Prospective review of a single center's general pediatric neurosurgical intraoperative and postoperative complication rates

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Object

The authors conducted a study to compare the complication rate (CR) of pediatric neurosurgical procedures in a general neurosurgery department to the CRs that are reported in the literature and to establish a baseline of CR for further targeted improvement of quality neurosurgical care.

Methods

The authors analyzed the prospectively collected data from a complication registration of 1000 consecutive pediatric neurosurgical procedures in 581 patients from the beginning of the registration in January 2004 through August 2008. A pediatric neurosurgeon was involved in 50.5% of the procedures. All adverse events (AEs) from induction of anesthesia until 30 days postoperatively were recorded.

Results

Overall, 229 complications were counted in 202 procedures. The overall CR was 20.2%, with a 2.7% intraoperative CR and a 17.5% postoperative CR. Tumor surgery was associated with the highest CR (32.7%), followed by CSF disorders (21.8%). The mortality rate was 0.3%. An unplanned return to the operating room in relation to an AE happened in 10.5% of all procedures and in 52% of procedures associated with AEs, the majority of which were related to CSF disorders.

Conclusions

The CR in pediatric neurosurgical procedures was significant, and more than half of the patients with an AE required a repeat surgical procedure. Analysis of CRs should be a prerequisite for the prevention of complications and for the development of targeted interventions to reduce the CR (for example, infection rates).

Abbreviations used in this paper:AE = adverse event; CR = complication rate; ETV = endoscopic third ventriculostomy; NSQIP = National Surgical Quality Improvement Program; RTOR = return to operating room.

Abstract

Object

The authors conducted a study to compare the complication rate (CR) of pediatric neurosurgical procedures in a general neurosurgery department to the CRs that are reported in the literature and to establish a baseline of CR for further targeted improvement of quality neurosurgical care.

Methods

The authors analyzed the prospectively collected data from a complication registration of 1000 consecutive pediatric neurosurgical procedures in 581 patients from the beginning of the registration in January 2004 through August 2008. A pediatric neurosurgeon was involved in 50.5% of the procedures. All adverse events (AEs) from induction of anesthesia until 30 days postoperatively were recorded.

Results

Overall, 229 complications were counted in 202 procedures. The overall CR was 20.2%, with a 2.7% intraoperative CR and a 17.5% postoperative CR. Tumor surgery was associated with the highest CR (32.7%), followed by CSF disorders (21.8%). The mortality rate was 0.3%. An unplanned return to the operating room in relation to an AE happened in 10.5% of all procedures and in 52% of procedures associated with AEs, the majority of which were related to CSF disorders.

Conclusions

The CR in pediatric neurosurgical procedures was significant, and more than half of the patients with an AE required a repeat surgical procedure. Analysis of CRs should be a prerequisite for the prevention of complications and for the development of targeted interventions to reduce the CR (for example, infection rates).

To provide patients with the proper knowledge for informed consent prior to surgical procedures, accurate intra- and postoperative complication rates (CRs) must be known. Published CRs for neurosurgical procedures are rarely reported in the literature.13 If presented, these CRs are often published by specialized centers treating special and specific diseases. Thus, the actual CRs published in the literature may be biased by centralization of expertise and therefore may not be representative of the average pediatric neurosurgeon or average neurosurgical center. Analysis of pediatric neurosurgical CRs occurring in general centers could provide a more accurate portrayal of complication risks by yielding more realistic data that can be shared with patients and families when obtaining informed consent. In fact, the patient should have the right to be informed of the results and CRs of the treating physician and/or institution instead of results and CRs obtained by others and elsewhere.

