1. Clavien-Dindo Classification of Surgical Complications: Interactive tutorial Harry Claireaux Slides modified from those by Dr. Stephen Chapman Protocol Launch Meeting and Research Skills Course September 16 th 2015, RCS England

2. What we will cover Outline of the Clavien-Dindo classification 8 short examples – open to the floor Protocol Launch Meeting and Research Skills Course September 16 th 2015, RCS England

3. Measure of morbidity Any deviation from the normal postoperative course (grades I-V) Classification via therapeutic consequence Grade allocated to each complication identified In the OAKS study please record the highest single grade per patient Protocol Launch Meeting and Research Skills Course September 16 th 2015, RCS England Clavien-Dindo classification of surgical complications

4. Protocol Launch Meeting and Research Skills Course September 16 th 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

5. Protocol Launch Meeting and Research Skills Course September 16 th 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

6. Protocol Launch Meeting and Research Skills Course September 16 th 2015, RCS England What you will see on

7. 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 Course September 16 th 2015, RCS England

8. 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 Course September 16 th 2015, RCS England

9. 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 Course September 16 th 2015, RCS England

10. 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 Course September 16 th 2015, RCS England

11. 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 Course September 16 th 2015, RCS England

12. 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 Course September 16 th 2015, RCS England

13. 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 Course September 16 th 2015, RCS England

14. 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 Course September 16 th 2015, RCS England

15. 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 Course September 16 th 2015, RCS England

16. 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 Course September 16 th 2015, RCS England