Impact of video-assisted informed consent on decision conflict and consultation time in gastric cancer surgery

Abstract

BACKGROUND

Gastric cancer (GC) surgery requires comprehensive informed consent (IC), but conventional in-person IC is time-consuming and cognitively demanding. We hypothesized that pre-consultation video IC (PVIC) aids would reduce decisional conflict and consultation time.

AIM

To evaluate whether supplementing in-person IC with video aids reduces decisional conflict and IC duration, and to determine the optimal timing for video viewing.

METHODS

In this single-center, randomized controlled trial, 60 patients undergoing gastrectomy for GC were assigned to either the PVIC group or the standard IC (SIC) group (video viewing after consultation). The primary endpoint was the decisional conflict scale (DCS) score. Secondary endpoints included the duration of in-person IC and the proportion of patients experiencing high decisional conflict (DCS ≥ 37.5). Data were analyzed using the t-test, χ² test, and Mann-Whitney U test.

RESULTS

Although the PVIC group showed lower DCS scores than the SIC group, the difference did not reach statistical significance (P = 0.056). However, the prevalence of high decisional conflict was significantly lower in the PVIC group (0% vs 20%; P = 0.024). Furthermore, the duration of in-person IC was significantly shorter in the PVIC group compared to the SIC group (mean difference: 13.5 minutes; P < 0.001).

CONCLUSION

PVIC aids significantly reduce IC duration and eliminate high decisional conflict. This approach enhances the efficiency and quality of patient education in GC surgery.

Key Words: Decision support techniques; Gastric cancer; Stomach neoplasms; Informed consent; Patient satisfaction; Physician-patient relations

Core Tip: Integrating video-assisted informed consent into clinical practice can enhance consultation efficiency and support shared decision-making in major gastrointestinal surgeries. Video aids were beneficial regardless of timing, but pre-consultation viewing was more effective in reducing decision uncertainty. Pre-consultation video aids may better prevent high decisional conflict compared to video viewing after consultation. Video aids for surgical informed consent reduced the duration of in-person consultations by approximately 40%.

INTRODUCTION

Informed consent (IC) is a cornerstone of shared decision-making, particularly in oncologic surgery, where the complexity of treatment often increases patient uncertainty. The IC process facilitates patient autonomy and helps reduce decisional conflict, a psychological state of uncertainty about treatment options that can impede care engagement. IC is widely recognized as a collaborative process that enhances patient satisfaction and ensures ethical compliance in surgical practice[1]. Beyond its ethical and medicolegal roles, addressing decisional conflict is especially important in surgical oncology, where patients often face irreversible decisions under emotionally charged conditions. For instance, in gastric cancer (GC) surgery, patients must navigate highly complex choices, such as the extent of gastric resection and the risk of permanent lifestyle alterations including dumping syndrome and nutritional deficits. These factors inevitably elevate decisional conflict[2,3]. When effectively delivered, IC improves patient comprehension of surgical risks and outcomes, builds trust, and reduces decisional uncertainty[4].

In the context of GC, these elements are especially critical due to the complexity, risks, and life-altering consequences of gastrectomy. In 2022, over 968000 new cases of stomach cancer were reported, resulting in approximately 660000 deaths, making it the fifth most common cancer worldwide in terms of both incidence and mortality[5]. Surgical resection with regional lymphadenectomy remains the only curative treatment[6,7]. However, decision-making has become increasingly complex with the integration of perioperative chemotherapy, individualized strategies based on patient-specific factors and tumor genetics[8], and changes in dietary habits that may influence postoperative lifestyle. As treatment strategies become more complex, patients face greater difficulty in understanding and making informed choices. This underscores the growing importance of a comprehensive and effective IC process in GC surgery. Despite advances in surgical techniques, gastrectomy still carries substantial risks. According to the Japan National Clinical Database 2021, operative mortality rates for distal and proximal/total gastrectomy are 1.1% and 2.2%, respectively, while the incidence of Clavien-Dindo grade III or higher complications ranges from 7.5% to 12.5%[9].