Furthermore, accurate registration of personal and institutional CRs (as well as results of treatment) allows comparison with published case series. By comparing one's own results with the published “standard of care,” one is able to recognize one's own shortcomings and areas for improvement in one's own institution. Also, reference values of CRs may be acquired in the institution as a baseline for further improvements,21 although the impact of such a registration on quality improvement remains to be established.20

A last major reason to look at institutional CRs, as compared with disease-specific or procedure-specific CRs, is that it offers the opportunity for commonalities to emerge, such as infections, CSF leaks, perianesthesia problems, and relatively rare but significant complications. These complications might be dismissed as incidental or nonsignificant in smaller procedure-specific series and not recognized as possibly structural complications that might be solved.

Therefore, complication registration is a prerequisite for improvement of neurosurgical care.

To establish our institutional CRs, we performed an analysis of our complications registration.

Methods

The study was approved by the local institutional review board (CMO Arnhem-Nijmegen). It was performed in an academic hospital serving an area of 1.7 million people for neurosurgery. For pediatric neurosurgery, however, the department serves a catchment area of approximately 3 million people. During the study period, the staff of the neurosurgical department consisted of 7 neurosurgeons, of which 1 was dedicated to pediatric neurosurgery (meaning > 50% of the caseload was pediatric and > 100 pediatric cases annually) because The Netherlands does not have a board certification for pediatric neurosurgery. All staff members participated in the surgical treatment of children. However, elective surgery in children was planned and performed preferably and predominantly by the pediatric neurosurgeon (E.J.v.L.).

A prospective registration using Microsoft Excel was constructed of all pediatric surgeries. Diagnosis in main groups and subgroups, type of operative procedure, and intra- and postoperative complications were registered, as well as the surgeon, return to operating room (RTOR), and further treatment. Information that might be essential for risk factor analysis (for example, comorbidity, medication use, and elective vs emergency surgery) was not entered into the registration. The registration became effective on January 1, 2004. Patients were subcategorized into groups in terms of their main diagnosis (Table 1).

TABLE 1:

Summary of surgical and medical complications*

Surgical MorbidityMedical Morbidity
neurological deficitcardiac
meningitisrespiratory/pneumonia
seizuresGI/hepatic
wound infectionrenal/GU/UTI
CSF leakhematological/TE
shunt blockagemetabolic
shunt infectionmiscellaneous
postop hemorrhage
inconclusive biopsy
death
abortion of procedure
miscellaneous

GI = gastrointestinal; GU = genito-urological; TE = thromboembolic; UTI = urinary tract infection.

One surgeon (E.J.v.L.) monitored the postoperative course of all patients for complications and added data to the registration on a daily basis. All adverse events (AEs), no matter how small, were registered during surgery, retrieved from operative charts, observed during daily ward rounds, and retrieved from clinical charts from the neurosurgical department. Since pediatricians and pediatric neurologists also took care of pediatric neurosurgery patients in close cooperation with the neurosurgeon, the clinical charts of those departments were also consulted on a regular basis for registered complications. Finally, during outpatient visits, parents were asked about complications occurring after discharge from the hospital that may or may not have required attention of the general practitioner or referring physician. All gathered AEs were discussed during the monthly morbidity and mortality conferences after which the staff, independent from the treating physician, decided whether the AE had to be registered as a complication or a sequela.

Intraoperative complications were defined as AEs occurring during the surgical procedure—from administration of local or general anesthesia to termination of local anesthesia/conscious sedation or extubation, respectively. Postoperative complications were defined as unfavorable events transpiring within 30 days of the operation. The rate of RTOR reflected subsequent visits to the operating room related to the initial procedure occurring within 30 days.

A CSF infection required the identification of an organism on Gram stain or CSF culture. We considered each mechanical shunt block within 30 days of surgery to be a complication. Endoscopic third ventriculostomy (ETV) failure within 30 days, however, was not considered to be a complication. Depending on the etiology of the hydrocephalus, ETV may achieve success rates of 50%–90%; therefore, an ETV failure should be considered a treatment failure rather than a complication. Multiple complications in the same patient were counted separately and linked to the appropriate procedure in case multiple procedures were performed.

