Comprehensive review of post-liver resection surgical complications and a new universal classification and grading system

Table 1 Comparison between the modified grading system and the Clavien-Dindo classification

Modified grades	Clavien-Dindo classification
Grade A	GradeI	Any deviation from the normal postoperative course that did not require special treatment
	Grade II	Cases requiring pharmacological treatment
Grade B	Grade IIIa	Cases requiring surgical or radiological interventions without general anesthesia
Grade C	Grade IIIb	Cases requiring surgical or radiological interventions performed under general anesthesia
	Grade IVa	Life-threatening complications involving single organ dysfunction
Grade D	Grade IVb	Life-threatening complications involving multiple organ dysfunction
	Grade V	Cases that resulted in death

Table 2 Grading system and representative management strategies for post-hepatectomy liver failure

Grades	Definition	Management strategies
Grade A	No change in the patient’s clinical management strategy required or manageable with medication	Diuretics, selective digestive decontamination, lactulose, glucagon-insulin therapy, stronger neo-minophagen C
Grade B	Manageable without invasive treatment	FFP transfusion, hyperbaric oxygen therapy
Grade C	Invasive treatment required	Plasma exchange, artificial liver support, surgery (including liver transplantation)

Artificial liver support is including high-flow hemodialysis with FFP transfusion. FFP: Fresh frozen plasma.

Table 3 Grading system and representative management strategies for bile leakage

Grades	Definition	Management strategies
Grade A	No change in the patient’s clinical management strategy required or manageable with simple drainage	Drainage within 7 d Antibiotic administration
Grade B	Manageable with interventional procedures	Drainage for 7 or more day, ethanol injection, fibrin paste injection, single ENBD, single EBD, single PTBD, PTPE, TAE
Grade C	Cases involving pneumoperitoneum, inflammation, multiple organ failure, or reoperation	Complicated IVR (combinations with any Grade Bs) Reoperation

ENBD: Endoscopic nasobiliary drainage; EBD: Andoscopic biliary drainage; PTBD: Percutaneous transhepatic biliary drainage; PTPE: Percutaneous transcatheter portal embolization; TAE: Transcatheter arterial embolization; IVR: Interventional radiology.

Table 4 Grading system and representative management strategies for acute renal failure

Grades	Definition	Management strategies
Grade A	Increase in serum creatinine level of ≥ 0.3 mg/dL from the baseline or 1.5 to 2-fold increase from the baseline	Dehydration
	Urinary output of less than 0.5 mL/kg per hour for more than 6 h	Diuretics
Grade B	Two-fold increase in the serum creatinine level from the baseline	Continuous mannitol + diuretics
	Urinary output of less than 0.5 mL/kg per hour for more than 12 h
Grade C	Dialysis treatment required (serum K > 6.0 mEq, BE < -10, uremia, hypouresis that lasts for more than three days)	Hemodialysis

Table 5 Grading system and representative management strategies for ascites

Grades	Definition in International Ascites Club (2003)	Definition in International Ascites Club (1996)
Grade A	Detected only on United States	Mild
Grade B	Moderate symmetrical distention of the abdomen	Moderate
Grade C	Marked abdominal distention	Massive or tense

Table 6 Grading system and representative management strategies for ascites

Grades	Definition	Management strategies
Grade A	Requiring any changes in the clinical management strategy or manageable with medication	Diuretics, sodium restriction
	Ascites discharge < 1000 mL/d in the drainage case
Grade B	Grade A ascites that lasts for more than 2 wk or requires peritoneal puncture	Peritoneal puncture
	Ascites discharge < 2000 mL/d in the drainage case
Grade C	Invasive treatment required	Denver peritoneovenous shunt, TIPS, PSE, splenectomy

TIPS: Transjugular intrahepatic portosystemic shunt; PSE: Partial splenic embolization.

Table 7 Grading system for superficial SSI and wound dehiscence

Grades	Definitions	Management strategies
Grade A	Manageable within 2 wk	Small open wound, outpatient service
Grade B	Requiring any management 2 wk and more	Large open wound, inpatient service
Grade C	Any management required under general anesthesia

Table 8 Grading system for deep and organ/space surgical site infections

Grades	Definitions	Management strategies
Grade A	Manageable without requiring any additional perioperative management within 2 wk	Antibiotics, simple drainage
Grade B	Requiring any management 2 wk and more	Additional drainage, irrigation
Grade C	Any management required under general anesthesia

Table 9 Grading system and representative management strategies for coagulation disorders

Grades	Definition	Managements
Grade A	Does not require any change in the clinical management strategy	Vitamin K, ATIII, LMWH, SPI, UFH, and DS
	Plat < 10 × 104 (preoperative Plat was within normal range)
	30% reduction in Plat (preoperative Plat was abnormal)
Grade B	Medication required for more than 5 d	Platelet transfusion
	Plat < 5 × 104 (preoperative Plat was within normal range)
	60% reduction in Plat (preoperative Plat was abnormal)
Grade C	Intensive care treatment required and involved the failure of other organs

Plat: Platelet count; ATIII: Anti-thrombin; LMWH: Low molecular weight heparin; SPI: Synthetic protease inhibitor; UFH: Unfractionated heparin; DS: Danaparoid sodium.

Table 10 Grading system and representative management strategies for pneumonia and respiratory disorder

Grades	Definition	Managements
Grade A	Meet SIRS criteria with imaging findings in less than 50% of the lung field or PaO2/FiO2 < 300	Antibiotics and oxygen
		Sputum suction
Grade B	Meet SIRS criteria with imaging findings in 50% and more of the lung field or PaO2/FiO2 < 200	Antibiotics and oxygen, IPPV, NPPV, bronchoscopy for sputum suction
Grade C	Requiring ventilator support	Ventilator

Systemic inflammatory response syndrome criteria is defined as two or more of the following clinical signs: bodily temperature > 38 °Cor < 36 °C, heart rate > 90/min, respiratory rate > 20 /min or PaCO₂ < 32 mmHg, WBC > 12000/μL or < 4000 /μL or immature cells > 10%. Pneumonia imaging is any of airspace opacity, lobar consolidation, or interstitial opacities. SIRS: Systemic inflammatory response syndrome; IPPV: Intermittent positive-pressure breathing; NPPV: Nasal positive-pressure ventilation.