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

David Martin, Styliani Mantziari, the ESA Study Group, Nicolas Demartines*, Martin Hübner, 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 DeckerCornelis 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, Bas Wijnhoven

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

31 Citations (Scopus)


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.

Original languageEnglish
Pages (from-to)2211-2219
Number of pages9
JournalWorld Journal of Surgery
Issue number7
Publication statusPublished - Jul 2020

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© 2020, Société Internationale de Chirurgie.


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