Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative
Authors:   PelvEx Collaborative, Chok A Y , Oliver A , Rasheed S , Tan E J , Kelly M E , Aalbers A G J , Abdul Aziz N , Abecasis N , Abraham-Nordling M , Akiyoshi T , Alberda W , Albert M , Andric M , Angenete E , Antoniou A , Auer R , Austin K K , Aziz O , Baker R P , Bali M , Baseckas G , Bebington B , Bedford M , Bednarski B K , Beets G L , Berg P L , Beynon J , Biondo S , Boyle K , Bordeianou L , Bremers A B , Brunner M , Buchwald P , Bui A , Burgess A , Burger J W A , Burling D , Burns E , Campain N , Carvalhal S , Castro L , Caycedo-Marulanda A , Chan K K L , Chang G J , Chew M H , Chong P , Christensen H K , Clouston H , Codd M , Collins D , Colquhoun A J , Corr A , Coscia M , Coyne P E , Creavin B , Croner R S , Damjanovic L , Daniels I R , Davies M , Davies R J , Delaney C P , de Wilt J H W , Denost Q , Deutsch C , Dietz D , Domingo S , Dozois E J , Duff M , Eglinton T , Enrique-Navascues J M , Espin-Basany E , Evans M D , Fearnhead N S , Flatmark K , Fleming F , Frizelle F A , Gallego M A , Garcia-Granero E , Garcia-Sabrido J L , Gentilini L , George M L , George V , Ghouti L , Giner F , Ginther N , Glynn R , Golda T , Griffiths B , Harris D A , Hagemans J A W , Hanchanale V , Harji D P , Helewa R M , Hellawell G , Heriot A G , Hochman D , Hohenberger W , Holm T , Holmström A , Hompes R , Jenkins J T , Kaffenberger S , Kandaswamy G V , Kapur S , Kanemitsu Y , Kelley S R , Keller D S , Khan M S , Kim H , Kim H J , Koh C E , Kok N F M , Kokelaar R , Kontovounisios C , Kristensen H Ø , Kroon H M , Kusters M , Lago V , Larsen S G , Larson D W , Law W L , Laurberg S , Lee P J , Limbert M , Lydrup M L , Lyons A , Lynch A C , Mantyh C , Mathis K L , Margues C F S , Martling A , Meijerink W J H J , Merkel S , Mehta A M , McArthur D R , McDermott F D , McGrath J S , Malde S , Mirnezami A , Monson J R T , Morton J R , Mullaney T G , Negoi I , Neto J W M , Nguyen B , Nielsen M B , Nieuwenhuijzen G A P , Nilsson P J , O’Dwyer S T , Palmer G , Pappou E , Park J , Patsouras D , Pellino G , Peterson A C , Poggioli G , Proud D , Quinn M , Quyn A , Radwan R W , Rasmussen P C , Rausa E , Regenbogen S E , Renehan A , Rocha R , Rochester M , Rohila J , Rothbarth J , Rottoli M , Roxburgh C , Rutten H J T , Ryan É J , Safar B , Sagar P M , Sahai A , Saklani A , Sammour T , Sayyed R , Schizas A M P , Schwarzkopf E , Scripcariu V , Selvasekar C , Shaikh I , Shida D , Simpson A , Smart N J , Smart P , Smith J J , Solbakken A M , Solomon M J , Sørensen M M , Steele S R , Steffens D , Stitzenberg K , Stocchi L , Stylianides N A , Swartling T , Sumrien H , Sutton P A , Swartking T , Taylor C , Teras J , Thurairaja R , Toh E L , Tsarkov P , Tsukada Y , Tsukamoto S , Tuech J J , Turner W H , Tuynman J B , Ramshorst G H van , Zoggel D van , Vasquez-Jimenez W , Verhoef C , Vizzielli G , Voogt E L K , Uehara K , Wakeman C , Warrier S , Wasmuth H H , Weber K , Weiser M R , Wheeler J M D , Wild J , Wilson M , Wolthuis A , Yano H , Yip B , Yip J , Yoo R N , Winter D C , Tekkis P P 
Published: February 2021

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.