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The extended postoperative complication score: A dual-axis reporting plan for general surgery
Federico Coccolini1, Enrico Cicuttin, Mircea Chirica
1Department of General, Emergency, and Trauma Surgery, Pisa University Hospital, Pisa, Italy (F.C., C.C.); Department of General, Emergency, and Trauma Surgery, Pavia University Hospital, Pavia, Italy (E.C.); Department of General and Emergency Surgery, Grenoble University Hospital, Grenoble, France (M.C.); Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia (V.R.); Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA, USA (R.C.); Department of General and Emergency Surgery, Macerata Hospital, Macerata, Italy (M.S.); Department of General and Emergency Surgery, Istanbul Medeniyet University, Istanbul, Turkey (A.I.); Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA (W.L.B.); Department of Cardiac Surgery, Pisa University Hospital, Pisa, Italy (A.C., L.B.); Department of General and Emergency Surgery, Legnano Hospital, Legnano, Italy (D.M.); Division of General Surgery, Rambam Health Care Campus, Haifa, Israel (Y.K.); Department of General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy (M.C.); Department of Emergency Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (H.K., M.C.); Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado (E.E.M.); Division of Surgery, Hillel Yaffe Medical Center, Hadera, Israel (B.K.); Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden (T.H.); Department of Surgery, Inova Fairfax Hospital, Fairfax County, VA (P.F.); Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Canada (A.W.K.); 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece (M.P.); Department of General, Emergency, and Trauma Surgery, Bufalini Hospital, Cesena, Italy (F.C.); Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, PA (G.B.).
Background:
Grading surgical complications and sequelae is of paramount importance for analyzing results and improving patient care and system performance and in optimizing resource allocation and use. Existing systems for surgical complication classification do not consistently account for baseline physiologic vulnerability and often conflate treatment intensity with clinical severity. This limitation reduces interpretability across diverse patient populations, particularly in emergency and elective general surgery.
Methods:
A multidisciplinary expert panel conducted a modified Delphi process to develop a dual-axis classification system, the Extended Postoperative Complication Score (EPCS). This system stratifies patients preoperatively into three baseline classes (A, B, C) reflecting physiologic reserve and immunocompetence. Postoperative events are then graded by physiologic impact from Grade 0 (minor, no impact) to Grade IV (death). Sequelae, defined as anticipated events related to underlying pathology or chronic disease, are separately categorized. Representatives of the most relevant international emergency and trauma surgical associations were involved (World Society of Emergency Surgery, European Society for Trauma and Emergency Surgery, American Association for the Surgery of Trauma, Panamerican Trauma Society, EndoVascular and Trauma Management Society, Global Alliance for Infections in Surgery).
Results:
The EPCS yields 18 mutually exclusive strata, combining five complication grades and three baseline classes, plus three sequelae codes. The matrix enables interpretable outcome reporting across settings, accounting for both event severity and host vulnerability. Expert consensus confirmed conceptual clarity and operational feasibility. The system allows applications to elective, urgent, and emergent operations, and is compatible with clinical audit, observational research, and pragmatic trials.
Conclusions:
The EPCS provides a structured, physiologically anchored method for postoperative complication stratification. Its dual-axis design may improve the validity of outcome comparisons and support real-world evaluation of surgical quality. Further validation is warranted through prospective multicenter implementation and time-bound observational methodologies. ( J Trauma Acute Care Surg . 2026;100: 324-330. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).
Level Of Evidence:
Prognostic and Epidemiological; Level V.
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