

n or

di

agno

stic

eva

luat

ion

only

; int

erve

ntio

n no

t in

dica

ted

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

-tio

n un

der

loca

l an

esth

esia

indi

cate

d (e

.g.,

inci

sion

and

dr

aina

ge, i

mpl

ant

rem

oval

)

Inte

rven

tion

unde

r ge

nera

l an

esth

esia

indi

-ca

ted

(im

plan

t re

mov

al)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

drai

nage

tube

pl

acem

ent;

pers

is-

tent

infe

ctio

n

Bla

dder

inju

ryFo

ley

cath

eter

pla

cem

ent

indi

cate

dM

edic

al m

anag

e-m

ent i

ndic

ated

(e

.g.,

antib

iotic

s)

–In

terv

entio

n un

der

gene

ral a

nest

he-

sia

indi

cate

d

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thD

isch

arge

d w

ith

Fole

y ca

thet

er

plac

emen

t

Uri

nary

inco

n-tin

ence

Inte

rmitt

ent c

athe

teri

za-

tion

or F

oley

cat

hete

r pl

acem

ent i

ndic

ated

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

ticho

lin-

ergi

cs)

Inte

rven

tion

unde

r lo

cal o

r lu

mba

r an

esth

esia

indi

cate

d (e

.g.,

clam

p, c

ol-

lage

n in

ject

ion)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

artifi

cial

ur

inar

y sp

hinc

ter)

Acu

te r

enal

fai

lure

, he

mod

ialy

sis

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

con

ditio

n re

quir

ing

Inte

rmit-

tent

cat

hete

riza

-tio

n; D

isch

arge

d w

ith F

oley

cat

h-et

er p

lace

men

t

Page 13: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

680 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Res

idua

l uri

ne/

Uri

nary

re

tent

ion

Inte

rmitt

ent c

athe

teri

za-

tion

or F

oley

cat

hete

r pl

acem

ent i

ndic

ated

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., ch

olin

er-

gics

)

Inte

rven

tion

unde

r lo

cal o

r lu

mba

r an

esth

esia

indi

cate

d (e

.g.,

endo

scop

ic

trea

tmen

t, ur

ethr

al

dila

tatio

n)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

fistu

la

clos

ure)

Acu

te r

enal

fai

lure

, he

mod

ialy

sis

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

con

ditio

n re

quir

ing

inte

rmit-

tent

cat

hete

riza

-tio

n; D

isch

arge

d w

ith F

oley

cat

h-et

er p

lace

men

t

Dys

pare

unia

Dis

com

fort

ass

ocia

ted

with

vag

inal

pen

etra

-tio

n; in

terv

entio

n no

t in

dica

ted

Est

roge

n ad

min

is-

trat

ion

indi

cate

dM

edic

al in

terv

entio

n un

der

loca

l ane

sthe

-si

a in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

–Pe

rsis

tent

pai

n as

soci

ated

with

se

xual

inte

rcou

rse,

pe

rsis

tent

dys

-pa

reun

ia

Ere

ctile

dys

-fu

nctio

nE

rect

ile d

ysfu

nctio

n;

inte

rven

tion

not

indi

cate

d, e

xcep

t for

ex

tern

al v

acuu

m d

evic

e fo

r m

anag

ing

erec

tile

dysf

unct

ion

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., Ph

osph

odi-

este

rase

5 in

hibi

-to

rs o

r in

trac

av-

erno

sal i

njec

tion

of v

asoa

ctiv

e ag

onis

ts)

Inte

rven

tion

unde

r lo

cal o

r lu

mba

r an

es-

thes

ia in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (e

.g.,

peni

le

pros

thes

is)

––

–Pe

rsis

tent

ere

ctile

dy

sfun

ctio

n

Cer

vica

l atr

esia

(u

teri

ne

atre

sia)

Clin

ical

or

vagi

nal o

bser

-va

tion

only

; int

erve

ntio

n no

t ind

icat

ed

Ass

ocia

ted

with

dy

smen

orrh

ea;

med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

alge

sics

)

Bou

gien

age

of c

ervi

-ca

l duc

t with

or

with

out l

ocal

ane

s-th

esia

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

(cer

-vi

cal d

ilata

tion)