Intraoperative hemorrhage was defined as unexpected excessive blood loss leading to a need for transfusion due to cardiovascular instability or premature abortion of procedure caused by poor visualization. Intraoperative CSF leakage was recorded as a complication in case the dura mater was opened unintentionally during extradural surgery. If an intraoperative complication led to a secondary intraoperative complication, only the initial complication was recorded. Moreover, if an AE occurred during an operation but was not known to be an AE, it was not counted as an intraoperative complication. For example, placement of a proximal ventricular catheter during ventriculoperitoneal shunt insertion was found upon postoperative imaging to be inadequate. Because it was not known to be problematic intraoperatively, it was not counted as an intraoperative complication but instead as a postoperative complication, just as an early CSF diversion failure would be.

Congenital disorders, mainly consisting of craniosynostosis and spinal dysraphism, were considered as one head group because these disorders are usually operated upon electively when the patients are usually in good condition and not symptomatic, such as in the other main groups.

Results

From January 2004 through August 2008, 1000 pediatric neurosurgical procedures were performed. These 1000 procedures were performed in 581 patients (mean 1.7 procedures per patient within this time frame). The patients' median age was 74 months and ranged from 1 day to 16.9 years.

Although the pediatric neurosurgeon (E.J.v.L.) performed the surgeries (n = 471) or directly supervised residents (n = 34) in 50.5% of the pediatric neurosurgical procedures, other attending neurosurgeons performed or supervised residents in the remaining 49.5%. The pediatric neurosurgeon performed the majority of the complex cases in addition to operations specific to the pediatric population, including 42% of CSF diversion procedures, 77% of the tumor procedures, 90% of dysraphism cases, and 100% of the craniosynostosis surgeries. Thus, 495 cases were performed by the other staff neurosurgeons and residents when the pediatric neurosurgeon was not on call or was on vacation. Two cerebrovascular surgeons, who also specialized in endovascular procedures, performed all cerebrovascular surgeries in the pediatric age group. Pediatric craniospinal trauma treatment and evacuation of intracranial and intraspinal abscesses/empyemas were evenly distributed among all neurosurgeons in the department.

Overall, 229 complications were counted in 202 procedures. Table 2 lists the number of procedures in which an intra- and/or postoperative complication occurred. The overall CR was 20.2%, with an intraoperative CR of 2.7% and a postoperative CR of 17.5%.

TABLE 2:

Intraoperative and postoperative complications occurring per procedure within each subgroup category

SubgroupNo. of CasesNo. of Procedures (%)
IntraopPostopOverall
CSF diversion4637 (1.5)94 (20.3)101 (21.8)
congenital1673 (1.8)25 (15.0)28 (16.8)
tumor15610 (6.4)41 (26.3)51 (32.7)
trauma1064 (3.8)5 (4.7)9 (8.5)
infection241 (4.2)3 (12.5)4 (16.7)
cerebrovascular231 (4.3)3 (13.0)4 (17.4)
miscellaneous611 (1.6)4 (6.6)5 (8.2)
total100027 (2.7)175 (17.5)202 (20.2)

The most common intraoperative complications were unexpected or abnormal massive blood loss leading to cardiovascular instability (8 cases) and premature abortion of the procedure (5 cases, 4 of which consisted of failed cannulation of the CSF space) (Table 3). Tumor surgery was associated with the highest rate of intraoperative complications (6.4%).

TABLE 3:

Intraoperative complications

ComplicationNo./1000 OpsRate/1000 Ops
death20.2%
hemorrhage80.8%
premature abortion of procedure50.5%
cardiopulmonary/anesthetic30.3%
inconclusive biopsy30.3%
unintended structural damage20.2%
CSF leak10.1%
other30.3%

The most common postoperative complications were CSF diversion failures (5.3%) and infections (5.2%) (Table 4). A CSF diversion failure occurred in 11.4% of CSF diversion procedures. Shunt infections accounted for almost half of all infections. The majority of CSF leaks (1.3%) and pseudomeningoceles (1.7%) occurred in posterior fossa surgery and tethered cord surgery. A new neurological deficit developed in 28 patients (2.8%). The majority of these occurred during tumor surgery (20 cases, accounting for 13% of tumor surgery procedures).

