A research agenda for gastrointestinal and endoscopic surgery

Abstract

Background

Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery.

Methods

A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2.

Results

A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: “What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?” The second highest-ranked question was: “Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?” Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment.

Conclusions

An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.

Appendix 1

Results of rounds 1 and 2 of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Research Delphi Project. The research questions are ranked according to mean importance on round 2

Question

• 1. Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?

• 2. Is minimally invasive surgery better than open surgery with respect to immunosuppression, tumor growth metastasis, and inflammatory response?

• 3. What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for gastroesophageal reflux disease (GERD)?

• 4. Does antireflux surgery prevent progression of Barrett’s esophagus and development of cancer?

• 5. In the morbidly obese population, what is the optimal protocol for deep vein thrombosis (DVT) prophylaxis in patients undergoing laparoscopic or open procedures?

• 6. What methods of simulation are most effective in helping surgeons learn techniques and skills for gastrointestinal and endoscopic surgery?

• 7. What is the optimal surgical treatment of morbid obesity?

• 8. In nonlocalizable gastrointestinal bleeding, what is the optimal treatment algorithm?

• 9. Are there techniques or materials that can be used at the time of a primary abdominal operation to prevent the development of a ventral hernia?

• 10. How does endoluminal treatment for GERD compare with medical and surgical treatments?

• 11. What is the optimal management for patients with rectal cancer who have a complete clinical response to neoadjuvant therapy?

• 12. What is the optimal technique and material for repairing ventral hernia in specific patient groups?

• 13. What are the best objective methods for measuring surgical proficiency?

• 14. In patients with treated colonic neoplasia, what is the most appropriate regimen of colonoscopic surveillance?

• 15. Are there new devices or biosurgical glues that decrease the incidence of anastomotic leak or stenosis?

• 16. Is laparoscopic total mesorectal excision equivalent to open resection for rectal cancer?

• 17. What is the optimal approach to the diagnosis and management of common bile duct stones?

• 18. What is the appropriate role of laparoscopy in staging gastrointestinal cancers?

• 19. What outcome measures should be used to determine successful treatment of GERD in clinical trials?

• 20. How can the best outcomes of gastrointestinal and endoscopic surgical procedures be reproduced in all practice settings?

• 21. Can dietary or lifestyle modification prevent colorectal neoplasia (e.g., aspirin, folate, alcohol)?

• 22. What is the role of natural orifice transendoluminal endoscopic surgery for abdominal surgery?

• 23. Can lymph node involvement in early colorectal cancer be accurately predicted without formal resection?

• 24. What are the predictors of failure and long-term outcome after laparoscopic gastric banding?

• 25. What metrics and pathways should determine whether a specific surgeon or institution may perform surgical procedures?

• 26. How should novel surgical technologies be introduced into surgical practice?

• 27. Is laparoscopic appendectomy better than open appendectomy?

• 28. Can improved ergonomic instrument design decrease surgeon muscle fatigue?

• 29. What is the impact of the skill of the operating team assisting the surgeon on the outcomes and performance of laparoscopic procedures?

• 30. What is the optimal method of managing inguinal hernia for specific patient groups?

• 31. What is the best technique for avoiding post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis?

• 32. What is the appropriate preoperative cardiac workup for the morbidly obese patient?

• 33. What is the role of bariatric surgery for patients who fall outside current National Institutes of Health (NIH) guidelines such as those younger than 18 years or older than 65 years and patients with a body mass index less than 35 kg/m² or a body-mass index 35 to 40 kg/m² without comorbidity?

• 34. Is bariatric surgery for type 2 diabetes in morbidly obese persons cost effective?

• 35. What quality-of-life instruments are necessary for adequate measurement of outcomes in gastrointestinal and endoscopic surgery?

• 36. What is the best endoluminal therapy for GERD?

• 37. Are endoluminal ablative therapies more effective than medical management of Barrett’s esophagus?

• 38. Does the presence of clinical pathways and specifically trained nursing staff result in decreased length of hospital stay?

• 39. What is the mechanism of resolution of type 2 diabetes after bariatric surgery?

• 40. What is the role of antireflux therapy for patients with short-segment Barrett’s esophagus?

• 41. What is the role of laparoscopy for the hemodynamically stable penetrating abdominal trauma patient?

• 42. When should gastric bypass surgery be used instead of antireflux surgery in morbidly obese patients with GERD?

• 43. What is the optimal management of appendiceal perforation with abscess in children?

• 44. What are the mechanisms of satiety after bariatric surgery?

• 45. What is best method of preventing and repairing parastomal hernia?

• 46. Does three-dimensional visualization in laparoscopic surgery decrease operative time, blood loss errors, conversion, or complications?

• 47. What is the best method of minimizing postoperative pain after laparoscopic surgery?

• 48. Does prosthetic mesh reinforcement improve the outcome of paraesophageal hernia repair?

• 49. What is the role of early ERCP in acute biliary pancreatitis?