––

–Pe

rsis

tent

ste

nosi

s of

the

cerv

ical

os

Vag

inal

fist

ula

Clin

ical

or

vagi

nal o

bser

-va

tion

only

; int

erve

ntio

n no

t ind

icat

ed

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

–In

terv

entio

n un

der

gene

ral a

nes-

thes

ia in

dica

ted

(vag

inal

fist

ula

clos

ure,

col

os-

tom

y)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thPe

rsis

tent

leak

age

from

vag

ina

Ova

rian

de

ficie

ncy

synd

rom

e

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., ho

rmon

e re

plac

emen

t th

erap

y)

––

––

Dea

thH

ot fl

ash

requ

irin

g co

ntin

ued

hor-

mon

e re

plac

emen

t th

erap

y, d

epre

s-si

on r

equi

ring

co

ntin

ued

psyc

hi-

atri

c ca

re

Page 14: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

681Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Cer

vica

l chy

-lo

us le

akag

eO

bser

vatio

n of

chy

lous

dr

aina

ge fl

uid

or p

ara-

cent

esis

flui

d on

ly; i

nter

-ve

ntio

n no

t ind

icat

ed

(dra

inag

e on

ly th

roug

h ex

istin

g dr

aina

ge tu

be)

Fat-

rest

rict

ed d

iet,

intr

aven

ous

nutr

i-tio

n in

dica

ted

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted.

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

Dea

thPe

rsis

tent

sen

satio

n of

pre

ssur

e in

the

neck

Sero

us le

akag

eC

linic

al o

bser

vatio

n on

ly; i

nter

vent

ion

not

indi

cate

d (d

rain

age

only

th

roug

h ex

istin

g dr

ain-

age

tube

)

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thE

xuda

te le

akag

e fr

om th

e w

ound

, oc

casi

onal

fev

er

and

infe

ctio

n,

disc

harg

ed w

ith

drai

nage

tube

Chy

lous

asc

ites

Obs

erva

tion

of c

hylo

us

drai

nage

flui

d or

par

a-ce

ntes

is fl

uid

only

; int

er-

vent

ion

not i

ndic

ated

(d

rain

age

only

thro

ugh

exis

ting

drai

nage

tube

)

Fat-

rest

rict

ed d

iet,

intr

aven

ous

nutr

i-tio

n in

dica

ted

Imag

e-gu

ided

dra

in

plac

emen

t/par

a-ce

ntes

is in

clud

ing

drai

n re

plac

emen

t in

dica

ted

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

Dea

thPe

rsis

tent

abd

omi-

nal f

ulln

ess

Subc

utan

eous

ph

lebi

tis

(Mon

dor

dise

ase)

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d ex

cept

for

N

SAID

s

Opi

oid

adm

inis

tra-

tion,

or

trea

tmen

t by

pai

n co

ntro

l sp

ecia

list i

ndi-

cate

d

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

–Su

rgic

al s

ite s

ubcu

-ta

neou

s ph

lebi

tis;

cord

-lik

e m

ass

Thr

ombo

sis/

embo

lism

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

ticoa

gu-

lant

s)

Inva

sive

trea

tmen

t in

dica

ted

(e.g

., th

rom

bus

abla

tion

via

cath

eter

, IV

C

filte

r)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (p

ulm

onar

y ar

tery

thro

mbe

c-to

my)

Sing

le o

rgan

fai

lure

ca

used

by

thro

mbi

(e

.g.,

lung

, bra

in,

hear

t)

Mul

tiple

org

an f

ailu

re

caus

ed b

y th

rom

bi

(e.g

., lu

ng, b

rain

, he

art)

Dea

thD

yspn

ea f

ollo

win

g pu

lmon

ary

infa

rc-

tion,

par

alys

is

follo

win

g ce

rebr

al

infa

rctio

n

Res

tric

ted

shou

lder

jo

int r

ange

of

mot

ion

Clin

ical

obs

erva

tion

only

; int

erve

ntio

n no

t in

dica

ted

exce

pt f

or

NSA

IDs

Opi

oid

adm

inis

tra-

tion,

or

trea

tmen

t by

pai

n co

ntro

l sp

ecia

list i

ndi-

cate

d

Surg

ical

inte

rven

tion

with

out g

ener

al

anes

thes

ia in

dica

ted

(e.g

., ne

rve

bloc

k)