Given these complexities and risks, IC must not only ensure patient comprehension but also reduce decisional uncertainty, particularly when life-altering treatments are being considered[10]. IC should include a detailed explanation of the surgical procedure, potential risks and benefits, possible complications, and alternative treatments. However, effectively communicating this extensive information in a way that patients and their families can understand remains a significant challenge. Surgeons often struggle to convey a comprehensive understanding in a single discussion due to the complexity of medical information and terminology. As a result, preoperative IC may require repeated explanations and prolonged discussions to build a reliable doctor-patient relationship. This process demands substantial time and physical and mental effort from surgeons.

Recently, video-assisted tools have emerged as a promising adjunct to conventional in-person IC, enhancing both patient understanding and engagement. While video-assisted preoperative IC tools have been shown to improve patient understanding and satisfaction without increasing anxiety compared to conventional IC in various clinical settings[11-16], scant evidence exists regarding their impact on decisional conflict, particularly in cancer-related surgeries such as gastrectomy, where such conflict can affect treatment adherence, patient satisfaction, and long-term outcomes. This gap has important implications for surgical practice and patient-centered care, particularly for surgeons seeking effective ways to support complex decision-making while managing time and communication burdens.

Decisional conflict is more frequently observed in oncologic surgery than in routine or benign conditions. Previous studies have shown that patients undergoing surgery for cancers such as head and neck cancer or breast cancer experience high levels of decisional conflict due to multiple treatment options, prognostic uncertainty, and the emotional burden of a cancer diagnosis[11-16]. In contrast, patients undergoing less complex procedures, such as cholecystectomy, generally report lower decisional conflict, likely due to a clearer risk, benefit profile and a more straightforward treatment pathway.

Few randomized controlled trials have examined the role of video tools in mitigating high decisional conflict in oncologic surgery, particularly outside the field of gastrointestinal surgery. In addition to their potential impact on patient decision-making, video tools may also reduce the psychological and time burden on surgeons associated with repetitive and time-consuming IC processes. IC for gastrectomy requires explaining various types of gastrectomy, reconstruction methods, and post-gastrectomy syndromes, including dumping syndrome and weight loss. Given these challenges, we hypothesized that patient-operated video aids for preoperative IC in GC surgery would facilitate decision-making while reducing both decisional conflict and the time surgeons spend on IC. Thus, we conducted an exploratory randomized controlled trial to evaluate the impact of IC video aids on decisional conflict among patients undergoing gastrectomy, as well as on IC duration and the optimal timing of video aids.

MATERIALS AND METHODS

This single-center, prospective, open-label, parallel randomized controlled trial evaluated the impact of video-assisted IC on decisional conflict among patients undergoing curative GC surgery in Japan. The study received ethical approval from the Fujita Health University Institutional Review Board, Toyoake, Japan in July 2022, and was registered in the University Hospital Medical Information Network database (UMIN000056846). All procedures involving human participants followed Japan’s ethical guidelines for medical research and the principles of the Declaration of Helsinki. This study adhered to the CONSORT reporting guidelines[17].

Patients scheduled for curative GC surgery were recruited during their initial consultation at Fujita Health University Hospital, an academic teaching hospital, and randomly assigned to one of two groups: The pre-consultation video IC (PVIC) group (intervention) or the standard IC (SIC) group (control). The primary comparison of this study was between patients who viewed the video aids before the face-to-face consultation (PVIC group) and those who received the standard in-person consultation alone (SIC group). In both groups, face-to-face consultations provided standardized explanations from faculty surgeons covering surgical procedures, potential risks and benefits, possible complications, and alternative treatments. After the in-person consultation and the primary assessment of decisional conflict, patients in the SIC group were subsequently provided access to the video aids. This delayed video viewing in the control group was implemented for ethical reasons to ensure equal access to information, and it also allowed for a secondary exploratory assessment of the effect of timing on decisional conflict (Figure 1).

Figure 1 CONSORT diagram. ¹The pre-consultation video informed consent group consists of patients who viewed the video before the in-person informed consent consultation. ²The standard informed consent group consists of patients who first underwent an in-person informed consent consultation, followed by supplementary video viewing. ASA: American Society of Anesthesiologists; PVIC: Pre-consultation video informed consent; SIC: Standard informed consent; IC: Informed consent.

