Outcome Analysis of Surgical Complications in Paediatric Solid Tumours – A Retrospective Clinical Study

Outcome Analysis of Surgical Complications in Paediatric Solid Tumours – A Retrospective Clinical Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcome Analysis of Surgical Complications in Paediatric Solid Tumours – A Retrospective Clinical Study Arihant Jain, Nitin James Peters, Ram Samujh, Amita Trehan, Muneer Abas Malik, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6054106/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Pediatric Surgery International → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose Postoperative complications can significantly impact patient outcomes and quality of life, particularly in children with solid tumors, as they may delay essential adjuvant therapy. This study aimed to evaluate the severity and effects of these complications and to validate the Clavien–Dindo classification system in pediatric patients following surgery for solid tumors. Methods A retrospective analysis was conducted on postoperative complications in children with solid tumors at a tertiary care teaching hospital over five years. Patient demographics and tumor types were recorded, and complications were categorized using the Clavien–Dindo classification. The study identified key risk factors for complications and their implications for patient care. Results In a study of 188 patients, the majority (n = 157; 83.5%) had low-grade (grade 1 or 2) postoperative complications. Higher intraoperative blood loss (p < 0.001), adjacent organ infiltration, and longer surgical times were associated with more severe complications. Patients with higher-grade complications also had longer hospital stays (Kendall’s Tau coefficient of 0.48). Among the 26 patients with tumor recurrence, 30% had experienced severe complications (grades 3 and 4). The Kaplan‒Meier curve and log-rank test (p < 0.001) showed that severe complications are linked to a lower survival probability. Conclusion The analysis of complications showed a significant effect on short-term surgical outcomes, and severe complications may also impact oncological outcomes. The Clavien-Dindo classification is a useful tool for grading postoperative complications in pediatric surgical oncology. Level of evidence : LEVEL III Clavien-Dindo classification pediatric solid tumors interleukin-6 postoperative complications adjuvant therapy quality improvement Figures Figure 1 Figure 2 Figure 3 Introduction Surgical excision is the cornerstone of the multimodal management of most pediatric solid tumors. Postoperative complications (POCs), however, are minor in any surgical procedure. Pediatric nonsurgical operations are complex and require expertise and extensive perioperative management. Postoperative complications in patients with solid tumors can be detrimental to the entire multimodal treatment process. The unexpected delay after surgery due to POCs is a significant cause of delay in adjuvant therapy. This finding may deviate from the protocols used, which, if they are adhered to, may lead to reasonably good outcomes for these patients [ 1 ]. An objective grading system to assess postoperative complications could help improve the quality improvement (QI) of pediatric oncology patients. Among the various available classification systems, the Clavien-Dindo (CD) classification system is based on the medical perspective of defining postoperative complications as 'Any deviation from the ideal postoperative course, that is not inherent to the procedure and does not compromise failure to cure. This system was first proposed in 1992 with subsequent revision in 2004, making it a more objective and reproducible method to classify postoperative complications based on the therapy needed to treat them [ 2 , 3 ]. Since then, this technique has been used in multiple surgical specialties, such as transplantation [ 4 ], pediatric surgery [ 5 ], oncology [ 6 ], pediatric urology [ 7 ], and neonatal surgery [ 8 ]; however, it needs validation in pediatric surgical oncology. This study was performed to assess postoperative complications in the first 30 days after surgery and to validate the use of the Clavien–Dindo classification system in pediatric surgical oncology patients. It is imperative that we carefully examine these complications to identify areas of improvement in patient care by preventing significant treatment protocol deviation. Methods This was a retrospective study in which data were retrieved from January 2017 to December 2022 after the data were approved by the Institutional Ethics Committee (INT/IEC/2021/SP6962). All patients who underwent surgery for pediatric solid tumors in the head and neck, thorax, abdomen, and axial skeleton were included. Patients with brain and bone tumors were excluded. The medical records were retrieved, and all postoperative complications were recorded and graded according to the Clavien–Dindo classification (supplement Table). The complications were assessed for the first 30 days after surgery [ 9 ]. All patients were treated according to their respective standard tumor management protocols via a multidisciplinary approach. Demographic factors such as age and sex were analyzed, and the other factors studied were the type of tumor, intraoperative events such as blood loss estimated by the gauze visual analog method (fully soaked gauze-4*4 cm–10 ml and mop-30*30 cm–100 ml), surgical complexity concerning organ infiltration, neurovascular contiguity, tumor spillage and operative time. Postoperative complications, postoperative duration of hospital stay, and delayed survival at the time of study were recorded. The normal distributions of continuous data, such as age, amount of blood loss, operative time, and duration of postoperative hospital stay, were analyzed via the Shapiro‒Wilk test. The means and standard deviations (SDs) were calculated for normally distributed continuous variables, whereas the medians and interquartile ranges (IQRs) were calculated for skewed data. Frequencies and percentages were calculated for categorical data such as sex, diagnosis, complications, postoperative complications, grading according to the Clavien–Dindo classification system, and mortality. The chi-square test/Fischer exact test was applied to find significant associations between categorical variables of the patients and subgroups. The Kruskal‒Wallis test was used to determine the associations between independent variables as a nonparametric test. To assess the validity of the CD classification system, grades were compared with intraoperative blood loss, operative time, postoperative duration of hospital stay, involvement of adjacent vital structures, tumor recurrence, etc. The log-rank test was used to compare survival among groups. Kendall's tau correlation coefficient and Cramer's V test are used to assess the strength of the associations between variables measured on an ordinal scale and a categorical scale, respectively. A P value of less than 0.05 was considered statistically significant with a 95% confidence interval. The survival of the patients at the time of the study was established via telephone interviews with family members. Results The mean age was 3.5 years, with 186 (99%) of the patients being less than 12 years of age. There was a total of 107 (57.2%) males. The diagnoses included Wilms’ tumor in 41 patients (21.8%), neuroblastoma in 37 patients (19.7%), Ewing sarcoma in 10 patients (5.3%), hepatoblastoma in 8 patients (4.3%), and others (48.9%), which included patients with non-Wilms’ renal tumors, soft tissue sarcomas, germ cell tumors, neuroblastoma and adrenal tumors. Most of the patients (83.5%) had grade 1 and 2 complications. Among all the patients who underwent surgery, only 13% had severe complications (grade 3 and grade 4) that required some form of intervention or intensive care during the postoperative period ( Table 1 ). Surgical site infections were observed in 10% of the patients, and most of them were managed conservatively. Additionally, 48% of patients required perioperative blood transfusions. In 18.2% and 8.6% of patients, lympho-vascular and adjacent organ injuries, respectively, were noted. A total of 6.4% of patients experienced intraoperative tumor spillage. The grade of postoperative complications was not significantly correlated with the child's age (p value of 0.975), sex (p value of 0.818), weight (p value of 0.399), or diagnosis (p value of 0.458). There was a significant difference (p<0.001) in intraoperative blood loss among the different grades of postoperative complications. Children with Grade 4A postoperative complications had the highest mean amount of intraoperative blood loss, with a medium positive correlation effect (Kendall’s Tau coefficient of 0.34), as shown in Fig 1A . There was a significant association between the operative time and complication grade. The patients with grade 4B complications had the highest mean operative time (150 minutes), as illustrated in Fig. 1B . Patients who underwent complex surgery involving the tumor-infiltrating liver, lungs/pleura, pericardium, diaphragm, viscera/mesentery, and encasing major blood vessels had a significantly higher grade of postoperative complications ( Tables 2A & 2B ). Patients with higher grades of postoperative complications had considerably longer postoperative hospital stays, with the longest mean duration of hospital stay being 29 days in patients with grade 4B complications, emphasizing the moderate strength of the association according to Kendall’s tau correlation (0.48) ( Fig. 2A ). Tumor recurrence was evaluated in 145 patients, and 26 (17.9%) patients experienced recurrence, with a significant difference (p-value of 0.002) between various grades of postoperative complications and tumor recurrence. More than 30% of patients with severe complications (grade 3 and grade 4) experienced recurrence ( Fig. 2B ). Over a variable period of follow-up of all included patients, 158 patients could be traced. Among them, 26 (16.5%) patients died during treatment. There was a significant association between the number of patients who died and the grade of complications, with bias-corrected Cramer's V indicating a strong association (0.47). The Kaplan‒Meier curve ( Fig 