Clavien-Dindo post operative morbidity grading system: What is the limitation? Various factors affecting postoperative complications.

Introduction: Providing quality care in surgical practice is the new goal of health care systems and hospitals worldwide. To assess the quality of care provided one of the parameters is assessment of post operative complications. Post operative morbidity and mortality within 30 days duration has been accepted as a standard parameter against which different hospitals can be weighed, though pre-existing co-morbidities and intra operative events have direct impact on post operative outcome, which is not considered in Clavien-Dindo grading system. Patients and methods:  For the duration of 15 months (from March 2013 to May 2014), post operative morbidity and mortality were recorded according to Clavien-Dindo grading system, of all the patients who underwent surgery for gastrointestinal problems, either in elective setting  or in emergency,  at our centre. Any complication occurring within 30 days of index surgery was taken into account. For patients who developed multiple complications, the one with higher grade was adopted for purpose of classification in to major or minor morbidity. Results: Within last 15 months total 763 patients were operated for gastrointestinal problems at our centre. Mean age was 47.4 years. Of them 477 (62.5%) were males and 286 (37.5%) were females. 560 (73.4%) patients were electively operated and 203(26.6%) were operated on urgent or emergent basis. Out of 763 operated, 123(16.1%), 97(12.7%), 17(2.2%), 34(4.4%), 9(1.1%) and 11(1.4%) developed grade I, II, III-a, III-b, IV-a and grade IV-b morbidity respectively. Mortality (grade V) was 13(1.7%). 459 (60.1%) patient did not develop any morbidity. 365(47.8%) patients had at least one or more pre existing co-morbidity or risk factors, while 398(52.1%) patients had no any existing co-morbidity. Patients who developed morbidity were operated in elective setting in 68 % cases and in emergency 32 % cases, while patients who did not develop any morbidity were those who were operated in elective setting in 77% and in emergency 23 % cases (p=0.03). But this difference was not observed for patients who developed either minor (grade I or II) or major (> grade II) morbidity (p=0.83). Again presence of one or more pre-existing co-morbidity (57% vs. 42%) was associated with high risk of developing post operative morbidity (p=0.02). Conclusion: Not providing due consideration to pre-existing co-morbidities or risk factors and intra operative events while recording post operative morbidities may influence actual quality assessment in surgical outcomes. This becomes the only limitation of well accepted Clavien-Dindo system. Optimisation of pre-existing co-morbidities in elective setting can help reduce post operative complications.