TABLE 4:

Postoperative complications

ComplicationNo./1000 OpsRate/1000 Ops
death10.1%
hemorrhage50.5%
early CSF diversion failure535.3%
infection total525.2%
 shunt related232.3%
 wound related40.4%
 meningitis related70.7%
 other infection181.8%
neurological deficit282.8%
CSF leak131.3%
pseudomeningocele171.7%
other333.3%

Tumor surgery was associated with the highest rate of intra- and postoperative complications. A complication occurred in 32.7% of these procedures. This was followed by CSF diversion procedures (21.8%) and surgery for congenital disorders (16.8%). In the latter group, the treatment of intracranial cysts led to a CR of 22% (5 of 23 cases), to 9.8% (5 of 51 cases) in cases of craniosynostosis, and to 19.5% (15 of 77 cases) in surgery for spinal deformities.

The pediatric neurosurgeon had an overall CR of 23% versus 17.2% for the nonpediatric neurosurgeons as a group, respectively. This difference was mainly caused by large differences of CRs in tumor surgery (38.3% vs 13%, respectively), trauma surgery (22.2% vs 5.7%, respectively), and the miscellaneous group (13.6% vs 5.1%, respectively). However, both groups were absolutely not comparable and therefore significance was not calculated. Although the pediatric neurosurgeon was involved in 77% of tumor surgeries, he performed 100% of surgeries for optic pathway gliomas, third ventricle and pineal region tumors, and brainstem tumors. In trauma surgery, the pediatric neurosurgeon performed only 14% of the procedures but 22% of the craniotomies and 44% of the decompressive craniotomies. The single group in which patients operated on by the pediatric neurosurgeon were comparable to those treated by nonpediatric neurosurgeons is the CSF diversion group; here we found no significant difference in CRs (21% vs 22.4%, respectively).

Thirteen patients died within 30 days after surgery. Three of the deaths were considered a result of a complication. The other 10 patients died of disease or after stopping treatment (8 trauma cases and 2 tumor cases). Two patients experienced asystole intraoperatively that led to subsequent death on the operating table. Each episode occurred during evacuation of traumatic hematomas: one during a suboccipital craniectomy for a cerebellar contusion/hematoma and the other during evacuation of a subdural hematoma with concomitant cerebral edema that led to asystole. Although both events were registered as complications, postoperative evaluation of these AEs did not identify preventable causes. For example, asystole seemed more likely to be caused by the primary disease, which was severe head trauma with severe cerebral edema and intracerebral hematoma in these 2 cases. One patient died several days after surgery for a supratentorial malignant ependymoma as a result of intraoperative bradycardia without cardiac output for a prolonged period. There was no apparent surgical cause for the bradycardia.

The number of patients requiring an unplanned RTOR in relation to a complication was 105 (10.5% of all procedures). The majority of these (n = 81 [77%]) were related to CSF diversion procedures. In this CSF diversion group, the rate of RTOR was 17.5%. The rate of RTOR was 12.5% in the infection group, 7% in the tumor group, 3% in the congenital group, 2% in the trauma group, and 0% in the cerebrovascular group.

The reason for RTOR in 53 cases (50%) was an early CSF diversion failure, 4 of which were in combination with an infection. Eleven surgeries (10%) had to be performed in relation to CSF leakage, 3 of which were in combination with an infection. Shunt infection was the reason for RTOR in 17 patients (16%). Repair of a pseudomeningocele had to be performed in 4 patients (4%). Evacuation of a postoperative hemorrhage had to be performed in 3 patients (3%), and RTOR for infection (abscess and empyema) was necessary in 4 cases (4%). Three inconclusive biopsies led to renewed biopsies in 3 patients (3%). Other reasons for RTOR occurred in 10 patients (10%). The RTOR rate for the pediatric neurosurgeon was 8.7%, whereas the rate was 12.3% when the pediatric neurosurgeon was not involved. The difference was not significant (p = 0.06).

