Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members
David Martín, Styliani Mantziari, Nicolas Demartines, Martin Hübner, the ESA Study Group, Henri Bismuth, Michael G. Sarr, Steven M. Strasberg, Steven D. Wexner, Mustapha Adham, Donato F. Altomare, Roland Andersson, Wolf O. Bechstein, Sebastiano Biondo, Maximilian Bockhorn, Luigi Bonavina, Daniel Casanova Rituerto, Pierre‐Alain Clavien, Nicolò de Manzini, G. C. Decker, Cornelis HC Dejong, Christos Dervenis, Olivier Farges, Joan Figueras, Abraham Louis Fingerhut, Helmut Frieß, Olivier Gléhen, Michael Gnant, Christian A. Gutschow, Dieter Hahnloser, Bertil Hamberger, J.F. Hamming, A. H. Hölscher, Jakob R. Izbicki, Sven Jonas, Aleksandar Karamarković, Henrik Kehlet, Ari Leppäniemi, Jan Lerut, Pål‐Dag Line, J. Peter A. Lodge, Jonathan Meakins, Marco Montorsi, Philippe Nafteux, Peter Naredi, Attila Oláh, Yves Panís, Fernando Pardo, Rowan W. Parks, Sergio Pedrazzoli, Patrick Pessaux, Hugo P. Marques, Gilberto Poggioli, Irinel Popescu, Pauli Puolakkainen, José Manuel Ramia, Jari Räsänen, John V. Reynolds, Riccardo Rosati, Hans‐Detlev Saeger, Stefan Schneeberger, Paul M. Schneider, Kjetil Søreide, Dirk L. Stippel, Christian Toso, Jean–Jacques Tuech, Erkki Tukiainen, Richard van Hillegersberg, Bas P. L. Wijnhoven, Desmond C. Winter, Giovanni Zaninotto
Abstract
BACKGROUND: Major surgery is a term frequently used but poorly defined. The aim of the present study was to reach a consensus in the definition of major surgery within a panel of expert surgeons from the European Surgical Association (ESA). METHODS: A 3-round Delphi process was performed. All ESA members were invited to participate in the expert panel. In round 1, experts were inquired by open- and closed-ended questions on potential criteria to define major surgery. Results were analyzed and presented back anonymously to the panel within next rounds. Closed-ended questions in round 2 and 3 were either binary or statements to be rated on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Participants were sent 3 reminders at 2-week intervals for each round. 70% of agreement was considered to indicate consensus. RESULTS: Out of 305 ESA members, 67 (22%) answered all the 3 rounds. Significant comorbidities were the only preoperative factor retained to define major surgery (78%). Vascular clampage or organ ischemia (92%), high intraoperative blood loss (90%), high noradrenalin requirements (77%), long operative time (73%) and perioperative blood transfusion (70%) were procedure-related factors that reached consensus. Regarding postoperative factors, systemic inflammatory response (76%) and the need for intensive or intermediate care (88%) reached consensus. Consequences of major surgery were high morbidity (>30% overall) and mortality (>2%). CONCLUSION: ESA experts defined major surgery according to extent and complexity of the procedure, its pathophysiological consequences and consecutive clinical outcomes.