An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

This study utilized the Delphi method to achieve consensus by soliciting international expert opinion on essential technical steps in LND and general aspects of anastomosis creation required to perform MITG for oncological indications (Fig. 1). The study utilized the AGREE II framework for the assessment of the methodological quality of practice guidelines (Appendices 1 and 2). AGREE II comprises 23 items organized into six quality domains: (i) scope and purpose; (ii) stakeholder involvement; (iii) rigor of development; (iv) clarity of presentation; (v) applicability; and (vi) editorial independence that targets various aspects of practice guideline quality [28]. The outcomes of this study were to create consensus on the most important steps of the operation required to achieve optimal oncological outcomes, minimize technical heterogeneity, and inform the training of future surgeons.

Thirty UGI/general surgery experts were invited to participate in the Delphi survey. Twenty-eight (93.3%) experts across 12 countries completed the first, and 25 (83.3%) completed the second and third Delphi round. The demographic characteristics of the experts are presented in Table 1.

Seventeen out of 30 experts were UGI surgeons (56.7%), and 13 (43.3%) were general surgeons. The majority of experts had more than 20 years experience in MIS.

The total time needed to complete all three rounds was seven months (11/2022–06/2023). In all three groups, there were 100 questions, 65 with 5-Likert scale answers regarding the importance, 19 with 5-Likert scale answers regarding the difficulty, and 16 with yes or no answers (Table 2).

The Cronbach's α for round 1 questions regarding importance (n = 46, 66.7%) was 0.886. For questions regarding the difficulty (n = 12, 17.4%) in round 1, Cronbach's α was 0.896. In round 2, Cronbach's α was 0.779 for questions regarding importance (n = 19, 59.4%) and 0.848 for questions regarding difficulty (n = 7, 21.9%) (Table 2).

Consensus was reached from 22 questions from round 1, 12 from round 2, and 7 from round 3 (Table 2). These were rephrased into 41 consensus statements regarding LND and general aspects of anastomosis creation in MITG (Table 3). The 41 statements were divided into general aspects of the MITG (n = 2), key technical aspects of LND (n = 33), general aspects of LND in MITG (n = 1), and general aspects of anastomosis creation (n = 5) (Table 3).

This is the first international Delphi consensus on the recommended technical steps regarding LND and general aspects of anastomosis creation in MITG for oncological indications. This study aimed to establish and summarize the current recommendations on technical steps required to achieve a high-quality MITG for gastric cancer, explicitly focusing on LND and general anastomosis creation. Thirty international UGI and general surgery experts from 12 countries participated in this study, answering 100 questions through 3 Delphi rounds, generating 41 final recommended statements. The study met the quality threshold of > 70% for all six domains of the AGREE II checklist [28].

The majority of the final consensus statements were attained in round 1 of the Delphi, with high interrater reliability and overall homogeneity in their MITG operating technique. This indicates there was general alignment among how experts perform MITG, validating the selection of our expert panel.

The results of this study identified several issues regarding the importance and perceived difficulty of performing LND in MITG. Statements that commonly reached consensus related to the importance of how to technically approach of the D2 LND steps. The areas of least consensus related to the perceived difficulty of performing LND of specific lymph node stations. For example, 12% of experts rated performing a sufficient LND along the proper hepatic artery (station 12a) as easy, whereas 12% reported it as very difficult. A potential reason for heterogeneous responses on LND difficulty could be the different experience levels of panelists not only with gastrectomy but also with other index procedures that involve similar operative steps or not, such as bariatric surgeries, hiatal hernia repairs, esophagectomies, or pancreatic surgeries, which might influence the difficulty perception of performing specific surgical steps in MITG. However, no difference in the difficulty statement was detected regarding the volume and experience of the panelists. The only ‘difficulty’ statement where the panelists reached agreement was that station 10 LND is extremely/very difficult, which correlates to MITG's challenges regarding the LND of the splenic hilum [36].

Other than defining aspects related to LND in MITG, it was important to determine the general aspects of the procedure, such as omentectomy and division of the gastrocolic ligament. Interestingly, the panelists agreed that performing omentectomy can be omitted in early tumor stages (T1/T2). However, the necessity of omentectomy in advanced stages (T3/T4) or irrespective of tumor stage did not reach consensus after three rounds despite having been recommended in many guidelines and available literature [37‐40].