Discussion

What is a Surgical Complication?

Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications.1 This shortcoming hampers comparison of outcome data among different centers and therapies and over time.

In medicine, a complication is “an unanticipated problem that arises following, and is a result of, a procedure, treatment, or illness” (Webster's New World Medical Dictionary, 3rd Edition) or “a pathological process or event occurring during a disease that is not an essential part of the disease; it may result from the disease or from independent causes” (The American Heritage Medical Dictionary, 2007). A surgical complication can be defined as “any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure” or “a surgical complication is any undesirable, unintended, and direct result of surgery affecting the patient which would not have occurred had the surgery gone as well as could reasonably be hoped.”19 A surgical complication should be discerned from sequelae, which are “conditions that are inherent in the procedure, and that thus will inevitably occur (such as scar formation or the inability to walk after an amputation).”19

A thin line often exists between complications and sequelae, and these 2 events may even overlap. Hemiparesis experienced after resection of a temporal tumor or a medulloblastoma is indeed a complication. However, during an attempt at radical resection of a tumor in the thalamus, a hemiparesis can just as well be considered a sequela of surgery instead of a complication. The same goes for visual field loss during optic pathway glioma resection: is it an anticipated and accepted sequela or a complication? In some cases, the difference between sequelae and complications is dependent upon the goals set before surgery. For instance, to increase radicality of tumor removal and thus survival (for example, during ependymoma surgery), one may accept increased neurological deterioration and disability beforehand.5,14

Another difficulty in defining a complication in neurosurgery is that an event may be a complication in a specific procedure but not in another procedure. The dura mater is opened deliberately in many neurosurgical procedures, but dura opening during extradural surgery (for example, craniosynostosis surgery) may become a complication (albeit usually an irrelevant complication for the patient if addressed appropriately).

In case of multiple complications, it may be difficult to classify them correctly, unless the complications are fully independent (for example, pneumonia and blindness). However, in some cases, a chain of events occurs in which one complication is the result of the other (for example, leakage of CSF through wound breakdown leading to shunt infection).

All of these factors together render the determination and classification of a complication sometimes rather arbitrary and are thus a main cause of bias in comparing different studies. Therefore, it is important to have a universal language and classification system. The Canadian Pediatric Neurosurgery Study Group has established a Canadian consensus definition of AEs and developed a morbidity data collection form.6 This is an important first step for uniform registration. However, several key issues are not addressed. How do we classify complications in a chain of events when a complication is the result of another complication—as separate complications or as a single registration? And how do we score the severity of a complication—as minor/major or based on the therapeutic consequences of the complication (medical/surgical, persistent/reversible)?

Clavien and Dindo developed a classification of surgical complications based upon the therapeutic consequences of a complication—for example, whether a medical or surgical intervention is needed for treatment of the complication or whether a disability, life-threatening situation, or even death has occurred. Their 5-point grading system of complication severity has been validated and proven to be objective, reliable, and reproducible for intra- and interinstitutional comparison.3,4 Landriel Ibañez et al. presented a useful modification of this classification for neurosurgery based on a 4-point grading scale that discerned between surgical and medical complications.11 This objectivized stratification of severity should obviate the use of subjective qualifications such as “minor,” “moderate,” and “major” complications and allow for easier comparison between studies. Maybe such a grading can be added to the Canadian Pediatric Neurosurgery Study Group initiative for pediatric neurosurgery.

