Clavien-Dindo indikator: Et eksempel fra den Danske KoloRektal Cancer database (DCCG)

Transcription

1 Clavien-Dindo indikator: Et eksempel fra den Danske KoloRektal Cancer database (DCCG) Peter-Martin Krarup Overlæge Abdominalcenter K, Bispebjerg Hospital

2 Disclosures AstraZeneca (Research collaboration) SacoMed / THD (Research collaboration) Ethicon (Speaker)

3 Agenda Background Clavien-Dindo classification of complication DCCG registration in 2009 and 2014 Data from the 2014 annual report

4 A core information set for colorectal cancer surgery McNair AGK 1,5, Whistance RN 1,2, Forsythe RO 1,2, Macefield R 1, Rees J 1, Jones JE 3, Smith G 3, Pullyblank AM 4, Avery KNL 1, Brookes ST 1, Thomas MG 6, Sylvester PA 6, Russell A 7, Oliver A 7, Morton D 8, Kennedy R 9, Jayne DG 10, Huxtable R 11, Hackett R 12, Dutton S 13, Coleman MG 14, Card M 6, Brown J 15, Blazeby JM 1,2 On behalf of the CONSENSUS-CRC (Core Outcomes and information SEts in SUrgical Studies ColoRectal Cancer) working group.

5 Identify all outcomes 1212 outcomes Group into domains 94 domains Gain consensus 10 core outcomes

6 Top 10 highest scored information domains Information domain % of patients rating of high importance Information domain % of professionals rating of high importance Resection margins 89.7 Anastomotic leak 95.9 Stoma rate 85.6 Resection margins 91.9 Distant recurrence 81.4 Operative mortality 88.9 Recurrence 79.4 Conversion to open 87.9 operation Local recurrence 79.4 Distant recurrence 86.9 Disease free 78.4 Re-operation 85.9 interval Non-progression 77.3 Local recurrence 85.9 Sphincter preservation 73.2 Stoma rates 83.8 Lymph node yield 72.2 Lymph node yield 83.8 Survival 72.2 Length of hospital stay 83.8

7 Oncological outcomes: Long-term survival Cancer recurrence Resection margins Operative outcomes: Anastomotic leak Peri-operative survival Surgical site infection Stoma rates and complications Conversion to open operation Quality of life: Physical and sexual function Faecal incontinence and urgency

8 Complications after colorectal surgery Morbidity Mortality ICU Re-operations Hospital stay Re-admission Cancer recurrence Costs

9 Complications and costs American College of Surgeons (NSQIP) Average added costs per complication: $11,000 Total costs of care increases 54% when a complication occur

10 DCCG 2009 registration form

11 Clavien-Dindo in the Danish Colorectal Cancer Database 2012: revision of complication registration Accessible Reproducible Comparable Grading of each complication Clavien-Dindo classification Grading of anastomotic leakage (Rahbari) Implemented in 2014

12 Definition of Complications Complications Any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure. Sequelae Scar formation inability to walk after an amputation Failure to cure Early recurrence of inguinal hernia Incompletely resected malignant tumors Clavien et al. Surgery (1992) 111:

13 The strength of the classification relies on the principle of grading complications based on the therapy used to treat the complication. Clavien et al. Surgery (1992) 111:

14 Dindo et al. Ann Surg (2004) 240:

15 Clavien-Dindo Classification Grade Grade I Grade II Grade III Definition Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included Requiring surgical, endoscopic or radiological intervention Grade IIIa Intervention not under general anesthesia Grade IIIb Intervention under general anesthesia Grade IV Grade IVa Grade IVb Grade V Life-threatening complication (including CNS complications) requiring IC/ICU management Single organ dysfunction (including dialysis) Multiorgan dysfunction Death Dindo et al. Ann Surg (2004) 240:

16 The classification revisited Steady yearly increase in the citation of the classification since its introduction in 2004 Worldwide reproducibility Grading of complications and perception of the severity correlated amongst patients, nurses and physians. Clavien et al. Ann Surg (2009) 250:

17 DCCG 2014 registration form

18 DCCG Annual report 2014 DCCG 2014 N = 5230 Operated N = 4449 Not operated N = 781 Local procedure N = 323 Abdominal procedure N = 4126 Surgical complication N = 708 (17%) No surgical complication N = 3418 (83%) DCCG Annual report 2014 (Published October 29 th 2015)

19 DCCG Annual report 2014 (Published October 29 th 2015)

20 DCCG Annual report 2014 (Published October 29 th 2015)

21 DCCG Annual report 2014 (Published October 29 th 2015)

22 DCCG Annual report 2014 (Published October 29 th 2015)

23 DCCG Annual report 2014 (Published October 29 th 2015)

24 DCCG Annual report 2014 (Published October 29 th 2015)

25 DCCG Annual report 2014 (Published October 29 th 2015)

26 DCCG Annual report 2014 (Published October 29 th 2015)

27 DCCG Annual report 2014 (Published October 29 th 2015)

28 DCCG Annual report 2014 (Published October 29 th 2015)

29 Leak: Colon vs. rectum

30 Short-term mortality after anastomotic leak Clavien-Dindo N 30-day mortality 90-day mortality Grade I 5 0 (0%) 0 (0%) Grade II 8 0 (0%) 0 (0%) Grade IIIa 18 1 (5.6%) 2 (11.1%) Grade IIIb (1.8%) 3 (2.7%) Grade IVa 32 2 (6.3%) 4 (12.5%) Grade IVb 12 1 (10%) 2 (20%) Grade V 5 4 (80%) 5(100%) Uoplyst 1 0 (0%) 0 (0%) Total (5.2%) 16 (8.4%)

31 Medical complications DCCG 2014 N = 5230 Operated N = 4449 Not operated N = 781 Local procedures N = 314 Abdominal procedures N = 4135 Medical complications N = 469 (11%) No medical complications N = 3666 (89%)

32 Surgical complications Surgical vs. medical complications Medical complications No Yes Total No 3446 (92%) 285 (8%) 3731 (100%) Yes 528 (74%) 190 (26%) 718 (100%) Total 3974 (89%) 475 (11%) 4449 (100%) If surgical complications, then 3 fold risk of a medical complication

33 90-days mortality and complications

34 Cardiovascular complications #1

35 Cardiovascular complications #2

36 Pulmonary complications

37 Thrombo-embolic complications

38 Renal complications

39 Other medical complications

40 Discussion Registration of complications is important Comprehensive registration of complications in the DCCG database Almost complete registration (0.3% missing) Validation of Clavien-Dindo within DCCG Perspective