• 50. Are there procedures whereby image-guided “virtual preoperative walkthrough” will improve operative time and surgical outcome?

• 51. How are large health databases best used to evaluate and improve outcomes in gastrointestinal and endoscopic surgery?

• 52. What metrics and pathways should determine whether a specific surgeon or institution may perform flexible endoscopy?

• 53. Is long-term survival and time to recurrence equivalent with radiofrequency ablation and resection of hepatic malignancy?

• 54. Are cardiac events and cardiac interventions decreased after bariatric surgery?

• 55. Is laparoscopic Heller myotomy more effective than balloon dilation in the treatment of achalasia?

• 56. For which procedures does robotic surgery offer advantages over other forms of surgical access?

• 57. What is the optimal management for patients requiring revisional bariatric surgery?

• 58. What is the optimal limb length in Roux-en-Y gastric bypass?

• 59. Is it necessary to close mesenteric defects during gastric bypass?

• 60. Is bowel preparation essential for laparoscopic colon surgery?

• 61. What patient factors affect the rate of stricture formation after gastrointestinal anastomosis?

• 62. What is the most effective method of preventing “fogging” of the laparoscope?

• 63. What is the role of endoluminal therapy for the management of dilated gastrojejunostomy after failed gastric bypass?

• 64. How can formation of marginal ulcer after gastric bypass be predicted prevented and treated?

• 65. What is the best method of bringing the Roux limb to the gastric pouch (retrocolic retrogastric, antecolic, or antegastric)?

• 66. How does the length of the biliopancreatic limb affect the outcome of Roux-en-Y gastric bypass?

• 67. What is optimal management of large bowel obstruction?

• 68. Is it necessary to close the fascia to prevent hernia formation after using dilating trocars?

• 69. Under what circumstances is elective laparoscopic lysis of adhesions appropriate?

• 70. Do surgeon experience and volume affect the cost of laparoscopic colon resection?

• 71. What is the natural history of untreated paraesophageal hernia?

• 72. What is the role of endoluminal therapy for morbid obesity?

• 73. How does fatigue impact competence and surgical judgment for gastrointestinal and endoscopic surgical procedures?

• 74. Does the use of different techniques of minimally invasive cholecystectomy affect outcome in specific patient groups?

• 75. Is hand-assisted colon resection better than laparoscopic resection for colon cancer?

• 76. What is the optimal nonsurgical management of fistula-in-ano?

• 77. Is hand-assisted colon resection better than laparoscopic resection?

• 78. What is the best treatment for recurrent dysphagia after Heller myotomy?

• 79. How can gastrogastric fistula after divided gastric bypass be predicted, prevented, and treated?

• 80. What is the role of dietary therapy in the prevention of recurrent diverticulitis?

• 81. What is the role of stenting in advanced colorectal cancer?

• 82. What is the optimal choice of fundoplication for laparoscopic Heller myotomy for achalasia?

• 83. Should intraabdominal abscess be drained percutaneously or with laparoscopic techniques?

• 84. Is thoracoscopic pulmonary wedge resection as efficacious as open resection and less morbid?

• 85. Is laparoscopic surgery better than open surgery for acute diverticulitis?

• 86. How does communication technology affect follow-up evaluation and compliance after bariatric surgery?

• 87. Does cost awareness modify a surgeon’s use of laparoscopic equipment or his or her operative approach?

• 88. Is there any benefit of general diagnostic laparoscopy during other laparoscopic procedures?

• 89. What is the appropriate clinical application of esophageal multichannel intraluminal impedance monitoring?

• 90. What are the indications for esophageal lengthening procedures (e.g., Collis gastroplasty)?

• 91. What is the role of cholecystectomy during weight loss surgery?

• 92. What is the best management of full-thickness rectal prolapse?

• 93. What is the optimal reconstruction after total gastrectomy?

• 94. For neurologically impaired children, what is the optimal management of GERD?

• 95. Does laparoscopic enteral access have an advantage over open enteral access?

• 96. What is the most effective and efficient method of processing flexible endoscopes?

• 97. What is the role of pancreatic duct aspiration for screening patients at high risk of developing pancreatic cancer?

• 98. Does vagotomy influence outcome after gastric bypass?

• 99. For patients who require laparoscopic surgery in remote locations such as natural disasters, battlefields, or space, which is best: local laparoscopy evacuation to a remote location or local open surgery?

• 100. In what setting is laparoscopic adrenalectomy appropriate for isolated adrenal metastasis?

• 101. Is thoracoscopic sympathectomy for palmar hyperhydrosis more efficacious and associated with fewer side effects than medical treatment?

• 102. What is the optimal treatment of morbid obesity?

• 103. Is minimally invasive parathyroidectomy or thyroidectomy better than conventional open surgery?

• 104. What is the optimal surgical management of hydatid cyst?

• 105. Is laparoscopic surgery better than open surgery for Hirschsprung’s disease with respect to fecal incontinence?

• 106. What is the appropriate treatment for visceral arterial aneurysms?