Specialist guidelines advise a preoperative multidisciplinary team (MDT) approach to determine surgical appropriateness and optimize perioperative care in the high risk surgical patient (1-4). Importantly, the patient, their family and the treating medical staff may all have different definitions of adverse outcome, emphasising the need for shared decision making (5-6). It stands to reason that predictive score that accurately predict the risk of unfavourable outcome for a particular patient and intervention may aid informed decision making. In 2016, our hospital formalized a preoperative MDT for all patients with an indication to undergo open aortic surgery, and any other cases where there are concerns about the appropriateness of the proposed surgical treatment plan. We describe four years of experience with a preoperative MDT.

This retrospective cohort study was performed in a regional teaching hospital, equipped with an emergency department, 400 clinical beds, 18 ICU beds, and three post anesthesia care unit beds. A Datawarehouse search was performed to identify all patients who had been discussed at the preoperative MDT meeting between 2-2016, and 5-2020. One-year follow-up was recorded. The online ACS NSQIP surgical risk calculator, Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) and the Preoperative Score to Predict Postoperative Mortality (POSPOM) were used retrospectively to estimate chances of an unfavorable outcome for the proposed or effectuated surgical plan (7-9). Descriptive statistics were performed to describe patient and meeting characteristics, 30-day outcome and one-year mortality.

Indications and recommendations During the study period, 185 patients were discussed a total of 212 times during 98 MDTs. Patients most commonly had vascular diagnoses (55%) - mainly aneurysms (53, 29%) or vascular occlusive disease 45 (24%) - followed by gastroenterological (17%), orthopaedic (9%), and oncological (8%) indications. In 69 (37%) cases, the final MDT meeting led to additional measures or an altered plan. If the subsequently actualized treatment plan deviated from the recommendations of the last MDT meeting (23, 12%), this was most often because of shared decision making (9, 5%) or improvement of the disease (5, 3%). Perioperative risk prediction Within the study period, 146 (79%) patients eventually underwent a surgical procedure for the primary indication. The predicted risk of unfavorable outcome for all patients and the proposed or effectuated surgical plan are detailed in table 1. Patients who underwent a procedure for the two most common diagnoses - vascular aneurysm and vascular occlusive disease - are shown separately. Patients who did not undergo surgery had higher predicted risk of re-admission than the operated group. The other differences in predicted risk were not significant. Of the operated patients, the vascular occlusive disease group had the highest predicted risk of any, and serious complications, including readmission, reoperation and discharge to a post-acute care facility. Perioperative outcome In actuality, 36% percent of the operated patients experienced complications within 30 days, leading to an in-hospital death rate of 7%, and 19% to be newly admitted to a nursing home (table 2). Vascular aneurysm patients had higher overall complication rates compared to the total cohort. Vascular occlusive disease patients had lower complication rates than both the total cohort and the aneurysm patients, and were less likely to die during admission or be discharged to a post-acute care facility. The difference in one-year mortality rates between the operated and the conservative group was not significant (17% vs 23%, p=.5).

The preoperative multidisciplinary team approach for high risk surgical patients led to a changed or extended perioperative treatment plan in 37% of the patients. In 5%, subsequent shared decision making led to waiver of the proposed surgical intervention. Postoperative complication and mortality rates were high, likely indicating that the preoperative concerns leading to presentation at the MDT were justified. However, future research should focus on the question whether the MDT correctly identified the cases in which the proposed intervention was not proportional, thus preventing higher morbidity rates. Preoperative risk scores indicated that vascular occlusion patients had the highest risk of complications, which was not reflected by the actual complication rates. Nevertheless, many complications, including in-hospital and one-year mortality appeared to be underestimated by the risk scores on a group basis and future studies should evaluate the validity of the various risk scores in the high risk patient category.

References 1. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35: 2383-431. - DOI' 2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: Executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64: 2373-405. - DOI 3. Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol 2017; 33: 17-32. - DOI 4. De Hert S, Staender S, Fritsch G, et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 35; 407-65. - DOI 5. Boyd O, Jackson N. How is risk defined in high-risk surgical patient management? Crit Care. 2005 Aug;9(4):390-6. doi: 10.1186/cc3057. Epub 2005 Feb 9. PMID: 16137389; PMCID: PMC1269426. 6. Kolh P, De Hert S, De Rango P. The Concept of Risk Assessment and Being Unfit for Surgery. Eur J Vasc Endovasc Surg. 2016 Jun;51(6):857-66. doi: 10.1016/j.ejvs.2016.02.004. Epub 2016 Apr 4. PMID: 27053098. 7. https://riskcalculator.facs.org/RiskCalculator/ Accessed 28-12-2021. 8. https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk Accessed 28-12-2021. 9. http://perioperativerisk.com/mortality/ Accessed 28-12-2021.