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Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members

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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.

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Acknowledgements

Collaborators of the ESA Study Group are: Henri Bismuth (Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France); Michael G. Sarr (Department of Surgery, Mayo Clinic, Rochester, USA); Steven M. Strasberg (Department of Surgery, Washington University School of Medicine, St. Louis, USA); Steven D. Wexner (Department of Colorectal Surgery, Cleveland Clinic Florida, USA); Mustapha Adham (Department of Surgery, Edouard Herriot Hospital, Lyon, France); Donato F. Altomare (Department of Emergency and Organ Transplantation, University Aldo Moro, Bari, Italy); Roland Andersson (Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden); Wolf Bechstein (Department of Surgery, Frankfurt University Hospital, Frankfurt, Germany); Sebastiano Biondo (Department of General and Digestive Surgery, Bellvitge University Hospital, Barcelona, Spain); Maximilian Bockhorn (Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany); Luigi Bonavina (Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy); Daniel Casanova Rituerto (Department of General Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain); Pierre-Alain Clavien (Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland); Nicolo De Manzini (Department of General Surgery, University Hospital of Trieste, Trieste, Italy); George Decker (Hôpitaux Robert Schuman, HRS-Zithaklinik, Luxembourg); Cornelis HC Dejong (Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands); Christos Dervenis (University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece); Olivier Farges (Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France); Joan Figueras (Josep Trueta Hospital, Girona, Spain); Abraham Louis Fingerhut (Department of Surgical Research, Medical University of Graz, Austria); Helmut Friess (Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany); Olivier Glehen (Department of Surgical Oncology, Centre Hospitalier Lyon-Sud, Lyon 1 University, Lyon, France); Michael Gnant (Department of Surgery, Comprehensive Cancer Center, Medical University Vienna and Pancreatic Cancer Unit, Vienna, Austria); Christian Gutschow (Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland); Dieter Hahnloser (Department of Visceral Surgery, Lausanne University Hospital CHUV and University of Lausanne, Lausanne, Switzerland); Bertil Hamberger (Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden); Jacob Frans Hamming (Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands); Arnulf H. Hölscher (Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany); Jakob R. Izbicki (Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany); Sven Jonas (Department of Hepato-, Pancreato- and Biliary Surgery, 310Klinik, Nuremberg, Germany); Aleksandar Karamarkovic (Faculty of Medicine, University Clinical Center, Clinic for Emergency Surgery, University of Belgrade, Serbia); Henrik Kehlet (Section for Surgical Pathophysiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark); Ari Kalevi Leppäniemi (Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland); Jan Lerut (Department of abdominal and transplantation surgery, University Hospitals Saint Luc, Brussels, Belgium); Pål-Dag Line (Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway); J. Peter A. Lodge (Department of HPB and Transplant Surgery, St James’s University Hospital NHS Trust, Leeds, UK); Jonathan Larmonth Meakins (Department of Surgery, McGill University Health Centre, Montreal, Canada); Marco Montorsi (General and Digestive Surgery Unit, Humanitas Research Hospital and University, Rozzano, Milan, Italy); Philippe Nafteux (Department of Thoracic Surgery and Disease of the Esophagus, KUZ Gathuisberg, Leuven, Belgium); Peter Naredi (Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden); Attila Oláh (Surgical Department, Petz Aladár County Teaching Hospital, Györ, Hungary); Yves Panis (Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France); Fernando Pardo (Clínica Universitaria de Navarra, Pamplona, Spain); Rowan W. Parks (Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK); Sergio Pedrazzoli (Clinica Chirurgica IV, University of Padua, Italy); Patrick Pessaux (Department of General, Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Université de Strasbourg, Strasbourg, France); Hugo Pinto Marques (Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, CHLC, Lisbon, Portugal); Gilberto Poggioli (Department of Medical and Surgical Sciences, Sant’Orsola, Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy); Irinel Popescu (Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania); Pauli Antero Puolakkainen (Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland); José M. Ramia Angel (Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain); Jari Rasanen (Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland); John Vincent Reynolds (Department of Clinical Surgery, Trinity Centre for Health Sciences, St. James’s Hospital and Trinity College Dublin, Dublin, Ireland); Riccardo Rosati (Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Milan, Italy); Hans-Detlev Saeger (Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Germany); Stefan Schneeberger (Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria); Paul M. Schneider (Centre for Visceral, Thoracic and Specialized Tumor Surgery, Klinik Hirslanden, Zurich, Switzerland); Kjetil Søreide (Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway); Dirk Stippel (Department of General, Visceral, and Cancer Surgery, University of Cologne, Köln, Germany); Christian Toso (Divisions of Abdominal and Transplant surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland); Jean-Jacques Tuech (Department of Surgery, Rouen University Hospital, Rouen, France); Erkki Juhani Tukiainen (Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland); Richard Van Hillegersberg (Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands); Bas Wijnhoven (Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands); Desmond C. Winter (Department of Colorectal Surgery, St Vincent’s University Hospital, Dublin, Ireland); Giovanni Zaninotto (Department of Surgery, Imperial College, London, UK).

