Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative.

Aik Yong Chok ,H Ø Kristensen,P J Lee,J J Tuech,C Deutsch,D Van Zoggel,C Roxburgh,G V Kandaswamy,H J Kim,A M Mehta,S R Kelley,M Davies,J Park,L Bordeianou,J M Enrique-Navascues,H Kim,K Boyle,M Limbert,W J H J Meijerink,H Yano,J Teras,E L K Voogt,A B Bremers,R Glynn,H Sumrien,D W Larson,L Damjanovic,P L Berg,H Clouston,M Bali,K Weber,J W M Neto,T Swartking,M S Khan,A J Colquhoun,S E Regenbogen,S T O’Dwyer,Vishwanath Hanchanale ,Alexandra Peterson ,Martha Quinn ,Martin R Weiser ,Vanessa Carvalho Do Lago ,Dean Harris ,Jacobus W A Burger ,Michael Bedford ,Søren Laurberg ,D C Winter ,John Mcgrath ,Dai Shida ,Maximilian Brunner ,Werner Hohenberger ,Christopher R Mantyh ,Maurizio Coscia ,Francisco Giner ,William H Turner ,Jeremy Wild ,Quentin Denost ,Antonio Caycedo‐Marulanda ,Matthew L Albert ,Omer Aziz ,Eduardo García‐Granero ,Tamara G Mullaney ,David Burling ,Christos Kontovounisios ,Nicola Fearnhead ,A C Lynch ,Philip Smart ,George J Chang ,Patrick Chong ,Sandeep Kapur ,John T Jenkins ,E James Ryan ,Kjersti Flatmark ,Shahnawaz Rasheed ,Arne M Solbakken ,W Vásquez-Jiménez ,Satish Warrier ,Johannes H W De Wilt ,Andrea Burgess ,Samuel D Kaffenberger ,Matteo Rottoli ,Luca Stocchi ,Deena Harji ,Mihailo Andric ,Frank Mcdermott ,Miranda Kusters ,M B Nielsen ,Gianluca Pellino ,Jurriaan B Tuynman ,Ionuţ Negoi ,Benjamin Cherng Hann Yip ,Torbjörn Holm ,P M Sagar ,Dimitrios Patsouras ,Giuseppe Vizzielli ,R P Baker ,Arnold R Lyons ,Nathan Ginther ,Andrew G Renehan ,Jitender Rohila ,David Proud ,Frank Frizelle ,Elaine Burns ,Marie Louise Lydrup ,Min Hoe Chew ,Alex H Mirnezami ,Henrik Christensen ,Petr Tsarkov ,Torbjörn Swartling ,Anna Martling ,I Shaikh ,Kay Uehara ,Anthony Antoniou ,Gabriella Jansson Palmer ,Thomas Golda ,David Hochman ,Sara Carvalhal ,Amit Sahai ,Niels F M Kok ,Gilberto Poggioli ,Avanish Saklani ,Martyn Evans ,Claire Taylor ,Mette Møller Sørensen ,Michael J Solomon ,J.l García-Sabrido ,Kirk K S Austin ,Laurent Ghouti ,Albert Wolthuis ,Nicholas Campain ,H.j.t Rutten ,Nj Smart ,Malcolm S Wilson ,Ir Daniels ,Wai Lun Law ,J.a.w Hagemans ,Roel Hompes ,Paul Sutton ,Shunsuke Tsukamoto ,G Beets ,Viorel Scripcariu ,James M Wheeler ,Alison Corr ,Eloy Espín‐Basany ,J Beynon ,Cornelis Verhoef ,Deborah S Keller ,Anna-Riia Holmström ,Alex Oliver ,Mirna Abraham-Nordling ,Sebastiano Biondo ,Arend G J Aalbers ,Peter Coyne ,Karyn B Stitzenberg ,Roland S Croner ,Rory Kokelaar ,Ben Creavin ,Yukihide Kanemitsu ,David W Dietz ,Stein Gunnar Larsen ,J R T Monson ,Gediminas Baseckas ,C F S Margues ,Brendan Bebington ,M J Duff ,Jasmine Morton ,Wijnand J Alberda ,Sebastián Domingo ,Karen Kl Chan ,Hans H Wasmuth ,Gabriëlle H Van Ramshorst ,D Collins ,Susanne Merkel ,Joost Rothbarth ,Scott R Steele ,Lorenzo Gentilini ,Ben Griffiths ,Michael E Kelly ,D Ray Mcarthur ,Pamela Buchwald ,Tim Eglinton ,Rebecca C Auer ,Alexis Schizas ,Sachin Malde ,Rami Radwan ,Luis M Castro ,Alexander G Heriot ,Hidde M Kroon ,Vijay George ,Eva Angenete ,Clare Delaney ,Yuichiro Tsukada ,Brian Keith Bednarski ,Tarik Sammour ,Nauman Aziz ,Bashar Safar ,Eugenia Schwarzkopf ,Emmanouil P Pappou ,Andrew Simpson ,P Rasmussen ,Rameez Sayyed ,G.a.p Nieuwenhuijzen ,Chelliah Selvasekar ,Mario Álvarez Gallego ,Mary Codd ,Takashi Akiyoshi ,Ramesh Thurairaja ,Nuno Abecasis ,Mark George ,Chris Wakeman ,Eric J Tan ,Daniel Steffens ,Ee‐Lin Toh ,Per J Nilsson ,Giles Hellawell ,Ramzi M Helewa ,Eric J Dozois ,Fergal J Fleming ,Mark Rochester ,Aaron Quyn ,N Stylianides ,Ri Na Yoo ,Ai-Tram N Bui ,Jeremy Yip ,Christopher Koh ,Rodrigo Rhuan Andrade Rocha ,Richard J Davies ,Joseph J Smith ,Emanuele Rausa ,Kellie L Mathis ,Bianka M Nguyen ,Paris Tekkis

doi:10.1093/bjsopen/zraa055

Abstract

BackgroundThe multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management.MethodsThe modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus.ResultsThe final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements.ConclusionThe perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.

Highlights

Perioperative and anaesthetic management undertaken for pelvic exenteration requires close multidisciplinary and interprofessional collaboration between the anaesthetic and surgical teams, nursing staff and connected health members
For patients requiring pelvic exenteration, the aims of preoperative assessment should be determining the level of surgical fitness, ascertaining functional reserve and the ability to withstand periods of significant physiological stress, and the identification of issues that can potentially result in adverse surgical and anaesthetic outcomes
As patients undergoing pelvic exenteration comprise a heterogeneous group with diverse individual patient profiles, medical co-morbidities and varying levels of performance status, there has been no consensus on their optimal risk stratification

Summary

Introduction

Perioperative and anaesthetic management undertaken for pelvic exenteration requires close multidisciplinary and interprofessional collaboration between the anaesthetic and surgical teams, nursing staff and connected health members. There have been no clear guidelines established for the optimal perioperative and anaesthetic management of these patients, with wide variations across different centres internationally Through this consensus statement, this international collaborative group sought to consolidate clinical experience and best practice collectively, based on current standards of care at this point in time. No clear guidelines have been established, and there is wide variation in clinical practice internationally This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management. Conclusion: The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research

Methods

Results

Conclusion