{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T22:23:28Z","timestamp":1790979808054,"version":"4.1.0"},"reference-count":0,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2025,2,28]],"date-time":"2025-02-28T00:00:00Z","timestamp":1740700800000},"content-version":"vor","delay-in-days":60,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,12,30]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Patients undergoing hepato-pancreato-biliary surgery are typically preoperatively assessed using the American Society of Anesthesiologists (ASA) classification, which is also used for case-mix adjustment when comparing centre outcomes. Studies determining the inter-rater variability of the ASA classification within hepato-pancreato-biliary surgery are currently lacking.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>An international survey was collected and a case-vignette study was performed (November 2022\u2013April 2023) regarding the ASA classification in patients undergoing hepato-pancreato-biliary surgery among anaesthesiologists and surgeons from (inter)national societies. The survey consisted of 23 questions and eight case-vignettes. Primary analysis included descriptive statistics and the inter-rater variability was calculated using Light's Kappa.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Overall, 1283 participants from 55 countries responded: 1073 (84%) anaesthesiologists and 210 (16%) surgeons. The ASA classification was commonly used, both clinically 1003\/1283 (78%) and for research 728\/762 (96%). The majority of respondents (n = 1019, 79%) declared that ASA score impacted their perioperative strategy. There inter-rater variability was fair\u2013moderate (Kappa 0.26\u20130.42) in all case-vignettes. Inter-rater variability differed within and among geographic regions for each case. Over 80% (n = 1138) of respondents stated that they would take the underlying disease (for example cancer) into account, but this changed the preferred ASA score within the case-vignettes by only 1%. Type of surgery changed the preferred score in the case-vignettes (13% difference). The most common suggestions to improve the ASA classification were to clarify whether type of operation should be considered, create a more extensive definition, and provide more examples.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Inter-rater variability was present within the ASA classification of patients undergoing hepato-pancreato-biliary surgery, which may impact perioperative strategy and hamper research results. Additional guidance to classify patients according to ASA is urgently needed. Until then, more objective measurements should be considered for case-mix adjustment within research.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/bjsopen\/zrae162","type":"journal-article","created":{"date-parts":[[2025,3,4]],"date-time":"2025-03-04T21:43:44Z","timestamp":1741124624000},"source":"Crossref","is-referenced-by-count":9,"title":["Inter-rater variability for the American Society of Anesthesiologists classification in patients undergoing hepato-pancreato-biliary surgery (MILESTONE-2): international survey among surgeons and anaesthesiologists"],"prefix":"10.1093","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0625-4349","authenticated-orcid":false,"given":"Simone","family":"Augustinus","sequence":"first","affiliation":[{"name":"Department of Surgery, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Cancer Center Amsterdam , Amsterdam ,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jasper P","family":"Sijberden","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Cancer Center Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero , Brescia ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthanja","family":"Bieze","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto , Toronto, Ontario ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vandana","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute , Mumbai, Maharashtra ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7729-2468","authenticated-orcid":false,"given":"Luca A","family":"Aldrighetti","sequence":"additional","affiliation":[{"name":"Hepatobiliary Surgery Division, Ospedale San Raffaele , Milano ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adnan","family":"Alseidi","sequence":"additional","affiliation":[{"name":"Division of Hepatopancreatobiliary and Endocrine Surgery, University of California , San Francisco, California ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco C","family":"Bonofiglio","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Hospital Italiano de Buenos Aires , Buenos Aires ,","place":["Argentina"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin C P","family":"Conlon","sequence":"additional","affiliation":[{"name":"Department of Surgery, Trinity College Dublin, Tallaght University Hospital , Dublin ,","place":["Ireland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katia","family":"Donadello","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care B, DSCOMI, University of Verona, University Hospital Integrated Trust of Verona , Verona ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8233-1505","authenticated-orcid":false,"given":"Joris","family":"Erdmann","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Cancer Center Amsterdam , Amsterdam ,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristina","family":"Ferrone","sequence":"additional","affiliation":[{"name":"Department of Surgery, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Guertin","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, The Ohio State University Wexner Medical Center & College of Medicine , Columbus, Ohio ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald","family":"Harter","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, The Ohio State University Wexner Medical Center & College of Medicine , Columbus, Ohio ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria E","family":"Franceschetti","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, Istituto Fondazione Poliambulanza , Brescia ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guiseppe