The final domain focused on general aspects of anastomosis creation in MITG. Due to the various technical approaches to performing the esophagojejunostomy in MITG, the statements focused on common facets of anastomosis creation rather than choosing one specific way of performing it. The panelists agreed that skillful, safe, efficient, tension- and torsion-free anastomosis is extremely or very important in MITG. The recommendation from round 3 that a frozen section should be performed if the tumor is perceived to be close to the resection margin also reached consensus (92%). However, the panelists could not agree on whether a frozen section should always be performed if the proximal resection margin was less than 6 cm (60% yes vs. 40% no) in round 2. Some surgical steps regarding anastomosis were still heterogenous among panelists, such as whether the R0 resection is oncologically acceptable irrespective of the resection margin distance after neoadjuvant therapy (68% yes vs. 32% no) and regarding the assessment of the perfusion of anastomosis. The panelists were asked whether the assessment of the perfusion of the anastomosis should be performed with indocyanine green fluorescence or a hyperspectral imaging camera, which revealed that 60% of experts stated that it should be performed and 40% of the panel reported it can be omitted. This result may reflect the relatively new use of such perfusion assessment tools in MITG, so the answers may change in the future to reflect the routine incorporation of these tools [41] in case scientific evidence can prove definitive advantages. Regarding the need for anastomosis assessment using an intraoperative leakage test, the panelists reached a consensus that it could be performed at the discretion of the operating surgeon to rule out leakage. This may reflect differences in clinical practice and the absence of evidence in favor of or against routine leak tests. This may also be a statistical problem since intraoperative detection of leaks represents a rather rare finding and thus may be difficult to handle statistically. On the other hand, leak tests may be of clinical value for detecting technical problems while not posing significant risks or added operative time or cost.

The strengths of this study are the solicitation of global expert opinion unifying views across Asia and Europe and the quality and experience of the experts taking part in this consensus. One of the advantages is the high expert response rate (93%) and low attrition rates (10%) between rounds and the high interrater agreement demonstrated by Cronbach's α, strengthening the content validity and effectiveness of the Delphi method. Furthermore, this study addressed a clinically important issue regarding MITG. Determining a sufficient level of agreement with performing an oncologically acceptable MITG is essential for several reasons. MITG is a complex surgical procedure that requires specialized knowledge and skills. The emphasis on compliance in D2 LND has been proven to be of great importance to patient outcomes [18, 25]. Obtaining a consensus from experts in the field ensures that the recommendations and guidelines for performing the procedure are based on the collective wisdom and experience of skilled surgeons. This helps establish a standard of care and minimizes the variability in surgical techniques, leading to standardized patient outcomes. The Delphi method also drives best practices in medicine since consensus-driven guidelines facilitate knowledge of the most effective and evidence-based approaches, leading to improved patient care. This also helps identify potential risks and develop strategies to mitigate them, thereby enhancing patient safety. By standardizing the procedure and promoting adherence to established guidelines, the quality of care provided to patients undergoing MITG can be improved, reducing the likelihood of adverse events and improving surgical safety.

Such consensus-based guidelines can be incorporated into training programs and surgical curricula to ensure that surgeons receive appropriate education and mentoring in MITG, fostering the development of competent and skilled practitioners. Most importantly, this research is essential for innovation. Delphi consensus can guide the direction of future studies, enabling the focus to shift toward the advancement of MITG. Additionally, consensus guidelines may promote innovation by encouraging the evaluation of new techniques, technologies, and approaches through well-designed research studies.

General limitations of the Delphi method and this study should be recognized. Although the Delphi method should be performed with anonymized panelists to mitigate potential bias and enhance quality and objectivity, this study required the identification of the panelists to ensure the participation of the uttermost experts in MITG. The Delphi method may also be susceptible to the ‘groupthink’ phenomena, where participants tend to conform to a dominant viewpoint or consensus rather than providing independent and diverse opinions. One way of mitigating this effect was the conscious decision to conduct the study online. However, this approach did hinder the establishment of meaningful discussions and clarifying responses on site, as panelists could not directly interact or engage in a real-time dialogue with each other or the researchers. Despite this Delphi consensus being created using a scoping strategy with international input, not all aspects of MITG have been addressed, for example, the optimal limb length and the preferences of exact anastomosis technique (e.g., handsewn versus circular stapler versus linear stapler technique) for anastomosis creation. Another limitation of this study is the lack of investigation about technical aspects or approaches; however, these were not the primary aim of the study, and they will be the object of further studies since the current study focused on oncological outcome and perioperative outcome with regards to general surgical technique.

The results of this study represent the first phase of the ANALYTIQs study that resulted from international collaboration in the EAES Research Sandpit in June 2022. The next step is creating a surgical quality assessment (SQA) tool and its application in video assessments of MITG. This will serve SQA in prospective and randomized studies to ensure optimized surgical performance [42]. The results of the applied SQA will also be used to develop artificial intelligence-based algorithms for automation of SQA. The long-term aims are to determine an SQA of this technique through video-based learning to ensure standardization and improve patient outcomes after MITG for oncological indications. Furthermore, the SQA tool could be used as an intraoperative guide for residents or young surgeons, with the final aim to shorten the learning curve and improve intra- and postoperative results. The predefined surgical steps that emphasize the most important aspects of LND of each lymph node station in MITG for gastric cancer could provide valuable structure in training young surgeons to master this procedure and ensure the best possible patient outcomes through technical impeccability.

In conclusion, this is the first study to determine the crucial technical steps in LND in MITG, deconstructing the integral elements within a complex minimally invasive procedure. It has identified the key technical steps of LND and general aspects of anastomosis creation required to perform adequate MITG for oncological indications by soliciting international expert opinion through a three-round Delphi consensus method. These statements should serve the standardization of the MITG and, through that, the improvement of oncological outcomes through adequate LND.