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

–C

ontin

ued

rest

ric-

tion

in th

e ra

nge

of m

otio

n of

the

shou

lder

join

t

Page 15: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

682 Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Fat n

ecro

sis

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d ex

cept

for

w

ound

ope

ning

and

w

ound

irri

gatio

n at

the

beds

ide

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

-tio

n un

der

loca

l an

esth

esia

indi

cate

d (e

.g.,

inci

sion

and

dr

aina

ge)

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thW

ound

fat

nec

rosi

s,

occa

sion

al c

icat

ri-

zatio

n, f

ever

or

infe

ctio

n

Skin

nec

rosi

s (fl

ap n

ecro

-si

s)

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., an

tibio

tics)

Med

ical

inte

rven

tion

unde

r lo

cal a

nest

he-

sia

indi

cate

d (e

.g.,

debr

idem

ent,

skin

gr

aftin

g)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (s

kin

graf

ting)

At l

east

one

org

an

failu

re (

e.g.

, pul

-m

onar

y di

sord

ers

requ

irin

g m

echa

ni-

cal v

entil

atio

n or

ne

phro

path

y in

di-

catin

g di

alys

is)

Seps

is o

r m

ultip

le

orga

n fa

ilure

Dea

thIn

suffi

cien

t epi

the-

lializ

atio

n, p

ersi

s-te

nt in

fect

ion

Subc

utan

eous

em

phys

ema

Clin

ical

obs

erva

tion

or

diag

nost

ic e

valu

atio

n on

ly; i

nter

vent

ion

not

indi

cate

d ex

cept

for

sub

-cu

tane

ous

punc

ture

and

co

mpr

essi

on w

ith b

reas

t ba

nd a

t the

bed

side

–R

adio

logi

cal i

nter

-ve

ntio

n tr

eatm

ent

with

out g

ener

al

anes

thes

ia in

dica

ted

(e.g

., su

bcut

aneo

us

drai

n in

sert

ion)

Inte

rven

tion

unde

r ge

nera

l ane

sthe

-si

a in

dica

ted

––

–D

isch

arge

d w

ith

subc

utan

eous

air

ac

cum

ulat

ion

Upp

er e

xtre

m-

ity e

dem

aIn

terv

entio

n no

t ind

icat

ed

exce

pt f

or ly

mph

atic

m

assa

ge a

nd e

last

ic

stoc

king

s

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., di

uret

ics)

Inte

rven

tion

unde

r lo

cal a

nest

hesi

a in

dica

ted

(lym

phat

ic

anas

tom

osis

)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (l

ymph

atic

an

asto

mos

is)

––

–C

ontin

ued

elas

tic

stoc

king

use

Low

er

extr

emity

ly

mph

edem

a (e

dem

a of

the

extr

emiti

es,

lym

phed

ema,

lo

caliz

ed

edem

a)

Inte

rven

tion

not i

ndic

ated

ex

cept

for

lym

phat

ic

mas

sage

and

ela

stic

st

ocki

ngs

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., di

uret

ics)

Inte

rven

tion

unde

r lo

cal a

nest

hesi

a in

dica

ted

(lym

phat

ic

anas

tom

osis

)

Inte

rven

tion

unde

r ge

nera

l ane

s-th

esia

indi

cate

d (l

ymph

atic

an

asto

mos

is)

––

–C

ontin

ued

elas

tic

stoc

king

use

Obt

urat

or/

fem

oral

neu

-ro

path

y (G

ait

dist

urba

nce)

Inte

rven

tion

not i

ndic

ated

ex

cept

for

wal

king

aid

an

d re

habi

litat

ion

Med

ical

man

age-

men

t ind

icat

ed

(e.g

., vi

tam

ins)

–In

terv

entio

n un

der

gene

ral a

nes-

thes

ia in

dica

ted

(e.g

., ne

rve

sutu

re)

––

–Pe

rsis

tent

res

tric

tion

in lo

wer

ext

rem

ity

addu

ctio

n

Page 16: Extended Clavien-Dindo classification of surgical ......ple, intra-abdominal abscess, pyothorax, delayed gastric emptying, and lung torsion were not listed as AE terms. Moreover, grading