K","family":"Fusai","sequence":"additional","affiliation":[{"name":"Hepatobiliary Surgery and Liver Transplantation Unit, Royal Free Hospital , London ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1917-6973","authenticated-orcid":false,"given":"Bas","family":"Groot Koerkamp","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus MC, University Medical Center Rotterdam , Rotterdam ,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7012-1196","authenticated-orcid":false,"given":"Thilo","family":"Hackert","sequence":"additional","affiliation":[{"name":"Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin-Young","family":"Jang","sequence":"additional","affiliation":[{"name":"Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine , Seoul ,","place":["South Korea"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Kander","sequence":"additional","affiliation":[{"name":"Department of Intensive and Perioperative Care, Sk\u00e5ne University Hospital, Lund and Lund University , Lund ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"Keck","sequence":"additional","affiliation":[{"name":"DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus L\u00fcbeck , L\u00fcbeck ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dominik","family":"Krzanicki","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia, Royal Free Hospital , London ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ho-Jin","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Seoul National University Hospital , Seoul ,","place":["South Korea"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keith","family":"Lewis","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson Medical School , New Brunswick, New Jersey ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Natalini","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, Istituto Fondazione Poliambulanza , Brescia ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Nau","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein , L\u00fcbeck ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7994-9870","authenticated-orcid":false,"given":"Timothy M","family":"Pawlik","sequence":"additional","affiliation":[{"name":"Department of Surgery, The Ohio State University Wexner Medical Center , Columbus, Ohio ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry A","family":"Pitt","sequence":"additional","affiliation":[{"name":"Department of Surgery, Rutgers Cancer Institute of New Jersey , New Brunswick, New Jersey ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rafaella","family":"Reineke","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute , Milan ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Salvia","sequence":"additional","affiliation":[{"name":"General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona , Verona ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eduardo","family":"de Santibanes","sequence":"additional","affiliation":[{"name":"Department of Surgery, Hospital Italiano, University of Buenos Aires , Buenos Aires ,","place":["Argentina"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shailesh V","family":"Shrikhande","sequence":"additional","affiliation":[{"name":"Department of GI and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute , Mumbai ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Surgery, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand , Johannesburg ,","place":["South Africa"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Attila","family":"Szijarto","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, I. sz. Seb\u00e9szeti Klinika, Semmelweis Egyetem , Budapest ,","place":["Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5940-8276","authenticated-orcid":false,"given":"Bobby","family":"Tingstedt","sequence":"additional","affiliation":[{"name":"Department of Surgery, Clinical Sciences Lund, Lund University, Sk\u00e5ne University Hospital , Lund ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2505-959X","authenticated-orcid":false,"given":"Alice C","family":"Wei","sequence":"additional","affiliation":[{"name":"Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, New York ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5995-5432","authenticated-orcid":false,"given":"John","family":"Windsor","sequence":"additional","affiliation":[{"name":"HBP\/Upper GI Unit, Auckland City Hospital\/Department of Surgery, University of Auckland ,","place":["New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"Abu Hilal","sequence":"additional","affiliation":[{"name":"Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero , Brescia ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuel","family":"Pardo","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Perioperative Care, University of California , San Francisco, California ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus W","family":"Hollmann","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2650-9350","authenticated-orcid":false,"given":"Marc G","family":"Besselink","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC, Location University of Amsterdam , Amsterdam ,","place":["The Netherlands"]},{"name":"Cancer Center Amsterdam , Amsterdam ,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,2,28]]},"container-title":["BJS Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/bjsopen\/article-pdf\/9\/1\/zrae162\/62202257\/zrae162.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/bjsopen\/article-pdf\/9\/1\/zrae162\/62202257\/zrae162.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,4]],"date-time":"2025-03-04T23:52:41Z","timestamp":1741132361000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/bjsopen\/article\/doi\/10.1093\/bjsopen\/zrae162\/8045794"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,30]]},"references-count":0,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2024,12,30]]}},"URL":"https:\/\/doi.org\/10.1093\/bjsopen\/zrae162","relation":{},"ISSN":["2474-9842"],"issn-type":[{"value":"2474-9842","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,2]]},"published":{"date-parts":[[2024,12,30]]},"article-number":"zrae162"}}