PVIC group (intervention): Patients viewed the video before the face-to-face consultation. SIC group (control): Patients first had an in-person consultation, followed by video viewing. This sequence, implemented for ethical reasons, also allowed assessment of effect of timing of video watching on decisional conflict. Face-to-face consultations were conducted by five faculty surgeons specialized in GC and trained to deliver structured, standardized explanations based on the IC template document.

Decisional conflict was assessed using the decisional conflict scale (DCS)[11-16], a validated self-administered questionnaire consisting of 16 items across five subscales: Uncertainty (3 items), informed (3 items), values clarity (3 items), support (3 items), and effective decision-making (4 items). Each item was rated on a 5-point Likert scale, from strongly agree (0 points) to strongly disagree (4 points). The total score is standardized on a 0-100 scale by multiplying the mean item score by 25, with higher scores indicating greater decisional conflict[18]. Scores below 25 were associated with decision implementation, whereas scores above 37.5 indicated decision delay or uncertainty[19,20]. In the PVIC group, DCS scores were recorded after both video viewing and the face-to-face consultation. In the SIC group, scores were recorded after the physician consultation and again after subsequent video viewing (Figure 1).

Participants

The inclusion criteria were as follows: Age 20-75 years, clinically diagnosed with stage I-III resectable GC, and scheduled for preoperative IC. Written IC was obtained after a detailed explanation of the study. Treatment strategies were explained based on preoperative evaluations following the Japanese GC Treatment Guidelines during the initial consultation. Exclusion criteria were a history of GC surgery (e.g., remnant GC), an American Society of Anesthesiologists (ASA) classification of 3 or higher, eligibility for neoadjuvant chemotherapy, psychiatric disorders, cognitive impairments, or any condition hindering participation. Patients unable to operate the web-based video platform independently or with family assistance were also excluded.

IC video aids

The video aids were accessed via the web-based platform MediOS (Contrea Inc., Tokyo, Japan), allowing patients to view them anytime via the internet, unlike traditional formats. The video aids were developed by Contrea Inc. (Video). To ensure medical accuracy and quality, the initial scripts were drafted by an in-house physician and rigorously peer-reviewed by a panel of leading experts in gastric surgery from prominent academic hospitals and cancer centers in Japan. Each video topic was assigned a primary expert supervisor, with additional cross-review provided by the broader panel, thereby ensuring a highly standardized and validated educational tool.

To enhance engagement and comprehension, the videos were structured into concise segments, each lasting a few minutes, with a total duration of 30 minutes (Table 1). The platform utilizes a modular system, allowing the attending surgeon to compile a customized playlist for each patient with a total duration of approximately 30 minutes; (Figure 2A). While the general information modules (e.g., function of the stomach, cancer staging) were identical for all patients, the procedure-specific modules were individually tailored. Because the appropriate type of resection (i.e., distal, proximal, or total gastrectomy) and the subsequent reconstruction methods vary depending on the patient's condition, the attending surgeon determined the necessary surgical procedure and selected the corresponding combination of videos to provide a personalized explanation.

Figure 2 Overview of the video aids and their impact on decisional conflict. A: Representative list of videos associated with gastric cancer. Physicians selected the most appropriate videos from each category based on individual needs. The image illustrates the interface displayed on a tablet device; B: Sample screenshot of explanation video aids with subtitles (English version); sample video segments excerpted from the explanatory videos. The content includes an explanation of the postoperative course and complications (English version), and an overview of distal gastrectomy with Roux-en-Y reconstruction (Japanese audio with English subtitles); C: A comparison of primary decisional conflict scale scores between the pre-consultation video informed consent and standard informed consent groups. PVIC: Pre-consultation video informed consent; DCS: Decisional conflict scale; SIC: Standard informed consent.

Table 1 Contents of video aids for informed consent in gastrectomy.

