Anastomotic leak following oesophagectomy: research priorities from an international Delphi consensus study
Authors:   Oesophago-Gastric Anastomosis Study Group on the West Midlands Research Collaborative, Kamarajah Sivesh K , Mohamed Imran , Nepogodiev Dmitri , Evans Richard P T , Hodson James , Griffiths Ewen A , Singh Pritam , Kamarajah Sivesh K , Griffiths Ewen A , Singh Pritam , Alderson Derek , Bundred James , Evans Richard , Gossage James , Griffiths Ewen A , Jefferies Benjamin , Kamarajah Sivesh K , McKay Siobhan , Mohamed Imran , Nepogodiev Dmitri , Siaw-Acheampong Kobby , Singh Pritam , van Hillegersberg Richard , Vohra Ravinder , Wanigsooriya Kasun , Whitehouse Tony , Bekele A , Achiam M P , Ahmed H , Ainsworth A , Akhtar K , Akkapulu N , Al-Khyatt W , Alasmar M , Alemu B N , Alfieri R , Alkhaffaf B , Alvarez L S , Amahu V , Andreollo N A , Arias F , Ariyarathenam A , Arndt A , Athanasiou A , Azagra J S , Baban C , Babor R , Baili E , Balla A , Beenen E , Bendixen M , Bennett J , Bergeat D , Bernardes A J , Bernardi D , Berrisford R , Bianchi A , Bjelovic M , Blencowe N , Boddy A , Bogdan S , Bolger J , Bonavina L , Bouras G , Bouwense S , Bowrey D , Bragg D , Bright T N , Broderick S , Buduhan G , Byrne B , Carey D , Carroll P , Carrott P , Casaca R , Castro R G , Catton J , Cerdeira M P , Chang A C , Charalabopoulos A , Chaudry A , Choh C , Ciprian B , Ciubotaru C , Coe P , Colak E , Colino R B , Colucci N , Costa P M , Daniela K , Das N , Davies A , Davies N , de Manzoni G , del Val I D , Dexter S , Dolan J , Donlon N , Donohoe C , Duffy J , Dwerryhouse S , Egberts J H , Ekwunife C , Elhadi A , Elhadi M , Elliott J A , Elnagar H , Elnagar F , Faraj H A , Farooq N , Fearon N , Fekaj E , Forshaw M , Freire J , Gačevski G , Gaedcke J , Giacopuzzi S , Gijón M M , Gisbertz S , Golcher H , Gordon A , Gossage J , Griffiths E , Grimminger P , Guner A , Gutknecht S , Harustiak T , Hedberg J , Heisterkamp J , Hii M , Hindmarsh A , Holm J , Hornby S , Isik A , Izbicki J , Jagadesham V , Jaunoo S , Johansson J , Johnson M A , Johnston B , Kapoulas S , Kauppi J , Kauppila J H , Kechagias A , Kelly M , Kelty C , Kennedy A , Khan M , Khattak S , Kidane B , Kjaer D W , Klarenbeek B , Korkolis D P , Koshy R M , Krantz S , Lagarde S , Larsen M H , Lau P C , Leeder P C , Leite J S , Liakakos T , Madhavan A , Mahdi S I , Mahendran H A , Mahmoodzadeh H , Majbar A , Manatakis D , Markar S , Martijnse I , Matei B , Matos da Costa P , McCormack K , McNally S , Meriläinen S , Merrett N , Migliore M , Mingol F , Khan M , Mitton D , Mogoanta S S , Mönig S P , Moorthy K , Muhinga M , Mwachiro M , Naeem A , Nasir I , Navidi M , Negoi I , Negoiță V , Niazi S K , Nilsson M , Pazdro A , Pera M , Perez C J , Perivoliotis K , Peters C , Phillips A W , Powell A , Prove L , Pucher P H , Rahman S , Räsänen J V , Read M , Reeh M , Reim D , Reynolds J , Robb W B , Robertson K , Rodica B , Rosero G , Rosman C , Saadeh L , Santos EG , Saunders J , Sayyed R , Schizas D , Scurtu R R , Sekhniaidze D , Serralheiro P A , Sevinç B , Sgromo B , Shakeel O , Siemsen M , Skipworth R , Smith B , Soares A , Spillane J , Steliga M A , Sundbom M , Sydiuk A , Takahashi A M L , Talbot M , Tan B , Tareen M A , Tewari N , Tez M , Theodorou D , Tita A , Toledo E , Townend P J , Triantafyllou T , Trugeda M , Tucker O , Turner P , Turrado V , Underwood T , Vaccari S , Valmasoni M , van Berge Henegouwen M , van Boxel G , van den Berg J W , van der Sluis P , van Hillegersberg R , van Lanschot J J B , van Workum F , Vickers J , Videira J , Viswanath Y , Vohra R , Voon K , Wadley M , Walker R , Wallner B , Walsh T N , Weindelmayer J , Welch N , Wheatley T , Wijnhoven B , Wong L F , Yanni F , Yeung J 
Published: December 2020

Abstract

Background
The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks.

Methods
A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income.

Results
In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis.

Conclusion
Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.