3A, 3B ) revealed that patients with lower grades (1 and 2) had a greater probability of survival than patients with severe grades (3 and 4) of complications did, with a log-rank test p value of < 0.001 ( Table 3 ). Surgical complications: Surgery plays an important role in the treatment of pediatric solid tumors. With advancements in surgical techniques, outcomes have improved substantially. Each type of tumor is associated with a unique set of complications. Neuroblastoma: This is an aggressive tumor due to its tissue infiltrating and vessel-encasing nature. Resection is associated with a high rate of complications. R1 resection has an acceptable good outcome. Even if the disease is high risk and metastatic with image-defined risk factors, > 90% resection of the primary and regional disease offers significantly better survival with low rates of progression. Overaggressive surgery can increase morbidity and mortality [10,11]. Retroperitoneal neuroblastomas have a propensity to encase major vessels, leading to vascular injury in 10% of patients, with most patients requiring perioperative blood transfusion [12]. In our study, the frequency of surgical complications in these children was 19.7%, 56.8% of whom had Grade 2 complications requiring blood transfusion. This contrasts with the literature, where most children with neuroblastoma had grade 1 complications [13]. This tumor commonly grows in adherence to nearby structures. In this study, the tumor was noted to be adhered to the liver in 13.5%, to the pancreas in 18.9%, to the kidneys in 45.9%, and to the mesentery of the bowel in 24% of patients. The highest frequency of adherence to the kidneys occurred because most of the tumors were suprarenal in location. In our study, 24.3% of patients had minor or major lympho-vascular injuries, probably because of proximity to vascular structures. Only 1 (2.7%) patient experienced a small bowel injury during the excision of the tumor, for which primary repair of the bowel was performed. In our study, 2 out of 37 patients experienced regional recurrence and underwent repeat surgery. Wilms’ tumor: - In our study, the most common complication was grade 1 (50%). There were 51 patients with renal tumors, of which Wilms’ tumor constituted 79% (41), with the remaining 21% having non-Wilms’ renal tumors, which is contrary to a study by Pastore G et al., where 90% of renal masses were Wilms’ tumor [14]. In this study, 3 patients with Wilms’ tumor had surgical site wound infection, 6 patients had minor lympho-vascular injury, and 2 patients had minor liver injury. Two patients developed small bowel obstruction and underwent exploratory laparotomy. Three (7.3%) patients with Wilms’ tumor experienced local recurrence, the frequency of which was significantly lower than that reported in the study published in The Lancet (13%) [15]. Compared with a study by Elgendy et al., in which 52% of patients experienced spillage, only one patient experienced intraoperative tumor spillage [16]. The most important surgical complication in Wilms’ tumor is spillage [17]. Interdisciplinary teamwork is needed to achieve better outcomes; for example, cardiothoracic and vascular surgeons are needed to achieve complete resection in patients with cavo-atrial thrombi [18,19]. In bilateral tumors, nephron-sparing surgery plays an important role. The risk of complications in this subset should not deter surgeons from attempting maximum nephron preservation. Hepatoblastoma: Most patients had Grade 2 complications requiring perioperative blood transfusion. Knowledge of surgical anatomy is necessary to achieve complete resection of the tumor with minimal complications. Complete tumor resection is a good prognostic factor. In our study, neoadjuvant chemotherapy was given to all patients, as this is associated with better outcomes. Common complications after hepatic resection are bleeding, bile leakage, and tumor spillage. The extent of resection usually determines the grade of surgical complications [20]. In this study, 57% of patients had minor or major vascular injuries. One out of seven patients had a minor biliary leak. This leads to significantly increased operative time and blood loss. Owing to prolonged surgeries, all patients were admitted to the intensive care unit for close monitoring. Among all tumor types, children with hepatoblastoma had the longest postoperative stay. All these patients underwent surgery during the early course of liver resection. One out of seven patients had local tumor recurrence, which was noted, and the patient underwent reoperation for resection of the involved segment. Ewing sarcoma: Most patients had Grade 2 complications. There was a total of 10 patients with Ewing sarcoma, of which the most common site of origin (80%) was the chest wall, with pain as the most common presenting symptom. Sacrococcygeal tumors: In this study, 9 patients underwent surgery for sacrococcygeal teratomas. The most common tumor type was Altman type 1. All patients underwent primary excision. The most common surgical complication was surgical site wound infection. There were other tumors, such as adrenocortical masses, pelvic rhabdomyosarcoma, and teratomas, which were also treated at our center. All of these patients had grade 1 and 2 complications as the most common complications. Discussion Surgical complications disrupt the normal course of postoperative treatment after any surgery and are detrimental to the further management of patients with pediatric solid tumors. These complications may delay the start of adjuvant therapy in these children. Complications must be distinguished from other negative surgical outcomes such as sequelae, which means ‘after-effects’ of surgery inherent to the procedure and failure to cure. In most of the studies, surgical complications are listed quantitatively [ 1 , 21 ]. It is important to conduct a qualitative assessment of postoperative complications to report them objectively. It is correctly believed that the perception and reporting of complications are often subjective and inconsistent, whereas the documentation of the therapy needed to treat them is often exact and objective. The use of retrospective studies for assessing surgical complications is associated with underreporting, whereas the use of prospective studies is limited by the observer effect known as the Hawthorne effect, where if the participating surgeons are aware of the study, their behavior and thus grades can change [ 5 ]. The CD classification system has proven important in retrospective studies where postoperative complications are poorly reported, but the therapies used to treat them are usually well documented [ 3 ]. In a study conducted by Joseph et al., [ 6 ] 85% of patients experienced grade 1 and 2 complications, which is similar to our findings, where 83.5% of patients experienced grade 1 and 2 complications. In our study, 48% of patients required perioperative blood transfusions, probably due to nutritional and chemotherapy-induced anemia, along with intraoperative blood loss. Surgeons need to be vigilant and adaptive to improve surgical techniques to minimize intraoperative blood loss in already vulnerable patients. As depicted in a study by Gonzalez et al., in children who underwent surgery for solid tumors, perioperative blood transfusion was associated with an increased risk of postoperative mechanical ventilation (p < 0.001) and an increased propensity for postoperative complications (p = 0.02) along with a longer postoperative duration of hospital stays (p < 0.01) [ 22 ]. Similarly, in our study, intraoperative blood loss was associated with increased severity of postoperative complications and thus prolonged hospital stay. Surgical complications often increase the cost of treatment. However, cost evaluation alone is not a valid tool for comparisons. The complexity of the surgery and the postoperative duration of hospital stay correlate with the severity of complications, as shown by Dindo D et al. in 2004, where the data of 6336 patients were collected and assessed [ 3 ]. This correlation was shown in many single-center studies. A retrospective study by Liu et al., which included 91 children with retroperitoneal tumors, concluded that compression or distortion of adjacent organs and vascular structures can lead to serious perioperative complications [ 23 ]. Our study revealed a noteworthy correlation between the grades of postoperative complications and the surgical complexities that arise from nearby organ infiltration, intraoperative blood loss, operative time duration and proximity to major blood vessels. These findings suggest that the severity of postoperative complications increases in tandem with the surgical complexities associated with these factors. Therefore, a detailed preoperative assessment of the extent of the tumor is crucial for preventing serious postoperative complications. Similarly, in our study, the postoperative duration of stay also increased significantly in patients with higher grades of complications. In a study by Brock et al., postoperative complications in 66,157 pediatric patients after gastrointestinal surgeries were assessed, which revealed that postoperative complications significantly increased the duration of hospital stay and cost of treatment [ 24 ]. There are multiple reasons for tumor recurrence. Surgery, along with postoperative complications, initiates an inflammatory cascade, which, as postulated by Beecher et al., increases the risk of tumor recurrence. Their review revealed that postoperative healing results in the release of many growth factors that can promote the mitogenic nature of tumor cells. Circulatory levels of growth factors such as interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) peak after an extensive surgical procedure. This promotes rapid angiogenesis, which is necessary for tumor growth, recurrence, and metastasis [ 25 ]. In our study, patients with severe (grade 3 and grade 4) postoperative complications had a greater risk of tumor recurrence. This can be attributed to a delay in postoperative adjuvant therapy, like the study by Becker et al [ 26 ]. Their study of 126 operated hepatoblastoma patients revealed that patients with higher grades of postoperative complications had worse