- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
DOI:10.4103/sni.sni_424_17Copyright: © 2018 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Broggi M, Zattra C, Ferroli P. How to compare outcomes and complications in neurosurgery: We must make the mission possible!. Surg Neurol Int 19-Mar-2018;9:65
How to cite this URL: Broggi M, Zattra C, Ferroli P. How to compare outcomes and complications in neurosurgery: We must make the mission possible!. Surg Neurol Int 19-Mar-2018;9:65. Available from: http://surgicalneurologyint.com/surgicalint-articles/how-to-compare-outcomes-and-complications-in-neurosurgery-we-must-make-the-mission-possible/
We have read with great interest the paper entitled: “How to compare clinical results of different neurosurgical centers? Is a classification of complications in neurosurgery necessary for this purpose?” published by Brock et al. on Surgical Neurology International.[
Specifically, the question Brock and coauthors are trying to address is how to compare surgical results of different hospitals and whether a classification of complications in neurosurgery is really necessary for this purpose. As a matter of fact, outcomes and complications are delicate issues in every surgical specialty and even more so in neurosurgery, where no shared definition nor classification of complications exist yet.
The authors surely offer a nice historical perspective and general overview on the current state-of-the-art regarding complications report and analysis. However, one of the limitations of the study becomes immediately evident, because it is centered only on surgical complexity assessment. Complication reporting, on the other hand, is unavoidably linked to the concept of quality assessment, whose achievement in healthcare management and especially in the surgical disciplines is an endeavor on many levels.
First and foremost, the definition of quality itself may widely differ between patients, the society, the administrators, and the healthcare policymakers.[
It has been demonstrated, for example, that the hospital and surgeon case volume have an impact on outcomes across a variety of subspecialties, including neurosurgery. These volumes’ relationship with mortality and neurological deficits after biopsy or resection of primary brain tumors have also been shown.[
Moreover, the role played by surgical complexity on the occurrence of complications and therefore on the outcome is still undervalued, even though its significance was already proposed by Clavien, a general surgeon, more than 20 years ago.[
In the past years, our group has been deeply committed to complication recording and outcome evaluation.[
Besides, the concept of evaluating outcome based on the modification of the patient's condition between the pre- and postoperative status rather than considering the absolute Karnofsky Performance Status (KPS) value is undeniable and actually quite obvious. Not surprisingly, the MCS was created by comparing the delta-KPS between the preoperative status and the discharge clinical conditions.[
The paragraph concerning biases due to multiple variables also deserves some scrutiny; it indeed confirms once again how difficult is the task of complexity and complications assessment and outcome measurement, but without offering any solution to the problem. For instance, no clear indication on which medical complications should be considered for the statistical analysis is given. In fact, although it might be true that pulmonary thromboembolism (PE) is not directly related to surgery, on the other hand, if the patient did not undergo surgery, he would not have developed PE in the first place. In the same way, considering a postoperative infection as something not directly related to the surgical procedure is very disputable.
Finally, as much as we are fervent supporters of the importance of surgical complexity grading, we also believe in the significance of creating a common definition and classification of complications.[
And even if, as the authors believe, surgical complexity was enough to pursue this plan, we have not found in this work any real proposition on how the grading should take place, if not for a timid indication on the need of designing the scale using numerical parameters. In truth, it seems like Brock and coauthors stepped into the very same mistake they warned the reader about at the beginning of their work, that is, a “mere intellectual exercise lacking any practical usefulness.”
What we propose, on the other hand, is an algorithm which may still not be perfect, but at least is trying to realistically address the problem. This consists, first and foremost, of a shared definition of complications.[
The other seminal characteristic of this project is that data, gathered by means of standardized protocols, scales, and classifications, should be shared among hospitals and multicenter trials involving big case-load-hospitals should be designed. Only by joining these efforts, true progress will happen. Only by applying proper quality tools, we, doctors, surgeons, and neurosurgeons, will be able to regulate our own practices, before others, such as insurances companies and hospital administrators, will do it for us.[
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Conflicts of interest
There are no conflicts of interest.
1. Brock S, Saleh C, Zekaj E, Servello D. How to compare clinical results of different neurosurgical centers? Is a classification of complications in neurosurgery necessary for this purpose. Surg Neurol Int. 2016. 7: S565-9
2. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992. 111: 518-26
3. Dindo D, Clavien PA. Quality assessment in surgery: Mission impossible?. Patient Saf Surg. 2010. 4: 18-
4. Ferroli P, Brock S, Leonardi M, Schiavolin S, Acerbi F, Broggi M. Complications in Neurosurgery: Application of Landriel Ibanez Classification and Preliminary Considerations on 1000 Cases. World Neurosurg. 2014. 82: e576-7
5. Ferroli P, Broggi M, Schiavolin S, Acerbi F, Bettamio V, Caldiroli D. Predicting functional impairment in brain tumor surgery: The Big Five and the Milan Complexity Scale. Neurosurg Focus. 2015. 39: E14-
6. Ferroli P, Caldiroli D, Leonardi M, Broggi M. Letter to the Editor: Complications in neurosurgery: The need for a common language. J Neurosurg. 2015. 122: 983-4