	Details
General	Function of the stomach; gastric cancer (stage, invasion, metastasis, symptoms)
Surgical approaches	Open surgery; laparoscopic surgery; robotic surgery
Type of procedures	Total gastrectomy (Roux-en-Y/double-tract reconstruction/jejunal interposition); proximal gastrectomy (esophagogastrostomy/double-tract reconstruction/jejunal interposition); distal gastrectomy (Billroth I/Billroth II/Roux-en-Y reconstruction)
Postoperative complications	Postoperative complications; pancreatic fistula; anastomotic leak; dumping syndrome
Postoperative course	Postoperative lifestyle; dumping syndrome

Animations and illustrations were incorporated to visually depict surgical techniques with subtitles to reinforce understanding (Figure 2B). This approach ensured that patients received comprehensive, tailored, and accurate information about their planned surgical procedure. The consulting surgeon selected the most appropriate video based on the patient’s planned procedure. Patient compliance with video viewing was ascertained through direct verbal confirmation by the attending physician during the consultation.

Endpoints

The primary endpoint was to compare DCS scores after the physician’s consultation for IC between the groups. This was assessed by evaluating the difference in DCS scores between the PVIC group, who received in-person IC after video viewing, and the SIC group, who received in-person IC alone. Secondary endpoints included the time required for face-to-face IC consultations in each group. The physician providing the explanation recorded the duration of the IC process, measuring the time from the patient’s entry into the consultation room to their exit, using a clock placed in the room. The recorded IC time included only explanations regarding scheduled gastrectomy and potential blood transfusion and excluded IC for postoperative high-care unit admission, possible physical restraints, or other research purposes. The proportion of patients with DCS scores ≥ 37.5, indicating high decisional conflict, was compared between post-consultation in the PVIC group and post-IC in the SIC group. As exploratory endpoints, DCS scores and the proportion of patients with high decisional conflict were assessed after both video viewing and in-person IC in each group to examine the impact of timing of watching video on decisional conflict. Further, surgical outcomes, including operative time, blood loss, postoperative complications, proportion of patients undergoing adjuvant chemotherapy, and length of hospital stay, were compared between the groups to confirm the clinical homogeneity of the cohorts and ensure that the primary endpoints were not confounded by imbalances in surgical complexity or invasiveness.

GC surgery

Patients enrolled in this study underwent robotic surgery for stage I-III GC. Cancer staging was done using the 15^th edition of the Japanese Classification of Gastric Carcinoma[7] and was based on findings from contrast-enhanced computed tomography, gastrography, endoscopy, and endosonography, as previously described[21]. Indications for endoscopic treatment and radical gastrectomy, including the extent of systematic lymph node dissection, followed the Japanese GC Treatment Guidelines[7]. Previous studies have reported detailed indications for radical gastrectomy, assessment of physical function, surgical techniques, perioperative management, the extent of gastric resection and lymph node dissection, and type of anastomosis[22-25].

Randomization

In this study, IC was obtained from patients referred from outside our hospital after completing preoperative assessment. The IC was obtained during the initial consultation for cases referred from the internal medicine department of our hospital, as surgical eligibility was generally determined at that time. After obtaining the IC for this study, patients were randomly assigned to two groups using a sealed-envelope method. The principal investigator generated the random allocation sequence, while one of the investigators enrolled participants and assigned them to interventions. Each participant was assigned by opening a pre-prepared opaque envelope containing the group allocation (PVIC or SIC) and a study-specific ID. Randomization was conducted without stratification, block randomization, or allocation adjustment factors. Patients assigned to the PVIC group received a QR code from their attending physician to access the explanatory video after confirming group allocation.

Statistical analysis

The sample size was calculated based on the expected standardized effect size (Cohen’s d) rather than specific raw mean differences and standard deviations, following the DCS User Manual[26]. Using Cohen’s guidelines (1988) and an effect size of 0.8 (representing a typical effect size for effective decision aids, which generally range from 0.4 to 1.2), with α = 0.05 and a power of 0.8, 26 patients per group were required. To account for potential attrition, the target enrollment was 30 patients per group, totaling 60 patients. A DCS score ≥ 37.5 was defined as high decisional conflict[25]. Primary and secondary statistical analyses were performed in the full analysis set, defined as all randomized patients. Continuous data were expressed as mean [95% confidence interval (CI)] and median [interquartile range (IQR)] unless otherwise specified. Continuous endpoints, including DCS scores and IC duration, were summarized as mean and 95%CI. Between-group comparisons of these endpoints were performed using the two-sample t-test, consistent with the mean-based sample size calculation. To assess the robustness of the findings, Welch’s t-test was additionally performed to account for potential unequal variances between groups. Furthermore, Mann-Whitney U tests were performed as non-parametric sensitivity analyses, and the Hodges-Lehmann estimate was calculated as a non-parametric estimate of the between-group location shift.