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Author notes

  1. David Martin and Styliani Mantziari shared first authorship.

Authors and Affiliations

  1. Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland

    David Martin, Styliani Mantziari, Nicolas Demartines & Martin Hübner

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  1. David Martin
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  2. Styliani Mantziari
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  3. Nicolas Demartines
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Consortia

the ESA Study Group

  • Henri Bismuth
  • , Michael G. Sarr
  • , Steven M. Strasberg
  • , Steven D. Wexner
  • , Mustapha Adham
  • , Donato F. Altomare
  • , Roland Andersson
  • , Wolf Bechstein
  • , Sebastiano Biondo
  • , Maximilian Bockhorn
  • , Luigi Bonavina
  • , Daniel Casanova Rituerto
  • , Pierre-Alain Clavien
  • , Nicolo De Manzini
  • , George Decker
  • , Cornelis HC Dejong
  • , Christos Dervenis
  • , Olivier Farges
  • , Joan Figueras
  • , Abraham Louis Fingerhut
  • , Helmut Friess
  • , Olivier Glehen
  • , Michael Gnant
  • , Christian Gutschow
  • , Dieter Hahnloser
  • , Bertil Hamberger
  • , Jacob Frans Hamming
  • , Arnulf H. Hölscher
  • , Jakob R. Izbicki
  • , Sven Jonas
  • , Aleksandar Karamarkovic
  • , Henrik Kehlet
  • , Ari Kalevi Leppäniemi
  • , Jan Lerut
  • , Pål-Dag Line
  • , J. Peter A. Lodge
  • , Jonathan Larmonth Meakins
  • , Marco Montorsi
  • , Philippe Nafteux
  • , Peter Naredi
  • , Attila Oláh
  • , Yves Panis
  • , Fernando Pardo
  • , Rowan W. Parks
  • , Sergio Pedrazzoli
  • , Patrick Pessaux
  • , Hugo Pinto Marques
  • , Gilberto Poggioli
  • , Irinel Popescu
  • , Pauli Antero Puolakkainen
  • , José M. Ramia Angel
  • , Jari Rasanen
  • , John Vincent Reynolds
  • , Riccardo Rosati
  • , Hans-Detlev Saeger
  • , Stefan Schneeberger
  • , Paul M. Schneider
  • , Kjetil Søreide
  • , Dirk Stippel
  • , Christian Toso
  • , Jean-Jacques Tuech
  • , Erkki Juhani Tukiainen
  • , Richard Van Hillegersberg
  • , Bas Wijnhoven
  • , Desmond C. Winter
  •  & Giovanni Zaninotto

Corresponding author

Correspondence to Nicolas Demartines.

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The authors declare that they have no conflict of interest.

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Collaborators of the ESA Study Group are co-authors of this study and can be found under the heading Acknowledgements.

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Martin, D., Mantziari, S., Demartines, N. et al. Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members. World J Surg 44, 2211–2219 (2020). https://doi.org/10.1007/s00268-020-05476-4

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