overall survival, possibly due to the delay in receiving adjuvant therapy. Similarly, in our study, patients with severe postoperative complications had a decreased probability of survival, as depicted by the Kaplan‒Meier curve. Similarly, a study by Lee et al. revealed that inflammation promotes epithelial-mesenchymal transition (EMT), which loosens cell-cell adhesion complexes and promotes the migratory and invasive properties of tumors [ 27 ]. In addition, our study demonstrated that systemic inflammation in the form of surgery and postoperative complications had a deleterious effect on the risk of tumor recurrence. Therefore, surgeons should make every possible effort to prevent and reduce the incidence of postoperative complications. The limitations of this study are that it is a retrospective analysis, and while suggesting a correlation between the postoperative complication grade and outcome concerning tumor recurrence or survival, we should consider other important parameters, such as the biological nature of the disease, delay in adjuvant therapy and contribution of preoperative chemotherapy, in increasing the risk of postoperative complications. This study is among the very few available studies showing the probable impact of postoperative complications on the disease outcome of pediatric solid tumors. Conclusion This study attempted to portray the importance of identifying and grading surgical complications objectively in pediatric surgical oncology. Severe complications, both surgical and oncological, were associated with worse outcomes. It is imperative to consider surgical complexities when planning interventions, as they have a significant effect on postoperative patient outcomes. By taking these parameters into account, surgical teams can better prepare for the risks associated with the procedure and mitigate any potential complications that may arise. The Clavien–Dindo classification system appears to be a necessary and effective tool for evaluating postoperative complications. Its straightforward approach ensures an objective and reproducible outcome, making it an essential component of any rigorous surgical outcome assessment. This system refrains from downgrading the severity of postoperative complications, especially during retrospective studies. Reporting postoperative complications via the Clavien–Dindo classification system eliminates subjectivity and biases to bestow us with the reliable outcome data desired by patients to improve the quality of care in pediatric surgical oncology. Declarations This manuscript was presented as a paper presentation on 29 th September 2022 at 54 th Congress of the International Society of Paediatric Oncology SIOP 2022, Barcelona, Spain. For this, an IPSO scholarship was awarded. Financial support and sponsorship – NIL. Conflicts of interest – There are no conflicts of interest. Author Contribution AJ Writing and analysis data collectionNJP Concept , writing editing, analysisRS Concept, EditingAT Editing, Data collectionMAM Data collection, editingRM, Clinical care, data collection, editingSD Data analysis, editingSS Editing, analysisJS writing, data analysisRPK Editing, Data collectionDB Editing, Data collectionRJ Editing, Data collectionMB Editing, Data collectionRK Editing, Data collectionSY Editing, Data collectionJKM Editing, Data collection References Ross A, Gomez O, Wang X, Lu Z, Abdelhafeez H, Davidoff AM et al. Timing of adjuvant chemotherapy after laparotomy for Wilms tumor and neuroblastoma. Pediatr Surg Int. 2021 Nov;37(11):1585-92. doi: 10.1007/s00383-021-04968-1. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992 May;111(5):518-26. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae. Barr ML, Belghiti J, Villamil FG, Pomfret EA, Sutherland DS, Gruessner RW et al. A report of the Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines. Transplantation. 2006 May 27;81(10):1373-85. doi: 10.1097/01.tp.0000216825.56841.cd. Thompson H, Jones C, Pardy C, Kufeji D, Nichols E, Murphy F et al. Application of the Clavien‒Dindo classification to a pediatric surgical network. J Pediatr Surg. 2020 Feb;55(2):312-315. doi: 10.1016/j.jpedsurg.2019.10.032. Joseph JM, Farron AM, Renella R, Gapany C. Can smaller-scale comprehensive cancer centers provide outstanding care in abdominal and thoracic pediatric solid tumor surgery? Results of a 14-year retrospective single-center analysis. Ann Surg Oncol. 2014 May;21(5):1726-31. doi: 10.1245/s10434-013-3455-y. Esposito C, Varlet F, Patkowski D, Castagnetti M, Escolino M, Draghici IM et al. Laparoscopic partial nephrectomy in duplex kidneys in infants and children: results of a European multicentric survey. Surg Endosc. 2015 Dec;29(12):3469-76. doi: 10.1007/s00464-015-4096-y. Catré D, Lopes MF, Madrigal A, Oliveiros B, Cabrita AS, Viana JS et al. Predictors of major postoperative complications in neonatal surgery. Rev Col Bras Cir. 2013 Sep-Oct;40(5):363-9. English, Portuguese. doi: 10.1590/s0100-69912013000500003. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al. The Clavien‒Dindo classification of surgical complications: five-year experience. Ann Surg. 2009 Aug;250(2):187-96. doi: 10.1097/SLA.0b013e3181b13ca2. Von Allmen D, Davidoff AM, London WB, Van Ryn C, Haas-Kogan DA, Kreissman SG et al. Impact of extent of resection on local control and survival in high risk neuroblastomas patients: a report from the COG A3973 study J Clin Oncol. 2017;35(2):208. Canete A, Jovani C, Lopez A, Costa E, Segarra V, Fernandez JM et al. Surgical treatment for neuroblastoma: complications during 15 years' experience. J Pediatr Surg. 1998; 33(10):1526-30. R.G. Azizkhan, A. Shaw, J.G. Chandler. Surgical complications of neuroblastoma resection. Surgery. 1985; 97(5):514-7. Steven W Guidi STEX, Jorg Fuchs. Surgical complications in Pediatric surgical oncology. Pediatr Blood Canc 2012;398-404. Pastore G, Znaor A, Spreafico F, Graf N, Pritchard-Jones K, Steliarova-Foucher E. Malignant renal tumors incidence and survival in European children (1978-1997): report from the Automated Childhood Cancer Information System project. Eur J Cancer. 2006 Sep;42(13):2103-14. Brok J, Lopez-Yurda M, Tinteren HV, Treger TD, Furtwängler R, Graf N et al. Relapse of Wilms' tumor and detection methods: a retrospective analysis of the 2001 Renal Tumor Study Group-International Society of Pediatric Oncology Wilms' tumor protocol database. Lancet Oncol. 2018 Aug;19(8):1072-81. Elgendy A, Abouheba M, Ebeid A, Shreif M.K. Shehata, Sameh Shehata. Surgical aspects, violations and outcomes of wilms tumor- a multicenter study in a resource limited country. Egy Pediatr. Assoc Gazette. 2020; (68):1 Roth H, Weirich A, Ludwig R, Daum R, Zimmermann H. Resection of nephroblastoma: problems and complications- evaluation of the Nephroblastoma study SIOP 9/GPOH. 1996; 113:1078-83. Godzinski J, Tournade MF, deKraker J, Lemerle J, Voute PA, Weirich A. Rarity of surgical complications after postchemotherapy nephrectomy for nephroblastoma. Experience of the International Society of Pediatric Oncology-Trial and Study "SIOP-9". International Society of Pediatric Oncology Nephroblastoma Trial and Study Committee. Eur J Pediatr Surg. 1998;8(2):83-6. Ritchey ML, Shamberger RC, Haase G, Horwitz J, Bergemann T, Breslow NE. Surgical complications after primary nephrectomy for Wilms' tumor: report from the National Wilms' Tumor Study Group. J Am Coll Surg. 2001;192(1):63-8 Guérin F, Gauthier F, Martelli H, Fabre M, Baujard C, Franchi S et al. Outcome of central hepatectomy for hepatoblastomas. J Pediatr Surg. 2010;45(3):555-63. Martin RC 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg. 2002 Jun;235(6):803-13. doi: 10.1097/00000658-200206000-00007. Gonzalez DO, Cooper JN, Mantell E, Minneci PC, Deans KJ, Aldrink JH. Perioperative blood transfusion and complications in children undergoing surgery for solid tumors. J Surg Res. 2017 Aug;216:129-137. doi: 10.1016/j.jss.2017.04.025. Epub 2017 May 5. PMID: 28807197. Liu Y, Hao X, Lu H, Duan Y, Dong Q, Qiao L. Factors Associated With Perioperative Complications in the Treatment of Pediatric Retroperitoneal Teratoma. J Surg Res. 2021 Mar;259:458-464. doi: 10.1016/j.jss.2020.09.007. Epub 2020 Oct 13. PMID: 33059908. Brock R, Chu A, Lu S, Brindle ME, Somayaji R. Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and sociodemographic risk factors. BMC Pediatr. 2022 Jun 22;22(1):358. doi: 10.1186/s12887-022-03418-8. PMID: 35733099; PMCID: PMC9215078. Beecher SM, OʼLeary DP, McLaughlin R, Kerin MJ. The Impact of Surgical Complications on Cancer Recurrence Rates: A Literature Review. Oncol Res Treat. 2018;41(7-8):478-482. doi: 10.1159/000487510. Epub 2018 Jun 13. PMID: 29895008. Becker K, Furch C, Schmid I, von Schweinitz D, Häberle B. Impact of postoperative complications on overall survival of patients with hepatoblastoma. Pediatr Blood Cancer. 2015 Jan;62(1):24-8. doi: 10.1002/pbc.25240. Epub 2014 Sep 22. PMID: 25251521. Lee B, Han HS. Tackling Surgical Morbidity and Mortality through Modifiable Risk Factors in Cancer Patients. Nutrients. 