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

Abstract

Background The 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. Methods The 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. Results The 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. 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.

Implementation of a peri‐operative pain‐management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery

“…The PelvEx Collaborative stated that regional techniques, such as epidural analgesia, can reduce postoperative opioid use [37]. It is noteworthy, however, that this recommendation is based on anecdotal experience rather than clinical data.…”

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

“…Perioperative strategies to optimise the outcomes of patients undergoing pelvic exenteration or extended resection for pelvic cancers is critical to maximising treatment success [ 40 ]. Pre-existing co-morbidities are associated with poorer outcomes [ 25 ].…”

“…A meta-analysis of fifteen studies revealed a significantly lower hospital length of stay in patients undergoing cancer surgery, demonstrating an accelerated post-operative recovery in patients exposed to prehabilitation in the pre-operative period [ 42 ]. To optimise patient outcomes, multidisciplinary collaboration is essential, incorporating opinions from members of the anaesthetic and surgical teams, nursing staff and other allied health professionals [ 40 ].…”

“…Anaerobic threshold (AT) indicates the status of the patient’s aerobic fitness and is predictive of perioperative outcomes [ 43 ]. The PelvEx Collaborative previously outlined five consensus recommendations to optimise preoperative assessment and preparation in patients undergoing pelvic exenteration [ 40 ]:…”

“…There is emerging evidence to suggest the feasibility of ERAS in complex cytoreductive surgery with an improvement in early clinical outcomes [ 107 , 108 , 109 ]. The PelvEx Collaborative has offered guidance on the perioperative management of patients undergoing exenterative surgery and acknowledges the need for individualised tailored post-operative treatment plans [ 40 ].…”