For the proportion of patients with high decisional conflict, relative risks with 95%CIs and numbers needed to treat were calculated. Exact Clopper-Pearson 95%CIs were also estimated for event proportions. A two-tailed P < 0.05 was considered statistically significant. Multiple imputation was planned for missing DCS values; however, it was not performed because no data were missing. All statistical analyses were conducted using IBM SPSS Statistics 26 (IBM Corporation, Armonk, NY, United States) or JMP Pro 17 (SAS Institute Inc., Cary, NC, United States).

RESULTS

Patient characteristics

A total of 60 patients were enrolled and randomly assigned to either the PVIC group (n = 30) or the SIC group (n = 30) from October 2022 to August 2024 (Figure 1). All participants received the allocated intervention, retained their consent after standardized explanations by faculty surgeons supplemented with video aids, and underwent planned robot-assisted gastrectomy, with no dropouts recorded during the study period. All patients were included in the final analysis.

Baseline characteristics of the patients are summarized in Table 2. The PVIC group had a median age of 64 years (IQR: 55-69), with 10 males (33%) and 25 patients (83%) classified as ASA-PS 2. The SIC group had a median age of 66 years (IQR: 60-73), with 10 males (33%) and 29 patients (97%) classified as ASA-PS 2. No significant differences were observed in clinical stages or surgical procedures between groups. While the SIC group had a higher proportion of patients undergoing proximal or total gastrectomy, the difference was not statistically significant.

Table 2 Patient characteristics and surgical procedures, n (%).

	PVIC1 group (n = 30)	SIC2 group (n = 30)	P value
Age, median (interquartile range), years	64.0 (54.8-69.3)	66.0 (49.5-73)	0.187
Sex
Male	10 (33.3)	10 (33.3)	1.000
Female	20 (66.7)	20 (66.7)
ASA-PS
1	5 (16.7)	1 (3.3)	0.197
2	25 (83.3)	29 (96.7)
Stage
I	22 (73.3)	27 (90)	0.135
II	5 (16.7)	3 (10)
III	3 (10)	0 (0)
Type of resection
DG	27 (90)	21 (70)	0.153
PG	2 (6.7)	6 (20)
TG	1 (3.3)	3 (10)
Lymph node dissection
D1+	16 (53.3)	19 (63.3)	0.431
D2	14 (46.7)	11 (36.7)

¹Pre-consultation video informed consent group comprised patients who viewed the video before in-person informed consent consultation.

²Standard informed consent group comprised patients who first underwent an in-person informed consent consultation, followed by supplementary video viewing.

PVIC: Pre-consultation video informed consent; SIC: Standard informed consent; ASA-PS: American Society of Anesthesiologists Physical Status; DG: Distal gastrectomy; PG: Proximal gastrectomy; TG: Total gastrectomy.

Two surgeons were responsible for most cases in both groups due to outpatient scheduling constraints. The median numbers of in-person consultations conducted by the five faculty surgeons were 2 (IQR: 0.5-13.5; range: 0-19) in the PVIC group and 4 (IQR: 2-11; range: 1-17) in the SIC group, which were not significantly different.

Endpoints

The DCS scores after the physician’s in-person consultation for IC were a mean of 13.5 (95%CI: 8.5-18.6) in the PVIC group and 20.5 (95%CI: 15.4-25.6) in the SIC group, and the difference did not reach statistical significance (mean difference: 7.0; 95%CI: -0.2 to 14.2; P = 0.056). This result was essentially unchanged when Welch’s t-test was used to account for unequal variances (P = 0.056). In the non-parametric sensitivity analysis, the Mann-Whitney U test showed the same direction of effect but remained statistically non-significant (P = 0.0795). No patients in the PVIC group had high decisional conflict, as compared with 6 patients (20%) in the SIC group (risk ratio: 0.08; numbers needed to treat: 5), with exact Clopper-Pearson 95%CIs of 0.00-0.12 and 0.08-0.39, respectively (P = 0.024). The duration of in-person IC was significantly shorter in the PVIC group, with a mean duration of 22.4 minutes (18.8-26.0) compared to 35.9 minutes (32.3-39.5) in the SIC group (mean difference: 13.5; 95%CI: 8.4-18.6; P < 0.001) (Table 3).