2022 Jul 28;14(15):3107. doi: 10.3390/nu14153107. PMID: 35956284; PMCID: PMC9370480. Tables Table 1 shows the distribution of patients in terms of postoperative complication grades. Post-Operative Complication Grade Frequency Percentage 95% CI Grade 1 79 42.0% 34.9% - 49.4% Grade 2 78 41.5% 34.4% - 48.9% Grade 3A 12 6.4% 3.5% - 11.1% Grade 3B 7 3.7% 1.6% - 7.8% Grade 4A 5 2.7% 1.0% - 6.4% Grade 4B 2 1.1% 0.2% - 4.2% Grade 5 5 2.7% 1.0% - 6.4% Table 2A – shows the significant associations between postoperative complication grade and tumor infiltration/adhesion to the liver and viscera or mesentery. Involvement: Liver Post-Operative Complication Grade Fisher's Exact Test Grade 1 Grade 2 Grade 3A Grade 3B Grade 4A Grade 4B Grade 5 Total χ2 P Value Yes 5 (6.3%) 18 (23.1%) 2 (16.7%) 1 (14.3%) 1 (20.0%) 1 (50.0%) 1 (20.0%) 29 (15.4%) 10.525 0.031 No 74 (93.7%) 60 (76.9%) 10 (83.3%) 6 (85.7%) 4 (80.0%) 1 (50.0%) 4 (80.0%) 159 (84.6%) Total 79 (100.0%) 78 (100.0%) 12 (100.0%) 7 (100.0%) 5 (100.0%) 2 (100.0%) 5 (100.0%) 188 (100.0%) Viscera/ Mesentery Fisher's Exact Test Grade 1 Grade 2 Grade 3A Grade 3B Grade 4A Grade 4B Grade 5 Total χ2 P Value Yes 15 (19.0%) 33 (42.3%) 4 (33.3%) 5 (71.4%) 2 (40.0%) 0 (0.0%) 2 (40.0%) 61 (32.4%) 16.068 0.006 No 64 (81.0%) 45 (57.7%) 8 (66.7%) 2 (28.6%) 3 (60.0%) 2 (100.0%) 3 (60.0%) 127 (67.6%) Total 79 (100.0%) 78 (100.0%) 12 (100.0%) 7 (100.0%) 5 (100.0%) 2 (100.0%) 5 (100.0%) 188 (100.0%) Table 2B shows the significant associations between postoperative complication grades and tumor infiltration/adhesion to the pericardium, lung or pleura, and diaphragm. Heart/ Pericardium Fisher's Exact Test Grade 1 Grade 2 Grade 3A Grade 3B Grade 4A Grade 4B Grade 5 Total χ2 P Value Yes 0 (0.0%) 3 (3.8%) 0 (0.0%) 0 (0.0%) 1 (20.0%) 1 (50.0%) 1 (20.0%) 6 (3.2%) 26.666 0.005 No 79 (100.0%) 75 (96.2%) 12 (100.0%) 7 (100.0%) 4 (80.0%) 1 (50.0%) 4 (80.0%) 182 (96.8%) Total 79 (100.0%) 78 (100.0%) 12 (100.0%) 7 (100.0%) 5 (100.0%) 2 (100.0%) 5 (100.0%) 188 (100.0%) Lungs/ Pleura Fisher's Exact Test Grade 1 Grade 2 Grade 3A Grade 3B Grade 4A Grade 4B Grade 5 Total χ2 P Value Yes 4 (5.1%) 14 (17.9%) 3 (25.0%) 0 (0.0%) 3 (60.0%) 1 (50.0%) 2 (40.0%) 27 (14.4%) 21.853 <0.001 No 75 (94.9%) 64 (82.1%) 9 (75.0%) 7 (100.0%) 2 (40.0%) 1 (50.0%) 3 (60.0%) 161 (85.6%) Total 79 (100.0%) 78 (100.0%) 12 (100.0%) 7 (100.0%) 5 (100.0%) 2 (100.0%) 5 (100.0%) 188 (100.0%) Diaphragm Fisher's Exact Test Grade 1 Grade 2 Grade 3A Grade 3B Grade 4A Grade 4B Grade 5 Total χ2 P Value Yes 3 (3.8%) 14 (17.9%) 1 (8.3%) 0 (0.0%) 2 (40.0%) 0 (0.0%) 1 (20.0%) 21 (11.2%) 13.750 0.020 No 76 (96.2%) 64 (82.1%) 11 (91.7%) 7 (100.0%) 3 (60.0%) 2 (100.0%) 4 (80.0%) 167 (88.8%) Total 79 (100.0%) 78 (100.0%) 12 (100.0%) 7 (100.0%) 5 (100.0%) 2 (100.0%) 5 (100.0%) 188 (100.0%) Table 3 – Association of postoperative complication grade with survival. Post-Operative Complication Grade Total N Events Censored Mean Survival 95% CI for Mean Median Survival 95% CI For Median P Value Grade 1 70 2 68 52.00 49.82 - 54.18 NA - NA Log Rank Test: p = <0.001 Grade 2 64 16 48 75.15 63.25 - 87.05 NA – NA Grade 3A 7 0 7 49.13 49.13 - 49.13 NA – NA Grade 3B 7 2 5 31.62 18.4 - 44.84 6 – NA Grade 4A 3 1 2 26.47 16.29 - 36.65 14 – NA Grade 4B 2 0 2 12.63 12.63 - 12.63 NA – NA Grade 5 1 1 0 0.50 0.5 - 0.5 0.5 NA – NA Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Revision requested 13 Mar, 2025 Reviews received at journal 13 Mar, 2025 Reviews received at journal 10 Mar, 2025 Reviewers agreed at journal 09 Mar, 2025 Reviewers agreed at journal 06 Mar, 2025 Reviewers agreed at journal 05 Mar, 2025 Reviewers invited by journal 05 Mar, 2025 Editor assigned by journal 03 Mar, 2025 Submission checks completed at journal 03 Mar, 2025 First submitted to journal 18 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6054106","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423588219,"identity":"78fb2a13-1372-4c46-967e-e0a9233ae209","order_by":0,"name":"Arihant Jain","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Arihant","middleName":"","lastName":"Jain","suffix":""},{"id":423588220,"identity":"804bbea3-d94c-495b-b8c5-3526c03a96b1","order_by":1,"name":"Nitin James Peters","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYDACZgaGAww8SAL8DAxsBLQwI2k5AMSSDYS0gKyBA5AWgwMEtJiz8x88XCBjF83Pf/bg4w8V9+yNbyQ/e/ChgkGeX+wAVi2WzcwMh2fwJOfOnJGXbHDgTHHithtp5oYzzjAYzpydgFWLwWGgFh4e5twNN3jMJA62JSSY3Ugwk+ZtY0gwuI1XS33u/vNnzH8c/Jdgbzwj/RsxWg7nbmDIMWM42JDAuEEih6AtBkAtx3Nn3MhLljhzLCFxxpk3ZZIzzkjg9sv5g48/8/ZU5/b3nz34oaImwZ6/PX2bxIcKG3l+aexawICxB0TC4lMArFICt3Iw+IGshf8AAdWjYBSMglEw0gAAg4hgPXHQ2v8AAAAASUVORK5CYII=","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":true,"prefix":"","firstName":"Nitin","middleName":"James","lastName":"Peters","suffix":""},{"id":423588221,"identity":"56ba5a2d-2d9b-4063-81fb-125309969ad2","order_by":2,"name":"Ram Samujh","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Ram","middleName":"","lastName":"Samujh","suffix":""},{"id":423588223,"identity":"037fe036-ae63-49db-8bd1-86e5a05daaca","order_by":3,"name":"Amita Trehan","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Amita","middleName":"","lastName":"Trehan","suffix":""},{"id":423588225,"identity":"58a9530a-a9b7-40eb-800e-a321afa023e1","order_by":4,"name":"Muneer Abas Malik","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Muneer","middleName":"Abas","lastName":"Malik","suffix":""},{"id":423588227,"identity":"10cbd75b-0c49-40db-95a8-572137198c3a","order_by":5,"name":"Renu Madan","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Renu","middleName":"","lastName":"Madan","suffix":""},{"id":423588229,"identity":"a8d6570c-d835-4374-8562-c36c3778a0b3","order_by":6,"name":"Shivani Dogra","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Shivani","middleName":"","lastName":"Dogra","suffix":""},{"id":423588230,"identity":"c8e7a3cb-bcf5-405c-8c84-97580b66d431","order_by":7,"name":"Shailesh Solanki","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Shailesh","middleName":"","lastName":"Solanki","suffix":""},{"id":423588231,"identity":"5f496c3b-8178-43bb-bd9f-85b5d5931bdc","order_by":8,"name":"Jitender Singh","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Jitender","middleName":"","lastName":"Singh","suffix":""},{"id":423588232,"identity":"e778c0ac-cbbf-4f6a-8ef8-ca2ef9d60e8e","order_by":9,"name":"Ravi P Kanojia","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Ravi","middleName":"P","lastName":"Kanojia","suffix":""},{"id":423588233,"identity":"a79b0e6c-f692-43e0-9bfb-eec826bf4d4b","order_by":10,"name":"Deepak Bansal","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Deepak","middleName":"","lastName":"Bansal","suffix":""},{"id":423588234,"identity":"82195208-af22-4d07-b898-d912cce87aef","order_by":11,"name":"Richa Jain","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Richa","middleName":"","lastName":"Jain","suffix":""},{"id":423588235,"identity":"5cd4c672-b038-4950-8974-2e0356be678e","order_by":12,"name":"Monika Bawa","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Monika","middleName":"","lastName":"Bawa","suffix":""},{"id":423588236,"identity":"c350db05-cacf-4eaa-a7cb-a4b16f0b9cd0","order_by":13,"name":"Rakesh Kapoor","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Rakesh","middleName":"","lastName":"Kapoor","suffix":""},{"id":423588237,"identity":"26d2b1f4-8840-4f9a-9b4c-bf4462614c72","order_by":14,"name":"Sandhya Yaddanapudi","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Sandhya","middleName":"","lastName":"Yaddanapudi","suffix":""},{"id":423588239,"identity":"90840906-6a00-43d3-a090-27771993c6ab","order_by":15,"name":"J K Mahajan","email":"","orcid":"","institution":"Post Graduate Institute of Medical Education and Research","correspondingAuthor":false,"prefix":"","firstName":"J","middleName":"K","lastName":"Mahajan","suffix":""}],"badges":[],"createdAt":"2025-02-18 08:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6054106/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6054106/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-025-06069-9","type":"published","date":"2025-07-01T15:58:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77767174,"identity":"b9cb35f1-63f8-4ba4-975e-ac73032e4c36","added_by":"auto","created_at":"2025-03-05 10:14:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":783693,"visible":true,"origin":"","legend":"\u003cp\u003eA shows that patients who experienced greater blood loss during surgery had more severe postoperative complications (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eB shows that the mean operative time (minutes) was highest in the Postoperative Complication Grade: Grade 4B group.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6054106/v1/b60f5eb16fb850bf88b6c065.png"},{"id":77767919,"identity":"587ff421-5704-483a-8e17-a890dc6b2bbf","added_by":"auto","created_at":"2025-03-05 10:22:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269613,"visible":true,"origin":"","legend":"\u003cp\u003eA shows the associations between postoperative complication grades and the postoperative duration of hospital stay, with the median stay being highest in patients with Grade 4B complications.\u003c/p\u003e\n\u003cp\u003eB shows the association between complication grade and tumor recurrence; more than 30% of patients with severe complications (\u0026gt; grade 3) experienced tumor recurrence.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6054106/v1/f9104d67ddf18de7db6b8673.png"},{"id":77767177,"identity":"e2adec63-beeb-42e6-906a-4e906b4816aa","added_by":"auto","created_at":"2025-03-05 10:14:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":932104,"visible":true,"origin":"","legend":"\u003cp\u003eA and B \u0026nbsp;The Kaplan‒Meier curves indicate lower survival rates in patients with higher grades of postoperative complications.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6054106/v1/0117b5f72c50bfee3d1e2251.png"},{"id":86179201,"identity":"93db325b-d02c-4b2d-ab4e-7053d2cabd45","added_by":"auto","created_at":"2025-07-07 16:17:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2579440,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6054106/v1/140205da-8f31-46ed-80a2-03f873485a04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome Analysis of Surgical Complications in Paediatric Solid Tumours – A Retrospective Clinical Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSurgical excision is the cornerstone of the multimodal management of most pediatric solid tumors. Postoperative complications (POCs), however, are minor in any surgical procedure. Pediatric nonsurgical operations are complex and require expertise and extensive perioperative management. Postoperative complications in patients with solid tumors can be detrimental to the entire multimodal treatment process. The unexpected delay after surgery due to POCs is a significant cause of delay in adjuvant therapy. This finding may deviate from the protocols used, which, if they are adhered to, may lead to reasonably good outcomes for these patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. An objective grading system to assess postoperative complications could help improve the quality improvement (QI) of pediatric oncology patients.