Gastroenterology
Volume 137, Issue 5 , Pages 1856-1857, November 2009

Reply

  • Sumihito Tamura

      Affiliations

    • Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
    • ,
  • Yasuhiko Sugawara

      Affiliations

    • Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
    • ,
  • Norihiro Kokudo

      Affiliations

    • Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
    • ,
  • Masatoshi Makuuchi

      Affiliations

    • Department of Surgery, Japanese Red Cross Medical Center, Tokyo, Japan

published online 01 October 2009.

Article Outline

 

We appreciate the interest that our concern1 has generated regarding the application of the Clavien system for surgical complications in the A2ALL study. We admire the philosophy and the achievements of the multicenter A2ALL study group, and will continue to follow their reports with keen interest. Morbidity in living donors continues to be the most serious concern in the field, and we consider discussions of this aspect valuable towards strengthening our global collaboration as medical professionals to improve patient care.

A2ALL is essentially a North American multicenter project for the study of living donor liver transplantation.2 The response to our comment from the A2ALL group3 stating that the newer Clavien system had not been published when the A2ALL study was planned, and that a system based on the earlier version with some modifications was adopted to initiate the quest, is with grounds. Use of a grading system that includes factors that are influenced by the medical system may be acceptable for documentation and comparison within regions that share a common social background. We respect the authors' decision to continue utilizing the 1994 version of the Clavien grading system for this reason.

Two facts, however, deserve attention. First, the newer version has undergone significant revision. It has evolved; therefore, simple comparison or translation between the 2 systems requires caution. Grade 2b in the earlier version (“Require therapeutic interventions, readmission to the hospital or ICU, or prolongation of regular ICU stay for more than 5 days”) cannot be easily categorized as grade 3 of the newer version (“Requiring surgical, endoscopic, or radiologic intervention”). For example, life-threatening complications such as acute respiratory distress syndrome necessitating mechanical ventilation, considered grade 2b in the initial classification, is recognized as a higher grade (grade IV) in the newer version.4 Of note, this subdivision of grade 2 (2a or 2b) is not clarified in the publication discussed by the author.5 Despite the authors' comment, conversion of the depicted data to the newer grading system may not be performed without referring to the raw data, which are not easily accessed by international readers.

Second, a classification system applicable throughout different countries and surgical cultures has further potential benefits. The modified 1994 version of the Clavien grading system adapted for the A2ALL study has not been widely accepted. The system is prone to influence by differences between regional medical systems, and has never been validated in the international surgical arena.4 In this aspect, the newer Clavien system has better potential to become the international de facto standard in describing surgical morbidity, if it is not already. In addition to the large, living donor series previously cited in our correspondence, the newer Clavien system has been applied in a more recent living liver donor series from South America,7 the Far East,6 in a pancreatic surgery series from Europe,8 in a living donor nephrectomy series from North America,9 and in many other series from various surgical fields on different continents.10

Last, living donors are not transplant recipients. Recipients may require a different grading system than living donors because of the far more invasive operative procedures and the use of potent immunosuppressants. Living donors—well-prepared and well-selected healthy individuals—undergo elective procedures with the expectation that possible negative events are comparable with general surgical procedures. In this aspect, a system applicable to other operative procedures may be more suitable for living donors, rather than that focused on or limited to liver transplantation.

We strongly believe that integrating the global experience for further improvement worldwide is the key in the current and coming era. The newer Clavien system, or the Zurich system, has evolved to overcome some of the limitations recognized in earlier systems. It may not be a perfect tool, but it deserves attention as the most suitable tool available to date.

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References 

  1. Tamura S, Sugawara Y, Kukudo N, et al. Systematic grading of morbidity after living donation for liver transplantation. Gastroenterology. 2008;135:1804
  2. Adult-to-adult living donor liver transplantation cohort study (A2ALL). Hepatology. 2003;38:792
  3. Freis C, Ghobrial RM A2ALL study group. Response to letter “Systematic grading of morbidity after living donation for liver transplantation”. Gastroenterology. 2009;137:1855–1856
  4. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213
  5. Ghobrial RM, Freise CE, Trotter JF, et al. Donor morbidity after living donation for liver transplantation. Gastroenterology. 2008;135:468–476
  6. Haga J, Shimazu M, Wakabayashi G, et al. Liver regeneration in donors and adult recipients after living donor liver transplantation. Liver Transpl. 2008;14:1718–1724
  7. Seda-Neto J, Godoy AL, Carone E, et al. Left lateral segmentectomy for pediatric live-donor liver transplantation: special attention to segment IV complications. Transplantation. 2008;86:697–701
  8. DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg. 2006;244:931–937
  9. Patel S, Cassuto J, Orloff M, et al. Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States. Transplantation. 2008;85:561–565
  10. SurgicalComplication.info.com [homepage on the Internet]. Available: http://www.surgicalcomplication.info/index-6.html. Accessed May 15, 2009.

 Conflicts of interest The authors disclose no conflict.

PII: S0016-5085(09)01691-6

doi:10.1053/j.gastro.2009.09.041

Refers to article:

  • Response to Letter “Systematic Grading of Morbidity After Living Donation for Liver Transplantation” , 01 October 2009

    Chris Freise, Mark Ghobrial, A2ALL Study Group
    Gastroenterology November 2009 (Vol. 137, Issue 5, Pages 1855-1856)

Gastroenterology
Volume 137, Issue 5 , Pages 1856-1857, November 2009

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