Learn more about the benefits of registering on the new BJS website

Measuring and achieving the best possible outcomes in surgery. BJS 2017; 104: 1121-1122.

Published: 10th May 2017

Authors: P.‐A. Clavien, M. A. Puhan

Full text

Your comments


Henrik Kehlet

8 months ago

Measuring and achieving better surgical outcomes?

In their editorial (1) Clavien and Puhan summarise the elegant improvements within standardising descriptors for the measurement of postoperative complications and finalised into the Comprehensive Complication Index (CCI). These developments serve as a rational basis for monitoring outcomes and to be used in benchmarking studies.

However, when it comes to “achieving” better outcomes their article might have benefitted from an additional discussion on further improvements when using the CCI. Thus, as suggested before, a time-course analysis of the complications would be beneficial because an initial early direct “surgical” complication (wound dehiscence, major bleeding, anastomotic leakage, etc.) may lead to a higher risk of “medical” complications (pulmonary, cardiac, thromboembolic, etc.). However, oppositely an initial “medical” complication may lead to a higher risk of a “surgical” complication.(2) Consequently, the time-course analysis of complications may improve our understanding on the pathophysiology of the postoperative morbidity and where an initial “surgical” complication needs attention to “surgical” expertise, while an initial “medical“ complication demands a focus on the all-over care setup within the “concept of fast-track surgery” or “enhanced recovery programs” which have been documented to decrease the risk of medical complications.(2)

Hopefully, the major improvements developed by Clavien and co-workers to assess surgical complications in more detail will assist to “achieve” better outcomes combined with the above considerations.

Henrik Kehlet
Section of Surgical Pathophysiology 7621
Rigshospitalet, Blegdamsvej 9
DK-2100 Copenhagen

1. Clavien PA, Puhan MA. Measuring and achieving the best possible outcomes in surgery. Br J Surg 2017; 104: 1121-1122.
2. Kehlet H, Jorgensen CC. Advancing surgical outcomes research and quality improvement within an enhanced recovery program framework. Ann Surg 2016; 264: 237-238.

    BJS admin

    7 months ago

    We would like to thank Dr. Kehlet for his valuable comments referring to our editorial ‘Measuring and achieving the best possible outcomes in surgery’. So far, the Comprehensive Complication Index (CCI®) has been used as an ‘all-inclusive’ outcome measure of postoperative complications that reflects the overall postoperative morbidity of one single or a whole group of patients (1,2). However, as Dr. Kehlet points out, the specific sequence of complications has not been addressed so far, neither in our nor in other surgical outcome studies. Developing this thought further, the question arises whether the severity of the first complication after surgery influences the probability and type (medical vs. surgical) of further complications? On another token, it would be interesting to explore whether the overall morbidity varies depending on the type of the first complication and on the type of surgery, hepatic, pancreatic or colonic.

    We fully agree with Dr. Kehlet that time-course analyses that explore patterns of complications over time may further advance our understanding of how postoperative morbidity accumulates and provide a rationale for interventions to lower the burden from negative post-operative events.

    We concur: now that fast-track surgery has gained traction in the perioperative procedures, these questions are worth a detailed analysis. The answers may emphasize the importance of fast-track surgery, which is known to reduce hospital length of stay and costs; however, regarding postoperative morbidity the findings are divided (3,4). Or, if surgical complications lead predominantly to medical ones, benchmarking postoperative outcome to detect improvement potentials of surgical processes (5,6) should be promoted.

    Roxane D. Staiger
    Milo Puhan
    Pierre-Alain Clavien

    Department of Surgery and Transplantation
    University Hospital of Zurich
    Rämistrasse 100
    8091 Zurich, Switzerland

    1. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 2013; 258(1): 1-7.
    2. Clavien PA VD, Staiger RD, Slankamenac K, Mehra T, Graf R et al. The Comprehensive Complication Index (CCI) – added value and clinical perspectives 3 years ‘down the line’. Ann Surg (in press) 2017.
    3. Wu SJ, Xiong XZ, Lu J, Cheng Y, Lin YX, Zhou RX, Cheng NS. Fast-Track Programs for Liver Surgery: A Meta-Analysis. J Gastrointest Surg 2015; 19(9): 1640-1652.
    4. Visioni A, Shah R, Gabriel E, Attwood K, Kukar M, Nurkin S. Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery. Ann Surg 2017.
    5. Rossler F, Sapisochin G, Song G, Lin YH, Simpson MA, Hasegawa K et al. Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors. Ann Surg 2016; 264(3): 492-500.
    6. Muller X, Marcon F, Sapisochin G, Marquez M, Dondero F, Rayar M et al. Defining Benchmarks in Liver Transplantation: A Multicenter Outcome Analysis Determining Best Achievable Results. Ann Surg 2017.