1. Unintended intraoperative damage to major vessels and/or organs requiring reconstruction or resection
i. Complete section of or major damage to hepatic artery requiring reconstruction
ii. Complete section of or major damage to splenic artery requiring reconstruction
iii. Complete section of or major damage t, portal vein requiring reconstruction
iv. Complete section of or major damage to cava vein requiring reconstruction
v. Complete section of or major damage to bile duct requiring reconstruction
vi. Damage to spleen requiring splenectomy
vii. Any unplanned bowel resection (not for oncological reasons)
viii. Partial or complete section of pancreas requiring resection (not for oncological reasons).
2. Intraoperative bleeding requiring urgent treatment
Acute major bleeding requiring urgent transfusions.
3. Unexpected medical conditions interrupting or changing the planned procedure
Life-threatening intraoperative events other than intraoperative damage and bleeding, which determine the interruption or complete change of the planned procedure, such as anaphylactic shock, cardiac arrest, myocardial infarction, etc.
Postoperative General Complications
4. Stroke causing patient’s permanent deficit
5. Need for CPR
Regardless of the underlying cause, patient needs cardiopulmonary resuscitation.
6. Myocardial infarction with patient’s transfer to CCU/ICU/other critical care facility
Myocardial infarction recorded as major complication if the patient needs to be transferred to CCU/ICU/other critical care facility, irrespective of the treatment.
7. Cardiac dysrhythmia requiring invasive treatment
Dysrhythmia atrial or ventricular, which requires invasive treatment (e.g., pace-maker, automatic implantable cardioverter defibrillator, etc.).
8. Acute myocardial failure with acute pulmonary edema or drop in EF > 50%
Acute myocardial failure that causes acute pulmonary edema or a large (> 50%) drop in EF. Acute pulmonary edema clinically detected. Drop in EF measured through echocardiogram.
9. Pulmonary embolism with symptoms confirmed by urgent CT scan
Pulmonary embolism recorded as major complication if (i) symptoms confirmed by CT scan, and (ii) CT scan required in urgency and not simply as a routine check for other reasons.
10. Need for prolonged intubation (> 24 hours after the surgical procedure)
11. Respiratory failure requiring reintubation
12. Need for tracheostomy
13. Pleural effusion requiring drainage
14. Pneumothorax requiring treatment
15. Acute liver dysfunction (the Child-Pugh score > 8 for longer than 48 hours)
Liver dysfunction recorded as major complication if the Child-Pugh score is greater than 8 for longer than 48 hours.
16. Acute renal insufficiency (postoperative creatinine twice its preoperative value) / renal failure requiring CVVH or dialysis
17. Infections (gastrointestinal, respiratory, urinary, or other) with both symptoms and germ isolation
Infections affecting (i) the gastrointestinal tract, (ii) the respiratory tract, (iii) the urinary tract, (iv) other systems, or (v) a combinations of systems. There should be both symptoms of an infection and germ isolation.
Postoperative Surgical Complications
18. Postoperative bleeding requiring both urgent transfusions and invasive treatment
Bleeding requiring both urgent transfusions and other invasive treatment (endovascular or endoscopic or surgical).
19. Postoperative bowel obstruction (clinical / radiological signs of obstruction, inability to enteral feed, longer need for NG suction)
Postoperative bowel obstruction considered a major complication if these conditions occur simultaneously: (i) there exist clinical and/or radiological signs of mechanical obstruction or paralytic ileus, (ii) a patient’s inability to enteral feed occurs, and (iii) there exists the need for nasogastric suction beyond the normal postoperative course.
20. Postoperative bowel perforation or necrosis requiring surgical treatment (or cause of death)
Postoperative bowel perforation or necrosis requiring surgical treatment, or being (post-mortem) diagnosed as the cause of death.
21. Duodenal leak (irrespective of presentation, method of identification, clinical consequences, and treatment)
Full thickness duodenal defect irrespective of (i) presentation, (ii) method of identification, (iii) clinical consequences, and (iv) treatment. An abscess close to the duodenal stump should also be recorded in this group.
22. Anastomotic leak (irrespective of presentation, method of identification, clinical consequences, and treatment)
Full thickness defect of esophago-jejunal, gastro-jejunal, jejuno-jejunal anastomoses irrespective of (i) presentation, (ii) method of identification, (iii) clinical consequences, and (iv) treatment. An abscess close to the anastomosis should also be recorded in this group.
23. Postoperative pancreatic fistula
A drain output of any measurable volume of fluid with an amylase level > 3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development / condition related directly to the postoperative pancreatic fistula (2016 International Study Group of Pancreatic Fistula’s definition).
24. Postoperative pancreatitis diagnosed both clinically and radiologically
Postoperative pancreatitis is considered a major complication if two conditions are met: (i) there exists a postoperative increase in serum amylases / lipases more than 3 times the normal value, and (ii) there are radiological signs of postoperative pancreatitis (e.g., edema or necrosis at CT scan).
25. Other postoperative abnormal fluid from drainage and/or abdominal collections without gastrointestinal leak(s) preventing drainage removal and/or requiring treatment
Postoperative biliary drain, postoperative chylous ascites, and other abnormal fluid from drainage, preventing or significantly delaying drainage removal (5 days or longer after the date set by a center’s protocols), as well as abdominal collections requiring invasive treatment.
26. Delayed gastric emptying (by 10th postoperative day) requiring treatment or delaying discharge
Failure to tolerate oral intake by the 10th postoperative day in the absence of bowel obstruction. This failure should (i) require endoscopic or surgical intervention, or (ii) delay a patient’s discharge for longer than 5 days with respect to the date set by a center’s protocols.
27. Other major complications requiring re-intervention or other invasive procedures
Other major complications, including evisceration, diaphragmatic hernia, feeding jejunostomy-related complications, etc., which require re-intervention or other invasive procedures.