DISCUSSION This study is as far as we know the first attempt to obtain a nationwide consensus of the performance of the gastric bypass and sleeve gastrectomy. In this discussion we will critically review the used Delphi technique, evaluate the validity of the results by comparing those of other authors and highlight parts of this consensus. The use of the Delphi technique is widely recognized as a tool to obtain consensus between groups of experts, but the definition and composition of such an expert panel may affect the results. There are no exact rules described in literature for the composition of such an expert group.6-7 For this study, all surgeons who performed metabolic bariatric operations routinely and, thus, are stakeholders of the results of this consensus were invited to participate in the expert group. In this way both surgeons who pioneered and surgeons with recent training could participate. The Delphi method itself ensures that all opinions can influence the consensus. As surgeons from 90% of the Dutch metabolic bariatric centres participated in this study, the expert group can be considered to represent the Netherlands, and our pre-set goal of reaching a minimum 50% response rate in the first round was reached. The number of participants for the consensus in sleeve gastrectomy was lower, as this procedure is not performed in all centres. The Delphi methodology has the advantage of being performed by email, as the participants were selected from all of the Netherlands. A panel meeting was omitted for the reason of travel distance. To ensure the possibility of redefining the sub-steps after the first round, the participants were encouraged to comment on their rankings through the SurveyMonkey®. A draw back of the used Delphi methodology is the ‘fatigue’ of the respondents and declining of response rates, described to occur after two or three rounds. To minimize this effect, it was stated beforehand to use the expert panel two times. Zevin et al. also used the Delphi technique to gain expert consensus on the sub-steps of LRYGB.22 With this consensus the Bariatric Objective Structured Assessment of Technical Skill (BOSATS) was created. In the research of Zevin et al. two rounds were also sufficient for consensus. To optimize the results a ‘pre-round’ of selecting the possible steps from an extensive literature search was added, which is considered an acceptable strategy.7 Nonetheless, the large number of sub-steps of the combined procedures may have influenced the results. For LRYGB, the sub-step 74 4
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