The American College of Surgeons has launched another initiative: the National Surgical Quality Improvement Program (NSQIP). This is a national program in the US in which a validated, risk-adjusted, outcomes-based program is used to measure and improve the quality of surgical care.18 Hospitals can subscribe to this program and should supply staffing themselves for data collection and analysis using a secure, web-based system. This staff member (called a surgical clinical reviewer) receives a special training program. Clinical data on variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major and minor surgical procedures in both inpatient and outpatient settings are analyzed. A pediatric program is also available and has been used for pediatric neurosurgery.16 The American College of Surgeons' NSQIP indicates that surgical outcomes improve and that hospitals participating in this initiative appear to be avoiding substantial numbers of complications, improving care, and reducing costs.7,8,10 A similar program would be very welcome for Europe as well, but participation costs and data security concerns will hamper such an initiative at least in our country in the near future.

It has been suggested that unplanned RTOR can and should be used as a quality indicator since it is relatively nondiscretionary and the data can be easily tracked and gathered.12,15 However, if used for comparison between institutions, case mix correction has to be performed because different procedures have different rates of RTOR (CSF procedures had a 7-fold increased risk of RTOR and surgery out-of-hours had a 2.5-fold increase as compared with elective surgery in the series of Mukerji et al.15).

Comparison of Pediatric Neurosurgery Complication Rates

In our study, we found an overall CR of approximately 20% in all pediatric neurosurgery procedures in our department. We found only 1 other article addressing overall institutional CRs in pediatric neurosurgery. The pediatric neurosurgical department at the SickKids hospital in Toronto reported an overall CR of 16.4% (data were also prospectively collected).5 The CRs in diagnostic subgroups were also comparable, but further differentiated comparison is difficult because of differences in classification. In the Toronto series, 64% of AEs required a second procedure, whereas in our series 52% of AEs required a second procedure. The overall unplanned 30-day RTOR in our series was 10.5% and that in the Toronto series was 10.4%,5 whereas this rate was 17% in a British single pediatric neurosurgery institution series.15 In the latter series, the unplanned reoperation rate increased to 28% during the 2-year follow-up study period.15

In Toronto, all patients were treated by pediatric neurosurgeons with a much higher caseload than in our institution. Toronto is therefore a good reference for comparison with our study. However, in such a tertiary referral center, the cases may be more complicated and thus more prone to complications, so comparison is therefore not always possible. In contrast to Toronto, only half of the procedures were performed by a pediatric neurosurgeon in our institution, while the other half were performed by general neurosurgeons. The single pediatric neurosurgeon had a higher CR than the general neurosurgeons (23% vs 17%, respectively). However, procedures that were very specific for the pediatric population were mainly performed by the pediatric neurosurgeon (100% of procedures for craniosynostosis and 90% for dysraphia), while 77% of oncology procedures were performed by the pediatric neurosurgeon. In the latter group, the pediatric neurosurgeon operated on all cases that were prone to higher CRs, such as third ventricle and pineal region tumors, craniopharyngiomas, optic pathway tumors, brainstem tumors, and ependymomas. The involvement of the general neurosurgeons was mainly limited to pilocytic astrocytomas and medulloblastomas. The pediatric neurosurgeon thus had a CR of 38% compared to 13% for the general neurosurgeons in this group of patients. In the group of CSF disorders, the CRs of the pediatric neurosurgeon and general neurosurgeons seemed to be the same, but the pediatric neurosurgeon performed surgery on the patients who were prone to a higher CR, especially the age group younger than 1 year and the complicated shunt dysfunction cases. Therefore, our study does not allow any conclusions to be drawn as to the usefulness of subspecialization in pediatric neurosurgery based on CR alone.

For general neurosurgery, few reports on overall CRs have been published. Theodosopoulos et al. analyzed a prospective series of more than 5000 consecutive neurosurgical procedures in an adult population, of which two-thirds were spine surgeries. They found a CR of 4.9% and an RTOR during the same hospitalization of 0.38%,21 which compares favorably to the aforementioned pediatric series. Houkin et al. registered an AE rate of 28.3% in a series of 643 neurosurgical interventions, while Bonsanto et al. had an AE rate of 16.4% in 8160 procedures.2,9 These rates are in line with published series in general surgery that report AE rates of 14%–39% and the aforementioned rates in pediatric neurosurgery.9

It is possible to further analyze our subgroups and compare them with published series of treatments for specific diseases. However, this is prone to different types of bias. First, these published series usually represent studies from specialized centers, with sufficient caseloads of the specific disease being reported on as well as special interests and expertise. Second, the reported CRs are often byproducts of reporting treatment results. Especially in retrospective studies, it is questionable whether complications have been registered adequately. Third, the special attention that is given to a group of patients under study may infer a lower CR, while at the same time CRs may be underestimated in patients undergoing routine procedures at the same institution.