\u003c/p\u003e \u003cp\u003eAmong the various available classification systems, the Clavien-Dindo (CD) classification system is based on the medical perspective of defining postoperative complications as 'Any deviation from the ideal postoperative course, that is not inherent to the procedure and does not compromise failure to cure. This system was first proposed in 1992 with subsequent revision in 2004, making it a more objective and reproducible method to classify postoperative complications based on the therapy needed to treat them [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since then, this technique has been used in multiple surgical specialties, such as transplantation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], pediatric surgery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], oncology [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], pediatric urology [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and neonatal surgery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; however, it needs validation in pediatric surgical oncology.\u003c/p\u003e \u003cp\u003eThis study was performed to assess postoperative complications in the first 30 days after surgery and to validate the use of the Clavien\u0026ndash;Dindo classification system in pediatric surgical oncology patients. It is imperative that we carefully examine these complications to identify areas of improvement in patient care by preventing significant treatment protocol deviation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This was a retrospective study in which data were retrieved from January 2017 to December 2022 after the data were approved by the Institutional Ethics Committee (INT/IEC/2021/SP6962). All patients who underwent surgery for pediatric solid tumors in the head and neck, thorax, abdomen, and axial skeleton were included. Patients with brain and bone tumors were excluded. The medical records were retrieved, and all postoperative complications were recorded and graded according to the Clavien\u0026ndash;Dindo classification (supplement Table). The complications were assessed for the first 30 days after surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. All patients were treated according to their respective standard tumor management protocols via a multidisciplinary approach.\u003c/p\u003e \u003cp\u003eDemographic factors such as age and sex were analyzed, and the other factors studied were the type of tumor, intraoperative events such as blood loss estimated by the gauze visual analog method (fully soaked gauze-4*4 cm\u0026ndash;10 ml and mop-30*30 cm\u0026ndash;100 ml), surgical complexity concerning organ infiltration, neurovascular contiguity, tumor spillage and operative time. Postoperative complications, postoperative duration of hospital stay, and delayed survival at the time of study were recorded.\u003c/p\u003e \u003cp\u003eThe normal distributions of continuous data, such as age, amount of blood loss, operative time, and duration of postoperative hospital stay, were analyzed via the Shapiro‒Wilk test. The means and standard deviations (SDs) were calculated for normally distributed continuous variables, whereas the medians and interquartile ranges (IQRs) were calculated for skewed data. Frequencies and percentages were calculated for categorical data such as sex, diagnosis, complications, postoperative complications, grading according to the Clavien\u0026ndash;Dindo classification system, and mortality. The chi-square test/Fischer exact test was applied to find significant associations between categorical variables of the patients and subgroups. The Kruskal‒Wallis test was used to determine the associations between independent variables as a nonparametric test. To assess the validity of the CD classification system, grades were compared with intraoperative blood loss, operative time, postoperative duration of hospital stay, involvement of adjacent vital structures, tumor recurrence, etc. The log-rank test was used to compare survival among groups. Kendall's tau correlation coefficient and Cramer's V test are used to assess the strength of the associations between variables measured on an ordinal scale and a categorical scale, respectively. A P value of less than 0.05 was considered statistically significant with a 95% confidence interval. The survival of the patients at the time of the study was established via telephone interviews with family members.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age was 3.5 years, with 186 (99%) of the patients being\u0026nbsp;less than 12 years of age. There was a total of 107 (57.2%) males. The diagnoses included Wilms\u0026rsquo; tumor in 41 patients (21.8%), neuroblastoma in 37 patients (19.7%), Ewing sarcoma in\u0026nbsp;10 patients\u0026nbsp;(5.3%), hepatoblastoma in 8 patients (4.3%), and others (48.9%), which\u0026nbsp;included patients with non-Wilms\u0026rsquo; renal tumors, soft tissue sarcomas, germ cell tumors, neuroblastoma and adrenal tumors. Most of the patients (83.5%) had grade 1 and 2 complications. Among all the patients who underwent surgery, only 13% had severe complications (grade 3 and grade 4) that required some form of intervention or intensive care during the postoperative period (\u003cstrong\u003eTable 1\u003c/strong\u003e). Surgical site infections were observed in 10% of the\u0026nbsp;patients, and most of them were managed conservatively. Additionally, 48% of patients required perioperative blood transfusions. In 18.2% and 8.6% of patients, lympho-vascular and adjacent organ injuries, respectively, were noted. A total of 6.4% of patients experienced intraoperative tumor spillage.\u003c/p\u003e\n\u003cp\u003eThe grade of postoperative complications was not significantly correlated with the child\u0026apos;s age (p\u0026nbsp;value of\u0026nbsp;0.975), sex (p\u0026nbsp;value of\u0026nbsp;0.818), weight (p\u0026nbsp;value of\u0026nbsp;0.399), or diagnosis (p\u0026nbsp;value of\u0026nbsp;0.458). There was a significant difference (p\u0026lt;0.001) in intraoperative blood loss among the\u0026nbsp;different grades of postoperative complications. Children with Grade 4A postoperative complications had the highest mean amount of intraoperative blood loss, with a medium positive correlation effect\u0026nbsp;(Kendall\u0026rsquo;s Tau coefficient of\u0026nbsp;0.34), as shown in \u003cstrong\u003eFig 1A\u003c/strong\u003e. There was a significant association between the operative time and complication grade.\u0026nbsp;The patients with grade 4B complications had the highest mean operative time (150 minutes), as illustrated in \u003cstrong\u003eFig. 1B\u003c/strong\u003e. Patients who underwent complex surgery involving the tumor-infiltrating liver, lungs/pleura, pericardium, diaphragm, viscera/mesentery, and encasing major blood vessels had a significantly higher grade of postoperative complications (\u003cstrong\u003eTables 2A \u0026amp; 2B\u003c/strong\u003e). Patients with higher grades of postoperative complications had considerably longer postoperative hospital stays, with the longest mean duration of hospital stay being 29 days in patients with grade 4B complications, emphasizing the moderate strength of the\u0026nbsp;association according to Kendall\u0026rsquo;s tau correlation (0.48) (\u003cstrong\u003eFig. 2A\u003c/strong\u003e). Tumor recurrence was evaluated in 145 patients, and 26 (17.9%) patients experienced recurrence, with a significant difference (p-value of 0.002) between various grades of postoperative complications and tumor recurrence. More than 30% of patients with severe complications (grade 3 and grade 4) experienced recurrence (\u003cstrong\u003eFig. 2B\u003c/strong\u003e). Over a variable period of follow-up of all included patients, 158 patients could be traced. Among them, 26 (16.5%) patients died during treatment. There was a significant association between the number of patients who died and the grade of complications, with bias-corrected Cramer\u0026apos;s V indicating a strong association (0.47). The Kaplan‒Meier curve (\u003cstrong\u003eFig 3A, 3B\u003c/strong\u003e) revealed that patients with lower grades (1 and 2) had a greater probability of survival than patients with severe grades (3 and 4) of complications did,\u0026nbsp;with a log-rank test p\u0026nbsp;value of \u0026lt; 0.001 (\u003cstrong\u003eTable 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical complications:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgery plays an important role in the treatment of pediatric solid tumors. With advancements in surgical techniques, outcomes have improved substantially. Each type of tumor is associated with a unique set of complications.\u003c/p\u003e\n\u003cp\u003eNeuroblastoma: This is an aggressive tumor due to its tissue infiltrating and vessel-encasing nature. Resection is associated with a high rate of complications. R1 resection has an acceptable good outcome. Even if the disease is high risk and metastatic with image-defined risk factors, \u003cu\u003e\u0026gt;\u003c/u\u003e 90% resection of the primary and regional disease offers significantly better survival with low rates of progression. Overaggressive surgery can increase morbidity and mortality [10,11].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eRetroperitoneal neuroblastomas have a propensity to encase major vessels, leading to vascular injury in 10% of patients, with most patients requiring perioperative blood transfusion [12].\u0026nbsp;\u003csup\u003e\u0026nbsp;\u003c/sup\u003eIn our study, the frequency of surgical complications in these children was 19.7%, 56.8% of whom had Grade 2 complications requiring blood transfusion. This contrasts with the\u0026nbsp;literature, where most children with neuroblastoma had grade 1 complications [13]. This tumor commonly grows in adherence to nearby structures. In this study, the tumor was noted to be adhered to the liver in 13.5%, to the pancreas in 18.9%, to the kidneys in 45.9%, and to the mesentery of the bowel in 24% of patients. The highest frequency of adherence to the\u0026nbsp;kidneys occurred because most of the tumors were suprarenal in location. In our study, 24.3% of patients had minor or major lympho-vascular injuries, probably because of proximity to vascular structures. Only 1 (2.7%) patient experienced a small bowel injury during the excision of the tumor, for which primary repair of the bowel was performed. In our study, 2 out of 37 patients experienced regional recurrence and underwent repeat surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Wilms\u0026rsquo; tumor: - In our study, the most common complication was grade 1 (50%). There were 51 patients with renal tumors, of which Wilms\u0026rsquo; tumor constituted 79% (41), with the remaining 21% having non-Wilms\u0026rsquo; renal tumors, which is contrary to a study by Pastore G et al., where 90% of renal masses were Wilms\u0026rsquo; tumor [14].