The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien–Dindo classification in radical gastric cancer surgery

Abstract

The comprehensive complication index (CCI) integrates all complications of the Clavien-Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC. Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution. From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8±11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p<0.05). The CCI demonstrated a stronger relationship with hospital stay (ρ=0.721, p<0.001) than did the CDC (ρ=0.634, p<0.001). For prolonged hospital stays (≥30days), only the CCI showed a moderate correlation (ρ=0.544, p=0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time-event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed. The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.