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

Amila Cizmic*, Ivan Romic, Andrea Balla, Nicolò Barabino, Gabriele Anania, Gian Luca Baiocchi, Branko Bakula, Carmen Balagué, Felix Berlth, Vasile Bintintan, Umberto Bracale, Jan-Hendrik Egberts, Hans F Fuchs, Suzanne S Gisbertz, Ines Gockel, Peter Grimminger, Richard van Hillegersberg, Noriyuki Inaki, Arul Immanuel, Daniel KorrPhilipp Lingohr, Pietro Mascagni, Nathaniel Melling, Marco Milone, Yoav Mintz, Salvador Morales-Conde, Yusef Moulla, Beat P Müller-Stich, Kiyokazu Nakajima, Magnus Nilsson, Matthias Reeh, Pierpaolo Sileri, Eduardo M Targarona, Yuki Ushimaru, Young-Woo Kim, Sheraz Markar, Felix Nickel, Anuja T Mitra

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method.

METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α.

RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance.

CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Original languageEnglish
Pages (from-to)488-498
Number of pages11
JournalSurgical endoscopy
Issue number2
Early online date26 Dec 2023
Publication statusPublished - Feb 2024


  • Consensus
  • Delphi
  • Gastrectomy
  • International
  • Laparoscopy
  • Lymphadenectomy
  • Minimally invasive surgery
  • Surgical quality assessment
  • Technical skills


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