\u0026nbsp; In this study, 3 patients with Wilms\u0026rsquo; tumor had surgical site wound infection, 6 patients had minor lympho-vascular injury, and 2 patients had minor liver injury. Two patients developed small bowel obstruction and underwent exploratory laparotomy. Three (7.3%) patients with Wilms\u0026rsquo; tumor experienced local recurrence, the frequency of which was significantly lower than that reported in\u0026nbsp;the study published in The Lancet (13%) [15]. Compared with a study by Elgendy et al., in which 52% of patients experienced spillage, only one patient experienced intraoperative tumor spillage [16]. The most important surgical complication in Wilms\u0026rsquo; tumor is spillage [17].\u0026nbsp; Interdisciplinary teamwork is needed to achieve better outcomes; for example, cardiothoracic and vascular surgeons are needed to achieve complete resection in patients with cavo-atrial thrombi [18,19].\u0026nbsp; In bilateral tumors, nephron-sparing surgery plays an important role. The risk of complications in this subset should not deter surgeons from attempting maximum nephron preservation.\u003c/p\u003e\n\u003cp\u003eHepatoblastoma: Most patients had Grade 2 complications requiring perioperative blood transfusion. Knowledge of surgical anatomy is necessary to achieve complete resection of the tumor with minimal complications. Complete tumor resection is a good prognostic factor. In our study, neoadjuvant chemotherapy was given to all patients, as this is associated with better outcomes. Common complications after hepatic resection are bleeding, bile leakage, and tumor spillage. The extent of resection usually determines the grade of surgical complications [20].\u0026nbsp;In this study, 57% of patients had minor or major vascular injuries. One out of seven patients had a minor biliary leak. This leads to significantly increased operative time and blood loss. Owing to prolonged surgeries, all patients were admitted to the intensive care unit for close monitoring. Among all tumor types, children with hepatoblastoma had the longest postoperative stay. All these patients underwent surgery during the early course of liver resection. One out of seven patients had local tumor recurrence, which was noted, and the patient underwent reoperation for resection of the involved segment.\u003c/p\u003e\n\u003cp\u003eEwing sarcoma: Most patients had Grade 2 complications. There was a total of 10 patients with Ewing sarcoma, of which the most common site of origin (80%)\u0026nbsp;was the chest wall, with pain as the most common presenting symptom.\u003c/p\u003e\n\u003cp\u003eSacrococcygeal tumors: In this study, 9 patients underwent surgery for sacrococcygeal teratomas. The most common tumor type was Altman type 1. All patients\u0026nbsp;underwent primary excision. The most common surgical complication was surgical site wound infection.\u003c/p\u003e\n\u003cp\u003eThere were other tumors, such as adrenocortical masses, pelvic rhabdomyosarcoma, and teratomas, which were also treated at our center. All of these patients had grade 1 and 2 complications as the most common complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurgical complications disrupt the normal course of postoperative treatment after any surgery and are detrimental to the further management of patients with pediatric solid tumors. These complications may delay the start of adjuvant therapy in these children. Complications must be distinguished from other negative surgical outcomes such as sequelae, which means \u0026lsquo;after-effects\u0026rsquo; of surgery inherent to the procedure and failure to cure. In most of the studies, surgical complications are listed quantitatively [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is important to conduct a qualitative assessment of postoperative complications to report them objectively. It is correctly believed that the perception and reporting of complications are often subjective and inconsistent, whereas the documentation of the therapy needed to treat them is often exact and objective. The use of retrospective studies for assessing surgical complications is associated with underreporting, whereas the use of prospective studies is limited by the observer effect known as the Hawthorne effect, where if the participating surgeons are aware of the study, their behavior and thus grades can change [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The CD classification system has proven important in retrospective studies where postoperative complications are poorly reported, but the therapies used to treat them are usually well documented [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In a study conducted by Joseph et al., [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] 85% of patients experienced grade 1 and 2 complications, which is similar to our findings, where 83.5% of patients experienced grade 1 and 2 complications. In our study, 48% of patients required perioperative blood transfusions, probably due to nutritional and chemotherapy-induced anemia, along with intraoperative blood loss. Surgeons need to be vigilant and adaptive to improve surgical techniques to minimize intraoperative blood loss in already vulnerable patients. As depicted in a study by Gonzalez et al., in children who underwent surgery for solid tumors, perioperative blood transfusion was associated with an increased risk of postoperative mechanical ventilation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and an increased propensity for postoperative complications (p\u0026thinsp;=\u0026thinsp;0.02) along with a longer postoperative duration of hospital stays (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, in our study, intraoperative blood loss was associated with increased severity of postoperative complications and thus prolonged hospital stay. Surgical complications often increase the cost of treatment. However, cost evaluation alone is not a valid tool for comparisons. The complexity of the surgery and the postoperative duration of hospital stay correlate with the severity of complications, as shown by Dindo D et al. in 2004, where the data of 6336 patients were collected and assessed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This correlation was shown in many single-center studies. A retrospective study by Liu et al., which included 91 children with retroperitoneal tumors, concluded that compression or distortion of adjacent organs and vascular structures can lead to serious perioperative complications [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Our study revealed a noteworthy correlation between the grades of postoperative complications and the surgical complexities that arise from nearby organ infiltration, intraoperative blood loss, operative time duration and proximity to major blood vessels. These findings suggest that the severity of postoperative complications increases in tandem with the surgical complexities associated with these factors. Therefore, a detailed preoperative assessment of the extent of the tumor is crucial for preventing serious postoperative complications. Similarly, in our study, the postoperative duration of stay also increased significantly in patients with higher grades of complications. In a study by Brock et al., postoperative complications in 66,157 pediatric patients after gastrointestinal surgeries were assessed, which revealed that postoperative complications significantly increased the duration of hospital stay and cost of treatment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are multiple reasons for tumor recurrence. Surgery, along with postoperative complications, initiates an inflammatory cascade, which, as postulated by Beecher et al., increases the risk of tumor recurrence. Their review revealed that postoperative healing results in the release of many growth factors that can promote the mitogenic nature of tumor cells. Circulatory levels of growth factors such as interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) peak after an extensive surgical procedure. This promotes rapid angiogenesis, which is necessary for tumor growth, recurrence, and metastasis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study, patients with severe (grade 3 and grade 4) postoperative complications had a greater risk of tumor recurrence. This can be attributed to a delay in postoperative adjuvant therapy, like the study by Becker et al [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Their study of 126 operated hepatoblastoma patients revealed that patients with higher grades of postoperative complications had worse overall survival, possibly due to the delay in receiving adjuvant therapy. Similarly, in our study, patients with severe postoperative complications had a decreased probability of survival, as depicted by the Kaplan‒Meier curve. Similarly, a study by Lee et al. revealed that inflammation promotes epithelial-mesenchymal transition (EMT), which loosens cell-cell adhesion complexes and promotes the migratory and invasive properties of tumors [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In addition, our study demonstrated that systemic inflammation in the form of surgery and postoperative complications had a deleterious effect on the risk of tumor recurrence. Therefore, surgeons should make every possible effort to prevent and reduce the incidence of postoperative complications.\u003c/p\u003e \u003cp\u003eThe limitations of this study are that it is a retrospective analysis, and while suggesting a correlation between the postoperative complication grade and outcome concerning tumor recurrence or survival, we should consider other important parameters, such as the biological nature of the disease, delay in adjuvant therapy and contribution of preoperative chemotherapy, in increasing the risk of postoperative complications. This study is among the very few available studies showing the probable impact of postoperative complications on the disease outcome of pediatric solid tumors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study attempted to portray the importance of identifying and grading surgical complications objectively in pediatric surgical oncology. Severe complications, both surgical and oncological, were associated with worse outcomes.