Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes
Authors:   The Beyond TME Collaborative, Ali S Mohammed , Antoniou Anthony , Beynon John , Bhangu Aneel , Bose Pradeep , Boyle Kirsten , Branagan Graham , Brown Gina , Burling David , Chang George J , Clark Susan K , Colquhoun Patrick , Crane Christopher H , Darzi Ara , Das Prajnan , de Wilt Johannes H W , Delaney Conor P , Desai Anant , Davies Mark , Dietz David , Dozois Eric J , Duff Michael , Dziki Adam , Fitzgerald J Edward , Frizelle Frank A , George Bruce , George Mark L , Georgiou Panagiotis , Glynne-Jones Rob , Goldin Robert D , Gupta Arun , Harji Deena , Harris Dean A , Hawkins Maria , Heriot Alexander G , Holm Torbjörn , Hompes Roel , Jeys Lee , Jenkins John T , Kiran Ravi P , Koh Cherry E , Laurberg Soren , Law Wai L , Liberman A Sender , Marshall Michele , McArthur David R , Mirnezami Alex H , Moran Brendan , Mortenson Neil , Myers Eddie , Nicholls R John , O'Connell P Ronan , O'Dwyer Sarah T , Oliver Alex , Pallan Arvind , Patel Prashant , Patel Uday B , Radley Simon , Ramsey Kelvin W D , Rasmussen Peter C , Richard Carole , Rutten Harm J T , Sagar Peter , Sebag-Montefiore David , Solomon Michael J , Stocchi Luca , Swallow Carol J , Tait Diana , Tan Emile , Tekkis Paris P , van As Nicholas , Vuong Te , Wiggers Theo , Wilson Malcolm , Winter Desmond , Woodhouse Christopher 
Published: June 2013

Consensus abstract

Background
The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.

Methods
Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus.

Results
The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management.

Conclusion
The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.