Clavien, Pierre-Alain

Dindo, Daniel

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EDITORIALSurgeon’s Intuition: Is It Enough to Assess Patients’ SurgicalRisk?Pierre-Alain Clavien Æ Daniel DindoPublished online: 29 July 2007 Socie´te´ Internationale de Chirurgie 2007A daily task of the modern surgeon is to assess the risk/benefit ratio of a procedure for a specific patient. The threekey ingredients are the experience of the clinician inevaluating the available therapies for the specific medicalproblems, his or her competence in performing the chosenprocedure, and knowledge about the risk factors. Patients,administrators, society, and health care policymakers ex-pect data regarding the outcome of respective proceduresas well as the ‘‘quality’’ of doctors or hospitals. This is achallenging task, as we still lack standardized or widelyaccepted tools to perform such quality assessment con-vincingly in many areas [1–4]. Another key task whenassessing the quality of surgery is to take into account thepopulation studied (i.e., risk adjustment). For example, wemay not expect the same results of cholecystectomy per-formed electively in healthy as we would in elderly dia-betic patients operated on urgently for acute cholecystitis.The results may also vary widely depending on perspec-tive. The identification of risk factors must take into ac-count the case mix as well as meaningful endpoints [5, 6].The last item is still often poorly reported in the currentliterature owing to the lack of accepted objective andreproducible outcome measures [1, 2, 7].Risk scores in surgery estimate the risk of one individualpatient or a patient population to develop complicationsafter surgical interventions. These scores may be classifiedinto three types [8]: First, there are general systems forassessing the operative risk, such as the Physiological andOperative Severity Score for the enumeration of Mortalityand Morbidity (POSSUM) [9]. Second, there are thosespecific for the type of morbidity to be evaluated, such asthe Goldman and Detsky indices for cardiac complications[10, 11]. Finally, risk-scoring systems can be related to aspecific condition or disease, such as the Acute Physiologyand Chronic Health Evaluation II (APACHE II) score [12]or the Ranson criteria to assess the severity of acute pan-creatitis [13]. The integration of several predictors of riskinto a score ensures an accurate and comprehensive methodfor risk assessment. Despite their availability and oftenestablished utility, surgical performance is still commonlyevaluated without assistance of such systems because theyare seen as too complex or too specific for a given patientpopulation, hindering their use in daily clinical practice.In the prospective observational study by Woodfield andhis colleagues (elsewhere in this issue) [14], risk assess-ment was conducted using a 100-mm visual analog scale(VAS) performed by the surgeons before and after surgery.Surgeons use this scale to indicate the estimated risk formajor complications as a number between 0 and 100. Al-though such a prediction of surgical risk by the surgeon isobviously subjective, the authors identified strong corre-lation with the incidence of postoperative complications.Interestingly, the surgeons’ risk assessment improved thepredictive ability of a multivariate model of objective cri-teria in predicting postoperative complications.The value of subjective prediction of postoperativecomplications has been established since the introductionof American Society of Anesthesiology (ASA) grading.The ASA classification, still widely used today, has playedan important role in preoperative risk evaluation for dec-ades [15]. One shortcoming of the ASA classification isthat it does not take into account the invasiveness orintrinsic risk of an operative procedure. We found that in aP.-A. Clavien (&)  D. DindoDepartment of Visceral and Transplantation Surgery, UniversityHospital Zurich, 100 Ramistrasse, Ch-8091 Zurich, Switzerlande-mail: clavien@chir.unizh.ch123World J Surg (2007) 31:1909–1911DOI 10.1007/s00268-007-9145-9population of more than 6000 patients, morbidity andmortality rates greatly varied within the same ASA gradedepending on the type of surgery and the underlying dis-ease (unpublished observation).The present surgeons’ risk assessment using a VAScorrects this limitation of the ASA grading system, as thetype of surgery and the underlying disease strongly influ-ences the surgeons’ evaluation. It would have been inter-esting to compare the accuracy of the surgeons’ riskassessment by VAS and the risk