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Benchmarking in Surgery

Benchmarking in Surgery – A New Concept for Surgical Outcome Improvement

Benchmarking” is comparing one’s business processes and performance metrics to industry best practices from other companies. Dimensions typically measured are quality, time and costs. Applied to surgery, the aim is here to define best possible outcomes for example in major liver surgery or in liver transplantaion. The introduction of standardized benchmarks for complex procedures may lead to improved patient outcomes or surgical performance, and eventually decrease cost.

Reference:  Staiger R, Clavien PA et al. Benchmarking in Surgery – A New Concept for Surgical Outcome Improvement. British Journal of Surgery 2019; 106: 59-64.

1rst Benchmark Project

Defining Benchmark Outcome Values for Major Hepatectomy


To measure and define the best achievable outcome after major hepatectomy.

No reference values are available on outcomes after major hepatectomies. Analysis in living liver donors, with safety as the highest priority, offers the opportunity to define outcome benchmarks as the best possible results.

Outcome analyses of 5202 hemi-hepatectomies from living donors (LDs) from 12 high-volume centers worldwide were performed for a 10-year period. Endpoints, calculated at discharge, 3 and 6 months postoperatively, included postoperative morbidity measured by the Clavien-Dindo classification, the Comprehensive Complication Index (CCI), and liver failure according to different definitions. Benchmark values were defined as the 75th percentile of median morbidity values to represent the best achievable results at 3 month postoperatively.

Patients were young (34 ± [9] years), predominantly male (65%) and healthy. Surgery lasted 7 ± [2] hours; 2% needed blood transfusions. Mean hospital stay was 11.7± [5] days. 12% of patients developed at least 1 complication, of which 3.8% were major events (≥grade III, including 1 death), mostly related to biliary/bleeding events, and were twice higher after right hepatectomy. The incidence of postoperative liver failure was low. Within 3-month follow-up, benchmark values for overall complication were ≤31 %, for minor/major complications ≤23% and ≤9%, respectively, and a CCI ≤33 in LDs with complications. Centers having performed ≥100 hepatectomies had significantly lower rates for overall (10.2% vs 35.9%, P < 0.001) and major (3% vs 12.1%, P < 0.001) complications and overall CCI (2.1 vs 8.5, P < 0.001).

The thorough outcome analysis of healthy LDs may serve as a reference for evaluating surgical performance in patients undergoing major liver resection across centers and different patient populations. Further benchmark studies are needed to develop risk-adjusted comparisons of surgical outcomes.

Rössler F, Clavien PA et al. Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors. Annals of Surgery 2016; 264: 492-500.

2nd Benchmark Project

Defining Benchmark Outcome Values for Liver Transplantation

This multicentric study of 17 high-volume centers presents 12 benchmark values for liver transplantation. Those values, mostly targeting markers of morbidity, were gathered from 2024 "low risk" cases, and may serve as reference to assess outcome of single or any groups of patients.


To propose benchmark outcome values in liver transplantation, serving as reference for assessing individual patients or any other patient groups.

Best achievable results in liver transplantation, that is, benchmarks, are unknown. Consequently, outcome comparisons within or across centers over time remain speculative.

Out of 7492 liver transplantation performed in 17 international centers from 3 continents, we identified 2024 low risk adult cases with a laboratory model for end-stage liver disease score ≤20 points, a balance of risk score ≤9, and receiving a primary graft by donation after brain death. We chose clinically relevant endpoints covering intra- and postoperative course, with a focus on complications graded by severity including the complication comprehensive index (CCI). Respective benchmarks were derived from the median value in each center, and the 75 percentile was considered the benchmark cutoff.

Benchmark cases represented 8% to 49% of cases per center. One-year patient-survival was 91.6% with 3.5% retransplantations. Eighty-two percent of patients developed at least 1 complication during 1-year follow-up. Biliary complications occurred in one-fifth of the patients up to 6 months after surgery. Benchmark cutoffs were ≤4 days for ICU stay, ≤18 days for hospital stay, ≤59% for patients with severe complications (≥ Grade III) and ≤42.1 for 1-year CCI. Comparisons with the next higher risk group (model for end stage liver disease 21-30) disclosed an increase in morbidity but within benchmark cutoffs for most, but not all indicators, while in patients receiving a second graft from 1 center (n = 50) outcome values were all outside of benchmark values.

Despite excellent 1-year survival, morbidity in benchmark cases remains high with half of patients developing severe complications during 1-year follow-up. Benchmark cutoffs targeting morbidity parameters offer a valid tool to assess higher risk groups.

Muller X, Clavien PA et al. Defining Benchmarks in Liver Transplantation: A Multicenter Outcome Analysis Determining Best Achievable Results. Annals Surgery 2018; 267: 419-425.

New Benchmark Project

Defining Benchmark Outcome Values for Pancreatico-Duodenectomy 

The aim of our new benchmark project is to define best possible outcomes in pancreatico-duodenectomy. This is a major surgical operation involving the removal of the head of the pancreas, the duodenum, the proximal jejunum, gallbladder, and part of the stomach. This operation is most often performed to remove cancerous or pre-cancerous tumors of the head of the pancreas. The goal of this study is to identify the best possible outcome (benchmarking), therefore data from high-volume centers in low risk patients will be analyzed. This study proposes outcome benchmarks for pancreatico-duodenectomy offering a novel tool to assess quality of care in different cohorts, centers and countries. Inferior outcomes for minimally invasive procedures call for caution before a wider promotion and center specific risk-profiles based on the proportion of benchmark procedures, rather than volume alone, might be relevant for future centralization policies. The project will be completed with a publication in a high ranked journal (currently under consideration).

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