Background: Expectation for improved surgical quality has focused scrutiny on complication analysis. Applying a classification scheme predicated on therapeutic intervention, we examined predictive factors for, and the economic impact of, complications of escalating severity after pancreatic resection.
Methods: 308 consecutive pancreatic resections (218 proximal; 90 distal) from 10/01 to 10/06 were stratified into the six Clavien complication grades: No Complication; I (minimal intervention); II (pharmacologic intervention); III (invasive intervention); IV (life-threatening); and V (death). Predictive factors were assessed for discrimination between categories, and clinical and economic metrics were compared.
Results: Patients regularly suffered minor adverse events (Grade I & II: 65%), but seldom developed major complications (Grade III - V: 17%). Patients with Grade I complications were clinically indistinguishable from those with no complications (Table). However, ICU utilization, duration of stay, discharge to rehabilitation facilities, and total hospital costs significantly increased from Grades II - IV. Oliguria represented the most common Grade I or II complication. Pancreatic fistula was the most common indication for invasive intervention (Grade III) and respiratory failure for management in intensive care settings (Grade IV). Hemorrhage was the most common cause of postoperative death (Grade V). On multivariate analysis, there were no identifiable risk factors for Grade I complications, however, age (> 75 years), diabetes, and operative blood loss (> 500ml) were factors associated with more significant complications (Grades II to IV). In addition, patient acuity (POSSUM) and pancreatic malignancy were predictive for Grade IV. Coronary heart disease was the only risk factor for death, which was an early (6.5 days) but more costly (,226/day) event.
Conclusion: Increasing severity of complications places considerable burden on patients and their health care resources. More severe complications require longer hospital stays, more aggressive management, and differential increases in resource utilization. Differences in predictive factors, type of complication, and costs distinguish the grades of severity.
Clinical and economic outcomes for complications of increasing severity.

	None	Grade I	Grade II	Grade III	Grade IV	Grade V	p Value
Patients (% all resections)	54 (18%)	85 (27%)	117 (38%)	31 (10%)	17 (6%)	4 (1%)	--
ICU Utilization	0 (0%)	0 (0%)	0 (0%)	5 (16%)	8 (47%)	4 (100%)	< .001
Duration of Stay (median, days)	7	7	8	12	21	6.5	< .001
Discharge to Rehabilitation Facilities	1 (2%)	6 (7%)	19 (16%)	7 (23%)	9 (53%)	--	< .001
Total Costs (median)	$16,385	$16,963	$18,603	$25,850	$61,721	$31,921	< .001
Cost per day (median)	$2,154	$2,204	$2,310	$2,344	$2,982	$6,226	< .001