title: Using a modification of the Clavien-Dindo system accounting for readmissions and multiple interventions: defining quality for pancreaticoduodenectomy.
abstract: BACKGROUND
  The Clavien-Dindo system (CD) does not change the grade assigned a complication when multiple readmissions or interventions are required to manage a complication. We apply a modification of CD accounting for readmissions and interventions to pancreaticoduodenectomy (PD).
  
  
  METHODS
  PDs done between 1999 and 2009 were reviewed. CD grade IIIa complications requiring more than one intervention and II and IIIa complications requiring significantly prolonged lengths of stay including all 90-day readmissions were classified severe-adverse-postoperative-outcomes (SAPO). CD IIIb, IV, and V complications were also classified SAPOs. All other complications were considered minor-adverse-postoperative-outcomes (MAPO).
  
  
  RESULTS
  Four-hundred forty three of 490 PD patients (90.4%) had either no complication or a complication of low to moderate CD grade (I, II, IIIa). When reclassified by the new metric, 92 patient-outcomes (19%) were upgraded from CD II or IIIa to SAPO. One-hundred thirty nine patients (28.4%) had a SAPO. Multivariable regression identified age >75 years, pylorus preservation and operative blood loss >1,500 ml as predictors of SAPO. Age was not associated with poor outcome using the unmodified CD system.
  
  
  CONCLUSIONS
  Established systems may under-grade the severity of some complications following PD. We define a procedure-specific modification of CD accounting for readmissions and multiple interventions. Using this modification, advanced age, pylorus preservation, and significant blood loss are associated with poor outcome.
authors.affiliation: Department of Surgery, NorthShore University Health System, Evanston, Illinois.
authors.forename: Marshall S
authors.initials: MS
authors.lastname: Baker
authors.forename: Karen L
authors.initials: KL
authors.lastname: Sherman
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Stocker
authors.forename: Amanda V
authors.initials: AV
authors.lastname: Hayman
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.forename: Richard A
authors.initials: RA
authors.lastname: Prinz
authors.forename: Mark S
authors.initials: MS
authors.lastname: Talamonti
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000592:standards; D010359:Patient Readmission; D011183:Postoperative Complications / Q000209:etiology*; D019106:Postoperative Hemorrhage / Q000209:etiology; D012720:Severity of Illness Index
keywords: pancreaticoduodenectomy; quality; surgical complications