Staging laparoscopy for gastric cancer: European consensus

Gastric cancer is the fifth most prevalent cancer and the third most common cause of cancer-related deaths globally1. Gastric cancer frequently metastasizes to the peritoneal cavity. The incidence of peritoneal metastases at the time of diagnosis, including free cancer cells in peritoneal washings, ranges from 15% to 32%, and its presence is associated with a poor prognosis2,3. Due to the low sensitivity of conventional imaging such as CT or PET-CT for peritoneal metastases, staging laparoscopy is performed to exclude small-volume macroscopic peritoneal dissemination or free cancer cells, and to assess the local resectability of the tumour4–6. Although staging laparoscopy has been part of diagnostic workup for patients with gastric cancer for over a decade, guidelines differ on patient selection and criteria of those at risk of peritoneal dissemination. Several guidelines limit its use to cT3/T4 tumours or gastric cancer with a high nodal burden (see supplementary material S3). In contrast, the National Institute for Health and Care Excellence (NICE) guideline recommends performing staging laparoscopy in all patients with gastric cancer7. Interestingly, all guidelines lack recommendations on how to perform staging laparoscopy, likely due to the significant variation in technical performance, which complicates comparison of procedure-based outcomes8. This inconsistency poses challenges when evaluating rates of peritoneal dissemination, limits the ability to understand the diagnostic accuracy of staging laparoscopy, and may lead to stage migration9. Standardizing staging laparoscopy would result in a more systematic execution of this diagnostic test, potentially leading to standardized staging and better patient selection, while improving data collection on clinical staging. It would facilitate international studies on gastric cancer staging and treatment of peritoneal metastases. A Delphi study could drive standardization, as it provides a method to systematically achieve expert consensus, without overpowering opinions of dominant participants10. This approach is particularly appropriate for the present situation given the high heterogeneity in used techniques, largely influenced by individual surgeons’ preferences8. Therefore, the authors performed a modified Delphi study to examine the extent of practice variation of staging laparoscopy amongst European gastric cancer surgeons, aiming to establish a standardized protocol.