Four out of 38 participants ended the survey prematurely. The expert group reached a Cronbach’s alpha consensus of 0.96 in the first round. Nineteen sub-steps were included as key steps after this first round as the lower bound of the 95% CI was > 4, meaning at least 95% of respondents found these steps very important or essential. Twelve of seventy-three substeps were deemed unnecessary as the upper bound of the 95% CI was < 3, meaning most participants found this task not or only sometimes important. The other sub-steps were reassessed in a second round. The already conclusive ratings are highlighted in bold in Table 2. In the second round, 33 participants responded, all in full (100%). For ten sub-steps, the CI in the second round had a lower limit > 3.5 and were included as key steps, resulting in a total of 29 key steps. Thirteen steps had a mean > 3.5, meaning most participants found the sub-step at least ‘important’; these steps were included as ‘advisable’. The Cronbach’s alpha was 0.82 in the second round. Sleeve Gastrectomy The LSG was broken down into six surgical steps: operative set up, starting laparoscopy, mobilization of the greater curvature, stapling the sleeve, check of the sleeve and finishing the procedure. The first two steps were very similar to the preparation of laparoscopy in LRYGB. The identified surgical steps were divided into 51 sub-steps, found in the first column of Table 3.14,18–21 Five participants indicated that LSG were not performed in their centres, leaving 33 participants (49%). In the first round fourteen steps (17%) obtained results with the entire 95% CI > 4, these were included as key steps. Five steps (10%) were excluded, and 32 steps (63%) were re-evaluated in a second round. A consensus with a Cronbach’s alpha of 0.95 was reached. In the second round, twelve of the remaining items were accepted as key steps with a lower limit of the CI > 3.5, and the seven steps with a mean > 3.5 were deemed ‘advisable’. The other thirteen sub-steps were excluded. The Cronbach’s alpha value was 0.87. The results of the Delphi analysis are displayed in Table 3. For both procedures this Delphi consensus resulted in a list of key steps and advised steps (Table 4). Due to the nature of the key step selection process, certain steps for both LRYGB and LSG required renaming. For example, the step ‘checking the bypass’ contained 6 sub-steps. Only ‘transecting small bowel between gastrojejunal and jejunojejunal anastomosis’ was marked as a key step, and this step was renamed ‘finishing the bypass’, see Table 4. 4 69 The crucial steps in gastric bypass and sleeve gastrectomy procedures
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