Table 3 Endpoints.

	PVIC1 group, (n = 30)	SIC2 group, (n = 30)	P value
Primary endpoint
DCS score, mean (95%CI)	13.5 (8.5-18.6)	20.5 (15.4-25.6)	0.056
Secondary endpoints
DCS score ≥ 37.53, n (%)	0 (0)	6 (20)	0.0244
IC time, mean (95%CI), minutes	22.4 (18.8-26.0)	35.9 (32.3-39.5)	< 0.0014

¹The pre-consultation video informed consent group consists of patients who viewed the video before the in-person informed consent consultation.

²The standard informed consent group consists of patients who first underwent an in-person informed consent consultation, followed by supplementary video viewing.

³A decisional conflict scale score ≥ 37.5 was defined as patients with high decision conflict.

⁴Statistically significant.

PVIC: Pre-consultation video informed consent; SIC: Standard informed consent; DCS: Decision conflict scale; CI: Confidence interval; IC: Informed consent.

Changes in DCS scores and the proportion of patients with high decisional conflict in both groups are detailed in Table 4. In the PVIC group, the mean DCS score significantly decreased from 19.0 (14.3-23.7, PVIC T1) to 13.5 (8.5-18.6, PVIC T2) after in-person IC (P = 0.002), with no patients remaining in the high-conflict category. In the SIC group, the mean DCS score also significantly decreased from 20.5 (15.4-25.6, SIC T1) to 12.4 (8.0-16.9, SIC T2) after in-person IC followed by the video aid (P < 0.001). However, even after watching the video aid, two patients (6.7%) had high conflict. After both the in-person consultation and IC video aid review, no substantial differences in DCS scores were observed between the groups [PVIC T2: 13.5 (8.5-18.6); SIC T2: 12.4 (8.0-16.9), P = 0.732].

Table 4 Decision conflict scale scores and proportion of patients with high decision conflict (decision conflict scale score ≥ 37.5).

PVIC1 group	T1 after video aids, (n = 30)	T2 after in-person IC, (n = 30)	P value
DCS score, mean (95%CI)	19.0 (14.3-23.7)	13.5 (8.5-18.6)	0.0024
DCS score ≥ 37.52, n (%)	2 (6.7)	0 (0)	0.150
SIC3 group	T1 after in-person IC, (n = 30)	T2 after video aids, (n = 30)	P value
DCS score, mean (95%CI)	20.5 (15.4-25.6)	12.4 (8.0-16.9)	< 0.0014
DCS score ≥ 37.52, n (%)	6 (20)	2 (6.7)	0.129

¹The pre-consultation video informed consent group consists of patients who viewed the video before the in-person informed consent consultation.

²A decision conflict scale score ≥ 37.5 was defined as patients with high decision conflict.

³The standard informed consent group consists of patients who first underwent an in-person informed consent consultation, followed by supplementary video viewing.

⁴Statistically significant.

PVIC: Pre-consultation video informed consent; IC: Informed consent; DCS: Decision conflict scale; CI: Confidence interval; SIC: Standard informed consent.

When stratified by type of gastrectomy (distal, proximal, or total gastrectomy), no differences or trends were observed in DCS scores (Figure 2C). Additionally, no significant differences were observed in surgical outcomes between the two groups (Table 5).

Table 5 Surgical outcomes, n (%)/median (interquartile range).

	PVIC1 group (n = 30)	SIC2 group (n = 30)	P value
Operative time, minutes	371 (326-481)	396 (347-470)	0.201
Volume of blood loss, mL	23.5 (10.8-55.8)	27.5 (10.8-49.3)	0.953
Stage I-IV	20/6/3/1	20/7/2/1	0.766
Postoperative complication, ≥ C-D grade III	1 (3.3)	3 (10)	0.612
Dumping syndrome3	1 (3.3)	3 (10)	0.612
Adjuvant chemotherapy	9 (30)	5 (16.7)	0.360
Length of hospital stay, day	12 (11-14)	10 (9-16)	0.191

¹The pre-consultation video informed consent group comprised patients who viewed the video before the in-person informed consent consultation.

