International Delphi consensus to define textbook outcome parameters for oncological gastrectomy (togs project)

Textbook Outcome (TO) is a quality indicator representing the ideal surgical postoperative course. The lack of consensus on TO parameters in Gastric Oncological Surgery (TOGS) hinders comparative outcomes analysis. This study aimed to establish a universally accepted set of TOGS parameters using Delphi consensus made by international experts in gastric cancer surgery. The Delphi process involved four phases: 1. Evidence Acquisition: A systematic review revealed significant variability in TOGS parameters. 2. Expert Panel Discussion: Eight international experts developed 18 preliminary questions for a survey. 3. Delphi Process: Two rounds of anonymous surveys among key opinion leaders measured agreement using a 5-point Likert scale, with consensus defined as ≥ 70%. A third round was conducted to revise questions on mortality, lymph nodes, and hospital stay. 4. Generation of Recommendations were created based on consensus from the three rounds Of 53 invited surgeons, 39 responded, and 34 completed both rounds. By the second round, ten parameters were agreed upon. 1) No 90-day mortality; 2) No complications ≥ III according to Clavien-Dindo classification; 3) No intraoperative complications according to the GASTRODATA classification; 4) R0 resection; 5) More than 25 lymph nodes analyzed in the surgical specimen; 6) No reoperation; 7) No readmission to the Intensive care Unit (ICU); 8) No readmission in the first 30 postoperative days; 9) Length of stay below the 75th percentile of the series; 10) Resumption of chemotherapy treatment, if indicated, within 8 weeks after surgery. TOGS consensus definition includes ten parameters specific to gastric cancer treatment. Validation in clinical practice is needed to confirm the proposed TOGS definition as a universal quality metric.