The CR in pediatric neurosurgery compares unfavorably to pediatric surgery. In a large cohort of more than 330,000 pediatric surgery procedures, a 10.3% rate of AEs was found.17 The difference may in part be explained by the large number of outpatient procedures in which the AE rate was 2.1% while the rate was 16.1% for inpatient procedures. This latter number is comparable to the AE rate in pediatric neurosurgery. Rice-Townsend et al. also found that a relatively small number of general pediatric surgical procedures contributed to a disproportionate share of AEs.17 Such a study has not been performed in pediatric neurosurgery, although neurooncological surgery seems to stand out with a higher CR than other procedures.

Changes of Procedures After Complication Registration

We started our complication registration to be able to compare our CRs with others to discover our flaws, blind spots, and weak performances in order to identify areas needing improvement. Also, we wanted to establish baseline values that could serve as an incitement for any improvement regardless of any comparison with others. The complications as listed in Table 4 suggest that many complications may be preventable. However, in their series with an AE rate of 28.3%, Houkin et al. considered 68.7% of their AEs predictable before or during the procedure, while only 3.3% of AEs were deemed avoidable.9 A medical error as the cause of the AE was observed in 1.1% of AEs.9 In their series of almost 10,000 neurosurgical procedures with complication registration, Steiger et al. were not able to establish a measurable impact on quality improvement of the introduction of an institutional morbidity and mortality conference.20

Nevertheless, we have learned several lessons from our complication registration and adapted several procedures and protocols as a result of it. Our shunt infection protocol has been adapted several times as we noticed that certain measures did not drop the shunt infection rate significantly. Since many shunts are implanted by general neurosurgeons, we have developed a protocolled shunt type selection to have a uniform policy for all staff members. The application of the Mayfield head holder has received more attention to prevent skull fractures and hematomas. Surgical hemostasis and blood replacement management in craniosynostosis surgery have been reviewed and given more attention to reduce the transfusion rate. Finally, more effort has been put into watertight dural closure after posterior fossa surgery and tethered cord surgery. Compared with general neurosurgery, oncological surgery has become more aggressive in our hands over time to increase survival rates, which may lead to an accepted increase of the CR in this subgroup.

Whether or not all of these measures will lead to a significant reduction of CRs in our patient group remains to be established. For that purpose, we will analyze our registration in the future for the next 1000 pediatric neurosurgical cases and compare the results with this series. In addition, our registration is lacking information that allows detailed risk factor analysis. This is an absolute shortcoming if further CR reduction is intended. An update of our registration, or even better—a project like a Dutch NSQIP—should be sought for in the near future.

Should We Disclose Our Complication Rates Fully to Our Patients?

It is neither practical nor desirable to list all possible complications to a patient. Not only would such a disclosure be time-consuming, but providing too much information can also reduce rather than enhance a patient's autonomy by confusing the patient. Furthermore, excessive information about theoretical complications may frighten the patient into refusing operations that may in reality be relatively low risk and highly beneficial. Clear disclosure that is neither deficient nor excessive in detail and that is tailored to the patient's own situation requires a combination of good judgment and communicative ability.1 Ideally, the surgeon tailors the information to the needs and circumstances of the individual patient. For that cause, a grading system of AEs such as the one presented by Landriel Ibañez et al. can be very helpful since it displays severity and treatability of AEs rather than a simple listing of AEs.11 This suggests a form of relative control of AEs by the surgeon, rather than being a victim of an AE that is suggested by a qualitative listing of AEs.