stratification using theASA grading system.Although the approach of Woodfield et al. is appealingmainly owing to its ‘‘easy use’’ and to the fact that it isbased exclusively on surgeons’ intuition, obviating theneed for sophisticated grading systems, a few aspects mustbe challenged. First, intuitive risk assessment is subjectiveand thereby strongly depends on the experience of thesurgeon. The question about the experience level of theassessing surgeons remains unanswered in the currentstudy. Younger surgeons might not be able to assess pa-tients’ preoperative risk sufficiently. Second, evaluation ofthe patients’ risk performed exclusively by surgeons mightlead to an inflated assessment. This might be difficult toprevent as the higher the estimated risk the better the risk-adjusted outcome will look. Hence, more objective pre-operative criteria must be considered for a reliable riskadjustment calculation. Another limitation of the study isthe lack of a standardized way of reporting complications.Although some definitions are given for major and minorcomplications, clear designations of minor and majorcomplications are missing, hampering the interpretationand reproducibility of the results. Terms such as minor andmajor are imprecise and should be abandoned [, 2]. Astandardized and validated complication grading system, ass1uggested recently by our group [7], would have enhancedthe strength of the present study. With this classification,which includes medical and patient perspectives, compli-cations are stratified according to the medical or surgicaltherapy required to treat the complication. It enablesobjective, precise documentation of postoperative compli-cations and is currently in use by us [16–18] and a numberof other centers [19–23].The authors also calculated a postoperative VAS scoreshowing higher predictive values for poor outcome than thepreoperative assessment. A postoperative increase in theVAS score was associated with a significantly highermortality rate (6.3% vs. 2.4%), major complication rate(20.1% vs. 11.0%), and overall complication rate (48.3%vs. 34.3%). This finding suggests that the preoperativeVAS assessment is lacking some important predictive va-lue. The postoperative VAS score is not contributing froma practical point of view, as risk assessment should bebased on preoperative evaluation only. This ensures thatthe estimation of the patient’s risk is not influenced by thesurgery itself. Additionally, identification of the patient’srisk at the preoperative stage is crucial for the informedconsent of the patient and to consider alternative treatmentmodalities.The article by Woodfield et al. importantly highlightsthe value of the surgeon’s intuition in assessing the risk ofsurgery in individual patients. However, more objectivedata must be considered for a reliable risk and qualityassessment. To ensure objectivity, quality assessment insurgery should cover four basic requirements: (1) outcomedata should be adjusted for the patient population of a gi-ven institution; (2) risk-adjustment systems should beobjective and easy to use; (3) risk-adjustment should besolely based on preoperative data to avoid bias related tothe surgery itself; and (4) outcome should be reported usinga uniform complication definition and stratification. As aresult, objective and comparable data suitable for qualitycontrol in surgery may be attained, and the quality of ourwork would be convincingly established.References1. Clavien PA, Sanabria J, Strasberg S (1992) Proposed classifica-tion of complication of surgery with examples of utility in cho-lecystectomy. Surgery 111:518–5262. Clavien PA, Camargo CA Jr, Croxford R, et al. (1994) Definitionand classification of negative outcomes in solid organ trans-plantation: application in liver transplantation. Ann Surg220:109–1203. Blumenthal D (1996) Quality of health care. N Engl J Med335:891–8944. Brook R, McGlynn E, Cleary P (1996) Quality of health care. NEngl J Med 335:966–9705. Daley J, Henderson W, Khuri S (2001) Risk-adjusted surgicaloutcomes. Annu Rev Med 52:275–2876. Grover F, Shroyer L, Hammermeister K, et al. (2001) A decade’sexperience with quality improvement in cardiac surgery usingVeterans Affairs and Society of Thoracic Surgeons Nationaldatabase. Ann Surg 234:464–4747. 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Surgeon's Intuition: Is It Enough to Assess Patients' Surgical Risk?

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Surgeon's Intuition: Is It Enough to Assess Patients' Surgical Risk?

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