\u003c/p\u003e \u003cp\u003eIt is imperative to consider surgical complexities when planning interventions, as they have a significant effect on postoperative patient outcomes. By taking these parameters into account, surgical teams can better prepare for the risks associated with the procedure and mitigate any potential complications that may arise.\u003c/p\u003e \u003cp\u003eThe Clavien\u0026ndash;Dindo classification system appears to be a necessary and effective tool for evaluating postoperative complications. Its straightforward approach ensures an objective and reproducible outcome, making it an essential component of any rigorous surgical outcome assessment. This system refrains from downgrading the severity of postoperative complications, especially during retrospective studies. Reporting postoperative complications via the Clavien\u0026ndash;Dindo classification system eliminates subjectivity and biases to bestow us with the reliable outcome data desired by patients to improve the quality of care in pediatric surgical oncology.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis manuscript was presented as a paper presentation on 29\u003csup\u003eth\u003c/sup\u003e September 2022 at 54\u003csup\u003eth\u003c/sup\u003e Congress of the International Society of Paediatric Oncology SIOP 2022, Barcelona, Spain. For this, an IPSO scholarship was awarded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship \u0026ndash; \u003c/strong\u003eNIL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest \u0026ndash; \u003c/strong\u003eThere are no conflicts of interest.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAJ Writing and analysis data collectionNJP Concept , writing editing, analysisRS Concept, EditingAT Editing, Data collectionMAM Data collection, editingRM, Clinical care, data collection, editingSD Data analysis, editingSS Editing, analysisJS writing, data analysisRPK Editing, Data collectionDB Editing, Data collectionRJ Editing, Data collectionMB Editing, Data collectionRK Editing, Data collectionSY Editing, Data collectionJKM Editing, Data collection\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eRoss A, Gomez O, Wang X, Lu Z, Abdelhafeez H, Davidoff AM et al. Timing of adjuvant chemotherapy after laparotomy for Wilms tumor and neuroblastoma. Pediatr Surg Int. 2021 Nov;37(11):1585-92. doi: 10.1007/s00383-021-04968-1.\u003c/li\u003e\n \u003cli\u003eClavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992 May;111(5):518-26.\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae.\u003c/li\u003e\n \u003cli\u003eBarr ML, Belghiti J, Villamil FG, Pomfret EA, Sutherland DS, Gruessner RW et al. A report of the Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines. Transplantation. 2006 May 27;81(10):1373-85. doi: 10.1097/01.tp.0000216825.56841.cd.\u003c/li\u003e\n \u003cli\u003eThompson H, Jones C, Pardy C, Kufeji D, Nichols E, Murphy F et al. Application of the Clavien‒Dindo classification to a pediatric surgical network. J Pediatr Surg. 2020 Feb;55(2):312-315. doi: 10.1016/j.jpedsurg.2019.10.032.\u003c/li\u003e\n \u003cli\u003eJoseph JM, Farron AM, Renella R, Gapany C. Can smaller-scale comprehensive cancer centers provide outstanding care in abdominal and thoracic pediatric solid tumor surgery? Results of a 14-year retrospective single-center analysis. Ann Surg Oncol. 2014 May;21(5):1726-31. doi: 10.1245/s10434-013-3455-y.\u003c/li\u003e\n \u003cli\u003eEsposito C, Varlet F, Patkowski D, Castagnetti M, Escolino M, Draghici IM et al. Laparoscopic partial nephrectomy in duplex kidneys in infants and children: results of a European multicentric survey. Surg Endosc. 2015 Dec;29(12):3469-76. doi: 10.1007/s00464-015-4096-y.\u003c/li\u003e\n \u003cli\u003eCatr\u0026eacute; D, Lopes MF, Madrigal A, Oliveiros B, Cabrita AS, Viana JS et al. Predictors of major postoperative complications in neonatal surgery. Rev Col Bras Cir. 2013 Sep-Oct;40(5):363-9. English, Portuguese. doi: 10.1590/s0100-69912013000500003.\u003c/li\u003e\n \u003cli\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al. The Clavien‒Dindo classification of surgical complications: five-year experience. Ann Surg. 2009 Aug;250(2):187-96. doi: 10.1097/SLA.0b013e3181b13ca2.\u003c/li\u003e\n \u003cli\u003eVon Allmen D, Davidoff AM, London WB, Van Ryn C, Haas-Kogan DA, Kreissman SG et al.\u0026nbsp;Impact of extent of resection on local control and survival in high risk neuroblastomas patients: a report from the COG A3973 study J Clin Oncol. 2017;35(2):208.\u003c/li\u003e\n \u003cli\u003eCanete A, Jovani C, Lopez A, Costa E, Segarra V, Fernandez JM et al. Surgical treatment for neuroblastoma: complications during 15 years\u0026apos; experience. J Pediatr Surg. 1998; 33(10):1526-30.\u003c/li\u003e\n \u003cli\u003eR.G. Azizkhan, A. Shaw, J.G. Chandler. Surgical complications of neuroblastoma resection. Surgery. 1985; 97(5):514-7.\u003c/li\u003e\n \u003cli\u003eSteven W \u0026nbsp;Guidi STEX, Jorg Fuchs. Surgical complications in Pediatric surgical oncology. Pediatr Blood Canc 2012;398-404.\u003c/li\u003e\n \u003cli\u003ePastore G, Znaor A, Spreafico F, Graf N, Pritchard-Jones K, Steliarova-Foucher E. Malignant renal tumors incidence and survival in European children (1978-1997): report from the Automated Childhood Cancer Information System project. Eur J Cancer. 2006 Sep;42(13):2103-14.\u003c/li\u003e\n \u003cli\u003eBrok J, Lopez-Yurda M, Tinteren HV, Treger TD, Furtw\u0026auml;ngler R, Graf N et al. Relapse of Wilms\u0026apos; tumor and detection methods: a retrospective analysis of the 2001 Renal Tumor Study Group-International Society of Pediatric Oncology Wilms\u0026apos; tumor protocol database. Lancet Oncol. 2018 Aug;19(8):1072-81.\u003c/li\u003e\n \u003cli\u003eElgendy A, Abouheba M, Ebeid A, Shreif M.K. Shehata, Sameh Shehata. Surgical aspects, violations and outcomes of wilms tumor- a multicenter study in a resource limited country. Egy Pediatr. Assoc Gazette. 2020; (68):1\u003c/li\u003e\n \u003cli\u003eRoth H, Weirich A, Ludwig R, Daum R, Zimmermann H. Resection of nephroblastoma: problems and complications- evaluation of the Nephroblastoma study SIOP 9/GPOH. 1996; 113:1078-83.\u003c/li\u003e\n \u003cli\u003eGodzinski J, Tournade MF, deKraker J, Lemerle J, Voute PA, Weirich A. Rarity of surgical complications after postchemotherapy nephrectomy for nephroblastoma. Experience of the International Society of Pediatric Oncology-Trial and Study \u0026quot;SIOP-9\u0026quot;. International Society of Pediatric Oncology Nephroblastoma Trial and Study Committee. Eur J Pediatr Surg. 1998;8(2):83-6.\u003c/li\u003e\n \u003cli\u003eRitchey ML, Shamberger RC, Haase G, Horwitz J, Bergemann T, Breslow NE. Surgical complications after primary nephrectomy for Wilms\u0026apos; tumor: report from the National Wilms\u0026apos; Tumor Study Group. J Am Coll Surg. 2001;192(1):63-8\u003c/li\u003e\n \u003cli\u003eGu\u0026eacute;rin F, Gauthier F, Martelli H, Fabre M, Baujard C, Franchi S et al. Outcome of central hepatectomy for hepatoblastomas. J Pediatr Surg. 2010;45(3):555-63.\u003c/li\u003e\n \u003cli\u003eMartin RC 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg. 2002 Jun;235(6):803-13. doi: 10.1097/00000658-200206000-00007.\u003c/li\u003e\n \u003cli\u003eGonzalez DO, Cooper JN, Mantell E, Minneci PC, Deans KJ, Aldrink JH. Perioperative blood transfusion and complications in children undergoing surgery for solid tumors. J Surg Res. 2017 Aug;216:129-137. doi: 10.1016/j.jss.2017.04.025. Epub 2017 May 5. PMID: 28807197.\u003c/li\u003e\n \u003cli\u003eLiu Y, Hao X, Lu H, Duan Y, Dong Q, Qiao L. Factors Associated With Perioperative Complications in the Treatment of Pediatric Retroperitoneal Teratoma. J Surg Res. 2021 Mar;259:458-464. doi: 10.1016/j.jss.2020.09.007. Epub 2020 Oct 13. PMID: 33059908.\u003c/li\u003e\n \u003cli\u003eBrock R, Chu A, Lu S, Brindle ME, Somayaji R. Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and sociodemographic risk factors. BMC Pediatr. 2022 Jun 22;22(1):358. doi: 10.1186/s12887-022-03418-8. PMID: 35733099; PMCID: PMC9215078.\u003c/li\u003e\n \u003cli\u003eBeecher SM, OʼLeary DP, McLaughlin R, Kerin MJ.\u0026nbsp;The Impact of Surgical Complications on Cancer Recurrence Rates: A Literature Review. Oncol Res Treat. 2018;41(7-8):478-482. doi: 10.1159/000487510. Epub 2018 Jun 13. PMID: 29895008.\u003c/li\u003e\n \u003cli\u003eBecker K, Furch C, Schmid I, von Schweinitz D, H\u0026auml;berle B. Impact of postoperative complications on overall survival of patients with hepatoblastoma. Pediatr Blood Cancer. 2015 Jan;62(1):24-8. doi: 10.1002/pbc.25240. Epub 2014 Sep 22. PMID: 25251521.\u003c/li\u003e\n \u003cli\u003eLee B, Han HS. Tackling Surgical Morbidity and Mortality through Modifiable Risk Factors in Cancer Patients. Nutrients. 2022 Jul 28;14(15):3107. doi: 10.3390/nu14153107. PMID: 35956284; PMCID: PMC9370480.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 shows the distribution of patients in terms of postoperative complication grades.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003ePost-Operative Complication Grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e42.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e34.9% - 49.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e41.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e34.4% - 48.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 3A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e3.5% - 11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 3B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1.6% - 7.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 4A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e2.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1.0% - 6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 4B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.2% - 4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221px;\"\u003e\n \u003cp\u003eGrade 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e2.