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Clinical validation and comparison of the Comprehensive Complication Index and Clavien-Dindo classification in predicting post-operative outcomes after cytoreductive surgery in advanced ovarian cancer
  1. Malika Kengsakul1,2,
  2. Gatske M Nieuwenhuyzen-de Boer1,3,
  3. Suwasin Udomkarnjananun4,
  4. Stephen J Kerr5,
  5. Helena C van Doorn1 and
  6. Heleen J van Beekhuizen1
  1. 1 Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
  2. 2 Department of Obstetrics and Gynecology, Srinakharinwirot University Panyananthaphikkhu Chonprathan Medical Center, Nonthaburi, Thailand
  3. 3 Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
  4. 4 Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  5. 5 Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  1. Correspondence to Dr Malika Kengsakul, Department of Gynecologic Oncology, Erasmus MC, Rotterdam, 3000 CA, The Netherlands; malika{at}


Objective The Comprehensive Complication Index (CCI) is an instrument used to measure cumulative post-operative complications. Our study aimed to validate the CCI after cytoreductive surgery for primary advanced-stage epithelial ovarian cancer, and to compare its diagnostic performance with the Clavien-Dindo classification.

Methods This prospective cohort study classified post-operative complications according to the Clavien-Dindo classification and the CCI. Logistic regression was used to determine the association between both classifications with intensive care unit admission, prolonged length of hospital stay (defined as stays longer than the 75th percentile of all stays in this study), 30-day readmission, and time to initiating chemotherapy after surgery >42 days. Area under the receiver operating characteristic curves (AUC) were used to assess the discriminative performance of each classification.

Results A total of 300 patients were included in the analysis. Most patients (n=255, 85%) underwent interval cytoreductive surgery. Complete cytoreduction was achieved in 235 (78%) patients. Overall, 30-day post-operative complications classified by the Clavien-Dindo classification occurred in 147 (49%) patients. Severe complications (grade ≥3a) occurred in 51 (17%) patients. Approximately 30% (n=82) had multiple complications. The CCI showed an excellent correlation with the Clavien-Dindo classification (r=0.906, p<0.001). In comparison with the Clavien-Dindo classification, the proportion of patients classified with severe complications increased from 17% to 30% when stratified with the CCI, and 20% of patients were diagnosed with a CCI score that correlated with a higher Clavien-Dindo classification grade. On regression analysis, both Clavien-Dindo classification and CCI had associations with intensive care unit admission, prolonged length of hospital stay, 30-day readmission, and time to chemotherapy >42 days (all p<0.05). AUC demonstrated that CCI (0.842, 95% CI 0.792 to 0.893) and Clavien-Dindo classification (0.813, 95% CI 0.762 to 0.864, p<0.001) had a good diagnostic performance for prolonged length of hospital stay.

Conclusions Both the Clavien-Dindo classification and CCI showed significant associations with all surgical outcomes. However, the cumulative complications score of the CCI demonstrated a more superior discriminative performance than the Clavien-Dindo classification for prolonged length of hospital stay in advanced-stage epithelial ovarian cancer.

  • ovarian neoplasms
  • surgical procedures, operative
  • postoperative complications
  • postoperative period

Data availability statement

Data are available upon reasonable request.

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  • Contributors MK, GNM-dB, SU, SJK, HCvD and HJvB contributed to the study conception and design. Material preparation and data collection were performed by MK and GNM-dB. The data analysis was performed by MK, SU and SJK. The first draft of the manuscript was written by MK and SU. All authors had reviewed and edited the manuscript. All authors approved the final manuscript for publication. MK, GNM-dB and HJvB are the guarantor of the manuscript.

  • Funding Data are collected in The PlaComOv-study. This randomized controlled trial is funded by the Netherlands Organization for Health Research and Development (ZonMw), number 843001805.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.