²The standard informed consent group comprised patients who first underwent an in-person informed consent consultation, followed by supplementary video viewing.

³Dumping syndrome during hospitalization: Patients with dumping syndrome did not overlap with those who had complications of Clavien-Dindo grade ≥ III.

PVIC: Pre-consultation video informed consent; SIC: Standard informed consent; C-D: Clavien-Dindo classification.

DISCUSSION

This study evaluated the impact of video-assisted IC on decisional conflict and consultation efficiency among patients undergoing GC surgery. Regarding the primary objective, although the post-consultation DCS scores trended lower in the PVIC group compared to the SIC group, the difference did not reach statistical significance. However, for the secondary endpoints, a clinically meaningful finding was the complete absence of high decisional conflict in the PVIC group, compared with 20% in the SIC group. Given that high decisional conflict is associated with decision delay and lower treatment confidence, this result suggests that providing video materials before in-person consultation may help prevent uncertainty and support decision readiness.

In addition, the PVIC group required approximately 40% less time for in-person consultations than the SIC group, indicating improved efficiency and reduced communication burden on clinicians. However, it is important to note that from the patients’ perspective, the total time dedicated to the IC process - including both the 30-minute video viewing and the subsequent in-person consultation - was longer in the PVIC group. This additional time burden should be considered when implementing video-assisted IC in routine practice. Nevertheless, pre-consultation video viewing may allow patients to review complex information at their own pace before meeting the surgeon, which may partly explain the lower prevalence of high decisional conflict observed in the PVIC group. No difference or trends were observed in DCS reduction when stratified by gastrectomy type, suggesting that the benefit of video-assisted IC may extend across different procedural subtypes in cancer surgery. These findings indicate that pre-consultation video aids may optimize the IC process by enhancing consultation efficiency, reducing surgeon workload, and reducing patients’ decisional conflicts, particularly high-level conflict, and better preparing patients for shared decision-making.

This is one of the first studies to investigate the role of video-assisted IC specifically in the context of gastrointestinal cancer surgery, where the complexity of treatment often exacerbates patient uncertainty. While previous research has mainly focused on patient comprehension and satisfaction[11-16], our findings highlight the potential for video aids to reduce decision delay and uncertainty. The significant reduction in consultation time further suggests that video aids can optimize clinical workflows, particularly in high-demand surgical practices. Furthermore, face-to-face communication quality can fluctuate due to the clinician's varying communication skills or fatigue. In this context, video-transmitted messages offer a significant advantage by ensuring high accessibility and comprehensiveness; they guarantee that all patients receive a standardized, visually supported, and plain-language baseline explanation, effectively compensating for potential face-to-face communication obstacles.

Despite these findings, one possible explanation for the lack of a statistically significant difference in DCS scores as the primary endpoint is that post-consultation scores in the SIC group were already sufficiently low. This may reflect the effectiveness of the standardized IC process implemented by faculty surgeons, who were trained to ensure consistency and comprehensiveness in their explanations. This standardization likely minimized variability in the quality of IC delivery and contributed to similar final DCS scores in both groups (PVIC T2 and SIC T2). Additionally, the study’s clinical trial setting may have led to more meticulous and detailed IC sessions than those in routine practice, as faculty surgeons may have been more attentive to the IC process under study conditions.

The lower prevalence of high decisional conflict in the PVIC group aligns with that reported in prior studies[11-16,27], suggesting that preparatory materials reduce patient anxiety and uncertainty by enhancing comprehension and confidence in decision-making. Videos provide a standardized source of information, allowing patients to process complex medical details at their own pace before consulting their physician. This preparatory exposure may improve understanding, clarify values, and build confidence, ultimately facilitating more effective communication during consultations[28]. The difference in DCS scores as the primary endpoint did not reach statistical significance; however, a downward trend was observed in both groups. The primary outcome should be interpreted considering the study design; because all patients received standardized in-person consultations from faculty surgeons, this study evaluated the additive benefit of video aids rather than their independent effect in isolation. However, the consistent reduction in DCS scores across both groups supports combining video aids and physician consultation, regardless of their timing. Integrating video aids with in-person IC may more effectively support patients’ decision confidence compared to relying on physician consultation alone.

