Gastrointestinal symptoms and disorders after oesophago-gastric cancer surgery: The RESTORE modified Delphi survey

Background Oesophago-gastric (OG) cancer surgery is life-changing with a significant impact on quality of life (QOL). OG cancer surgery reconfigures the upper gastrointestinal (GI) tract altering its physiological function. Certain disorders such as anastomotic stricture are well recognised whereas others, such as small intestinal bacterial overgrowth, are increasingly being diagnosed. As multimodality treatment improves survival, more poly-symptomatic patients are living with these disorders as a consequence of surgery. We aimed to establish consensus on the definitions of relevant symptoms and disorders, as well as appropriate investigation and treatment. Standardisation will form a foundation for optimising QOL in this growing patient group. Methods This on-line modified Delphi study focused on patients after oesophagectomy, gastrectomy or subtotal gastrectomy for cancer (OG cancer surgery). The survey covered symptoms, common conditions, and symptoms triggering investigation for recurrence. The survey was designed using non-systematic reviews and expert opinion. Items were rated from 1 (completely disagree) to 9 (absolutely agree). Multi-disciplinary experts were identified through word of mouth and expressions of interest at previous conferences. Two rounds were completed, with some revisions after first round review. Median ratings were determined. Consensus agreement was judged as 70% or more respondents in agreement (7-9) and less than 15% disagreement (1-3). Results 86 and 77 complete surveys were received in rounds 1 and 2. Respondents were multidisciplinary, including OG surgeons, oncologists, gastroenterologists, radiologists, dietitians and nurse specialists. 7 upper GI, 13 non-specific and 6 lower GI symptom definitions were agreed. Clinical definitions, diagnostic criteria, first line investigations and treatments were agreed for 10 conditions: anastomotic stricture, acid reflux, non-acid reflux oesophagitis, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption. Agreement was also reached across many second-line investigations and treatments, and 12 of 14 (86%) symptom triggers to investigate for recurrence. Conclusions The RESTORE multidisciplinary consensus study has established a foundation for assessing and treating 10 conditions negatively affecting QOL after OG cancer surgery. Standardised symptom definitions will guide diagnostic assessments. Agreed condition definitions and diagnostic criteria will allow robust measurement of their incidence, and evaluation of treatment effects. Future work will aim to develop algorithms for managing these conditions. This work will raise standards of diagnosis and treatment of conditions that affect patients after OG cancer surgery, allowing collection of robust data to evaluate improvements in symptoms and QOL.