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1.0% - 6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2A \u0026ndash; shows the significant associations between postoperative complication grade and tumor infiltration/adhesion to the liver and viscera or mesentery.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvolvement:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"16\" style=\"width: 379px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-Operative Complication Grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026apos;s Exact Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e18 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e29 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e10.525\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e74 (93.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e60 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e159 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e78 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e188 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eViscera/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMesentery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"16\" style=\"width: 379px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026apos;s Exact Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e33 (42.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e61 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e16.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e64 (81.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e45 (57.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e127 (67.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e78 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003e188 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 2B shows the significant associations between postoperative complication grades and tumor infiltration/adhesion to the pericardium, lung or pleura, and diaphragm.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeart/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePericardium\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 379px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026apos;s Exact Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e6 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e26.666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e75 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e182 (96.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e78 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e188 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Lungs/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePleura\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 379px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026apos;s Exact Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e14 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e27 (14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e21.853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e75 (94.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e64 (82.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e9 (75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e161 (85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e78 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e188 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Diaphragm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 379px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026apos;s Exact Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e14 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e21 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e13.750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e76 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e64 (82.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e11 (91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e4 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e167 (88.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e79 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e78 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e12 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e188 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 \u0026ndash; Association of postoperative complication grade with survival.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-Operative Complication Grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCensored\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Survival\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI for Mean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian Survival\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI For Median\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e52.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e49.82 - 54.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNA - NA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" style=\"width: 64px;\"\u003e\n \u003cp\u003eLog Rank Test: p = \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e75.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e63.25 - 87.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNA \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 3A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e49.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e49.13 - 49.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNA \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 3B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e31.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e18.4 - 44.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;6 \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 4A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e26.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e16.29 - 36.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e14 \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 4B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12.63 - 12.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNA \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003eGrade 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.5 - 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNA \u0026ndash; NA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Clavien-Dindo classification, pediatric solid tumors, interleukin-6, postoperative complications, adjuvant therapy, quality improvement","lastPublishedDoi":"10.21203/rs.3.rs-6054106/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6054106/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative complications can significantly impact patient outcomes and quality of life, particularly in children with solid tumors, as they may delay essential adjuvant therapy. This study aimed to evaluate the severity and effects of these complications and to validate the Clavien–Dindo classification system in pediatric patients following surgery for solid tumors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective analysis was conducted on postoperative complications in children with solid tumors at a tertiary care teaching hospital over five years. Patient demographics and tumor types were recorded, and complications were categorized using the Clavien–Dindo classification. The study identified key risk factors for complications and their implications for patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn a study of 188 patients, the majority (n = 157; 83.5%) had low-grade (grade 1 or 2) postoperative complications. Higher intraoperative blood loss (p \u0026lt; 0.001), adjacent organ infiltration, and longer surgical times were associated with more severe complications. Patients with higher-grade complications also had longer hospital stays (Kendall’s Tau coefficient of 0.48). Among the 26 patients with tumor recurrence, 30% had experienced severe complications (grades 3 and 4). The Kaplan‒Meier curve and log-rank test (p \u0026lt; 0.001) showed that severe complications are linked to a lower survival probability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis of complications showed a significant effect on short-term surgical outcomes, and severe complications may also impact oncological outcomes. The Clavien-Dindo classification is a useful tool for grading postoperative complications in pediatric surgical oncology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence\u003c/strong\u003e: LEVEL III\u003c/p\u003e","manuscriptTitle":"Outcome Analysis of Surgical Complications in Paediatric Solid Tumours – A Retrospective Clinical Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-05 10:14:16","doi":"10.21203/rs.3.rs-6054106/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-13T12:32:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-13T12:14:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-10T19:21:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85326635049036818900059593485331044194","date":"2025-03-09T14:46:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63508526339359463869716468663117587941","date":"2025-03-06T08:53:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230712978505533302640530898763504131255","date":"2025-03-05T18:29:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-05T18:26:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-03T20:04:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-03T09:27:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2025-02-18T08:16:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f42e13cb-b6c8-4cdc-8009-9f3f11b543ce","owner":[],"postedDate":"March 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:07:18+00:00","versionOfRecord":{"articleIdentity":"rs-6054106","link":"https://doi.org/10.1007/s00383-025-06069-9","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2025-07-01 15:58:28","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-03-05 10:14:16","video":"","vorDoi":"10.1007/s00383-025-06069-9","vorDoiUrl":"https://doi.org/10.1007/s00383-025-06069-9","workflowStages":[]},"version":"v1","identity":"rs-6054106","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6054106","identity":"rs-6054106","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}