Patients in the PVIC group did not have high decisional conflict; however, some in the SIC group had high decisional conflict, suggesting that pre-consultation video aids may better prepare patients for in-person IC. The persistence of high decisional conflict in some patients from the SIC group, even after viewing the video, indicates that once high conflict develops following an initial in-person IC, supplemental video aids alone may be insufficient to resolve it. We hypothesize that this limitation may stem from the unidirectional nature of video information, which cannot respond interactively to individual questions or concerns. However, as our study was not designed to assess these underlying psychological mechanisms, further qualitative research, such as patient interviews, is necessary to fully elucidate the reasons behind persistent decisional conflict.

Advancements in technology, including the widespread use of smartphones and tablets, have made video viewing more accessible and convenient than that using traditional DVD or computer-based formats. The cloud-based platform in this study allowed patients to watch videos at their preferred time and location, potentially improving comprehension through repeated viewing with significant others. Such platforms also facilitate easy management of viewing histories, offering opportunities for future research to assess patient understanding and decisional conflict more comprehensively. The utility of video aids demonstrated in this study extends beyond their use for obtaining IC for GC surgery. Their effectiveness in explaining complex cancer procedures suggests their applicability not only to more common benign conditions, such as cholecystectomy or hernia repair, where treatment decisions are less complex, but also to a range of advanced surgeries in cancer and transplantation medicine.

This study has several limitations. Although it was a randomized clinical trial, it was a single-center study, which may limit the generalizability of the findings. Second, the standardized IC training provided to faculty surgeons likely improved IC quality in both groups, potentially reducing observable differences in DCS scores. Third, while the sample size was adequate for detecting differences in high decisional conflict proportions, it may have been insufficient to detect smaller differences in overall DCS scores. Although the difference in mean DCS scores did not reach statistical significance, the observed trend and the complete absence of high-conflict cases in the PVIC group suggest a potentially meaningful clinical benefit, which may warrant further investigation in a larger, adequately powered study. Baseline DCS scores could vary due to individual patient personality traits, making equal quantification challenging. While randomization was assumed to distribute these traits equally, the lack of DCS measurement before the initial consultation limits the understanding of baseline decisional conflict and may have influenced the interpretation of the results. Moreover, although all patients watched the video, objective data on the extent of participant engagement - such as attentiveness, specific knowledge retention, and repeated viewings - were not collected, potentially affecting the interpretation of the video aid’s true impact on decisional conflict. Furthermore, while the IC videos provided detailed explanations of postoperative lifestyle considerations, they were not tailored to individual patient characteristics and lacked information on mid- and long-term surgical and oncological outcomes, which may influence patient’s decision-making. The long-term impact of this comprehensive IC approach remains unclear, as decision conflict was not measured beyond the immediate perioperative period. Additionally, this study focused strictly on elective surgeries. Our video-assisted approach is likely impractical for emergency surgical cases, where severe time constraints and critical patient acuity preclude the use of preparatory multimedia aids. Further research is warranted, considering the multiple factors influencing patient decision conflicts.

CONCLUSION

This study highlights the potential of pre-consultation video aids to reduce high decisional conflict and improve consultation efficiency in GC surgery. Although the difference in overall mean DCS scores did not reach statistical significance, no patients in the PVIC group had high decisional conflict, and the duration of in-person consultations was significantly shorter in the PVIC group. These findings suggest that pre-consultation video aids may improve the efficiency of the IC process and help reduce high decisional conflict in patients undergoing GC surgery. Further multicenter studies with objective measures of video engagement are warranted. These findings support the integration of video-assisted IC into routine clinical practice, particularly for complex surgical procedures.

ACKNOWLEDGEMENTS

The authors thank Daisuke Komuta and Aiko Yoshida at Contrea Inc. for their technical contributions to this study.