683Surg Today (2016) 46:668–685

1 3

Tabl

e 1

con

tinue

d Prin

cipl

e of

gra

ding

III

IIIa

IIIb

IVa

IVb

VSu

pple

men

tal

expl

anat

ion

of

suf

fix “

d”

Wou

nd p

ain

Clin

ical

obs

erva

tion

only

; int

erve

ntio

n no

t in

dica

ted

exce

pt f

or

NSA

IDs

Opi

oid

adm

inis

tra-

tion,

or

trea

tmen

t by

pai

n co

ntro

l sp

ecia

list i

ndi-

cate

d

Surg

ical

inte

rven

tion

indi

cate

d (e

.g.,

nerv

e bl

ock)

––

––

Hom

e pa

in c

ontr

ol

Oth

ers

(No

AE

te

rm)

Dev

iatio

n fr

om n

orm

al

post

oper

ativ

e co

urse

. M

edic

atio

n, s

urgi

cal

inte

rven

tion,

end

osco

pic

trea

tmen

t, or

rad

iolo

gi-

cal i

nter

vent

ion

trea

t-m

ent n

ot in

dica

ted

Tre

atm

ent w

ith a

ntie

met

-ic

s, a

ntip

yret

ics,

ana

lge-

sics

, or

diur

etic

s; e

lec-

trol

yte

repl

enis

hmen

t; or

ph

ysic

al th

erap

y is

not

in

clud

ed in

this

cat

egor

y (e

ven

if th

ese

trea

t-m

ents

are

indi

cate

d, th

e co

nditi

on is

cat

egor

ized

as

Gra

de I

); o

pen

wou

nd

infe

ctio

n at

the

beds

ide

is G

rade

I

Med

icat

ion

indi

cate

d ex

cept

fo

r an

tiem

et-

ics,

ant

ipyr

etic

s,

anal

gesi

cs, a

nd

diur

etic

sC

ases

req

uiri

ng

bloo

d tr

ansf

usio

n or

intr

aven

ous

hype

ralim

enta

tion

are

incl

uded

Surg

ical

, end

osco

pic,

or

rad

iolo

gica

l int

er-

vent

ion

trea

tmen

t in

dica

ted

(with

out

gene

ral a

nest

hesi

a)

Surg

ical

, end

o-sc

opic

, rad

iolo

gi-

cal i

nter

vent

ion

trea

tmen

t ind

i-ca

ted

(int

erve

n-tio

n un

der

gen-

eral

ane

sthe

sia)

IC/I

CU

man

agem

ent

indi

cate

d; li

fe-

thre

aten

ing

com

-pl

icat

ions

(in

clud

-in

g co

mpl

icat

ions

in

the

cent

ral

nerv

ous

syst

em)

AN

D s

ingl

e or

gan

failu

re (

incl

udin

g di

alys

is)

IC/I

CU

man

agem

ent

indi

cate

d; li

fe-t

hrea

t-en

ing

com

plic

atio

ns

(inc

ludi

ng c

ompl

ica-

tions

in th

e ce

ntra

l ne

rvou

s sy

stem

) A

ND

mul

tiple

org

an

failu

re

Dea

th

IC in

term

edia

te c

are,

IC

U in

tens

ive

care

uni

t, T

PN

tota

l par

ente

ral n

utri

tion,

PP

I pr

oton

pum

p in

hibi

tor,

NG

tube

nas

ogas

tric

tube

, CT

com

pute

d to

mog

raph

y

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684 Surg Today (2016) 46:668–685

1 3

more widely used. One controversial issue is that AE terms are not well defined and different AE terms designate the same AEs in different clinical trials. For example, when intestinal obstruction occurs, some investigators could report this AE as “ileus”, but others refer to it as “small bowel obstruction” or “colon obstruction”. Under such circumstances, the incidence of this AE cannot be counted accurately. A second issue is that only general grading cri-teria are defined and therefore, grading can be difficult in some cases and subject to bias by the grader. For example, primary non-operative treatment for intestinal obstruction is gastroenteric tube decompression. Nasogastric tube or nasoenteric tube is utilized depending on the severity, but the original Clavien-Dindo classification does not define what grading should be applied for any type of gastroen-teric tube placement for decompression.