Conclusions

The CR of pediatric neurosurgical procedures in a general neurosurgical institution is significant but comparable to the CR in a specialized pediatric neurosurgical center. Maintaining a prospective registration collecting all procedural complications allows for detecting systemic commonalities in CRs, comparing with other institutions, and adding to morbidity and mortality conferences that usually review single complications. However, we are in need of an international standardized and uniform qualitative complication registration that integrates a grading system for the severity of the complication.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: van Lindert. Acquisition of data: van Lindert, Leonardo. Analysis and interpretation of data: van Lindert, Leonardo. Drafting the article: van Lindert. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: van Lindert. Statistical analysis: van Lindert. Administrative/technical/material support: van Lindert. Study supervision: van Lindert.

Portions of this work were presented in abstract form at the XIV World Congress of Neurosurgery, Boston, MA, August 30–September 4, 2009.

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    Raval MVDillon PWBruny JLKo CYHall BLMoss RL: American College of Surgeons National Surgical Quality Improvement Program Pediatric: a phase 1 report. J Am Coll Surg 212:1112011

  • 17

    Rice-Townsend SHall MJenkins KJRoberson DWRangel SJ: Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures. J Pediatr Surg 45:112611362010

  • 18

    Shiloach MFrencher SKJ JrSteeger JERowell KSBartzokis KTomeh MG: Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210:6162010

  • 19

    Sokol DKWilson J: What is a surgical complication?. World J Surg 32:9429442008

  • 20

    Steiger HJStummer WHänggi D: Can systematic analysis of morbidity and mortality reduce complication rates in neurosurgery?. Acta Neurochir (Wien) 152:201320192010

  • 21

    Theodosopoulos PVRinger AJMcPherson CMWarnick REKuntz C IVZuccarello M: Measuring surgical outcomes in neurosurgery: implementation, analysis, and auditing a prospective series of more than 5000 procedures. Clinical article. J Neurosurg 117:9479542012

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Article Information

Address correspondence to: Erik J. van Lindert, M.D., Ph.D., Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. email: e.vanlindert@nch.umcn.nl.

Please include this information when citing this paper: published online November 15, 2013; DOI: 10.3171/2013.9.PEDS13222.

© AANS, except where prohibited by US copyright law.

Headings

References

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Adedeji SSokol DKPalser TMcKneally M: Ethics of surgical complications. World J Surg 33:7327372009

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Bonsanto MMHamer JTronnier VKunze S: A complication conference for internal quality control at the Neurosurgical Department of the University of Heidelberg. Acta Neurochir Suppl 78:1391452001

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Dindo DDemartines NClavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:2052132004

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Morris EBLi CKhan RBSanford RABoop FPinlac R: Evolution of neurological impairment in pediatric infratentorial ependymoma patients. J Neurooncol 94:3913982009

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Raval MVDillon PWBruny JLKo CYHall BLMoss RL: American College of Surgeons National Surgical Quality Improvement Program Pediatric: a phase 1 report. J Am Coll Surg 212:1112011

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Rice-Townsend SHall MJenkins KJRoberson DWRangel SJ: Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures. J Pediatr Surg 45:112611362010

18

Shiloach MFrencher SKJ JrSteeger JERowell KSBartzokis KTomeh MG: Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210:6162010

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Sokol DKWilson J: What is a surgical complication?. World J Surg 32:9429442008

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Steiger HJStummer WHänggi D: Can systematic analysis of morbidity and mortality reduce complication rates in neurosurgery?. Acta Neurochir (Wien) 152:201320192010

21

Theodosopoulos PVRinger AJMcPherson CMWarnick REKuntz C IVZuccarello M: Measuring surgical outcomes in neurosurgery: implementation, analysis, and auditing a prospective series of more than 5000 procedures. Clinical article. J Neurosurg 117:9479542012

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