The JCOG PC criteria were established to address these issues. The advantages of the JCOG PC criteria are as fol-lows: First, commonly experienced surgical AEs are speci-fied and listed. To compare precisely the frequency of surgi-cal complications between studies, use of the common AE terms specified in the JCOG PC criteria is recommended. Second, grading definitions are straightforward and opti-mized for surgical complications. With these advantages, the JCOG recommends that the JCOG PC criteria be used to supplement the Clavien-Dindo classification, while maintaining the overall Clavien-Dindo classification. In JCOG, some disease-oriented subgroups are conducting clinical trials including surgery and using both the CTCAE and JCOG PC criteria to evaluate postoperative compli-cations. After these trials are completed, we will evaluate the concordance between the grading by the CTCAE and that by the JCOG PC criteria. We also plan to explore the advantages and disadvantages of the JCOG PC criteria.

The JCOG PC criteria have some limitations. First, these AE terms were chosen somewhat arbitrarily, but by experi-enced surgeons, and specific grading was decided based on the opinions and experience of our committee members. A second limitation of the JCOG PC criteria is that they do not include intraoperative complications. Our intent was to further define and clarify the criteria of the Clavien-Dindo classification and we considered that incorporating intra-operative complications would deviate too much from the original concept. Another common classification may be

required to define and grade intraoperative complications. A third limitation is that all descriptions in the Clavien-Dindo classification pertain to early postoperative com-plications. Here, ‘early postoperative’ generally indicates the time from surgery to the first hospital discharge, but in theory, the Clavien-Dindo classification can be applied broadly to late postoperative complications after hospital discharge. Within this context, the JCOG PC criteria are mainly intended to be used for early postoperative compli-cations, but they can also be used after hospital discharge, although would require more definitions and AEs.

In conclusion, the goals of the JCOG PC criteria are to standardize the AE terms used for early postoperative com-plications by providing more detailed grading guidelines based on the Clavien-Dindo classification. We suggest that researchers use the JCOG PC criteria in every surgical trial to allow for precise comparison of the frequency of surgical complications among trials.

Acknowledgments This project was supported by the National Cancer Center Research and Development Fund (23-A-16, 26-A-4). We thank Hiroaki Hiraga and Yasuji Miyakita for their specialist advice.

Compliance with ethical standards

Conflict of interest Hiroshi Katayama and his coauthors declare no conflicts of interest regarding this research.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://crea-tivecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

References

1. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecys-tectomy. Surgery. 1992;111(5):518–26.

2. Clavien PA, Strasberg SM. Severity grading of surgical compli-cations. Ann Surg. 2009;250(2):197–8.

3. Nelson H, Sargent D, Wieand HS, Fleshman J, Anvari M, Stryker SJ, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350(20):2050–9.

Table 2 Characteristics of the three criteria

CTCAE ver4.0 Clavien-Dindo classification JCOG PC criteria

AE terms Specified Not specified Specified

Grading definitions Defined for each AE Single common definition for all AEs Defined for each AE (following the general definition of the Clavien-Dindo classification)

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685Surg Today (2016) 46:668–685

1 3

4. Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, et al. Gastric cancer surgery: morbidity and mor-tality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy–Japan Clinical Oncology Group study 9501. J Clin Oncol. 2004;22(14):2767–73.

5. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, et al. Short-term endpoints of conventional versus laparo-scopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lan-cet. 2005;365(9472):1718–26.

6. Bonjer HJ, Haglind E, Jeekel I, Kazemier G, Pahlman L, Hop WCJ, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncology. 2005;6(7):477–84.

7. Dindo D, Demartines N, Clavien PA. Classification of sur-gical complications: a new proposal with evaluation in a

cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

8. http://www.jcog.jp/doctor/tool/Clavien_Dindo.html. Accessed 12 Aug 2015.

9. Cancer Therapy Evaluation Program NCI. Common Toxicity Criteria, Version 2.0. 1998.

10. Cancer Therapy Evaluation Program NCI. Common Terminol-ogy Criteria for Adverse Events (CTCAE) Version 3.0 2006.

11. Cancer Therapy Evaluation Program NCI. Common Terminol-ogy Criteria for Adverse Events (CTCAE) Version 4.0. 2009.

12. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96.