Conversion of laparoscopic colon resection does not affect survival in colon cancer

Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.

Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis

BACKGROUND

Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease.

METHODS

All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest.

RESULTS

Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436).

CONCLUSION

In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.

Impact of Conversion from Laparoscopy to Open Surgery in Patients with Right Colon Cancer

Conversion to open surgery is reported in up to 20 per cent of laparoscopic colectomies for cancer. This study aims to compare postoperative outcomes and survival between converted and successful laparoscopic right colectomy for cancer. Records of patients who underwent laparoscopic right colectomy for cancer between 2005 and 2015 were retrieved from the CLermontFerrand Ircad Mondor Hopital European Tours (CLIMHET) database. Perioperative, postoperative, and survival outcomes were evaluated. Multivariate analysis was performed to identify predictive factors for conversion. Overall, 445 patients underwent a successfully completed laparoscopic right colectomy and 28 (5.9%) were converted to open surgery. A higher rate of minor complications was found in the conversion group, whereas patient recovery outcomes were similar. Previous open and laparoscopic surgeries were significant predictors of conversion. No significant difference was found in overall and disease-free survival rates between converted and nonconverted procedures. In the setting of laparoscopic right colectomy for cancer, the conversion rate is low and does not have an impact on patient survival. Conversion is associated with higher rates of minor postoperative complications but recovery and survival outcomes are comparable with successful laparoscopic colectomies. The present results support the use of laparoscopy for right colon resection even in patients at risk of conversion.

Influence of Conversion and Anastomotic Leakage on Survival in Rectal Cancer Surgery; Retrospective Cross-sectional Study

BACKGROUND

Conversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery.

METHODS

Patients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage.

RESULTS

Out of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (p = 0.025 and p = 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (p = 0.002 and p = 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322-3.551) and DFS (1.592, 1077-2.353). Conversion was an independent predictor of DFS (1.525, 1.071-2.172), but not of OS.

CONCLUSION

Technical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.

Short- and Long-term Outcomes of Minimally Invasive Versus Open Multivisceral Resection for Locally Advanced Colorectal Cancer

BACKGROUND

Colorectal cancer invading the adjacent organs/structures is detected in 5% to 20% of all surgical interventions performed for the management of colorectal cancer.

OBJECTIVE

Our purpose is to verify the safety and feasibility of laparoscopic surgery for the treatment of locally advanced colorectal cancer invading the adjacent organs.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted at a single institution in Japan.

PATIENTS

We compared the morbidity, appropriate oncological resection, and disease-free survival of laparoscopic and open multivisceral resection in patients with colorectal carcinoma in the period between 2007 and 2015.

MAIN OUTCOME MEASURES

The primary outcome measures were curative resection rate, morbidity rate, and recurrence of laparoscopic and open multivisceral resection in patients with colorectal cancer.

RESULTS

Thirty-one patients received laparoscopic surgery, and 50 received open surgery. The amount of blood loss was smaller in the laparoscopic group than in the open group (60 vs 595 mL, p < 0.01). Curative surgery was performed in 46 patients of the open group (92.0%) and in 30 patients of the laparoscopic group (96.8%). Days until oral intake (5 vs 7 days, p < 0.01) and postoperative hospital stay (14 vs 19 days, p < 0.01) were shorter in the laparoscopic group. Overall morbidity was not different between the groups (22.5% vs 40.0%). Three-year disease-free survival rates were 62.7% in the open group and 56.7% in the laparoscopic group (p = 0.5776).

LIMITATION

This study was a retrospective small study conducted at a single institute.

CONCLUSION

Laparoscopic multivisceral resection may be a safe, less invasive alternative to open surgery, with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological end points. See Video Abstract at http://links.lww.com/DCR/A785.

Effect of cancer characteristics and oncological outcomes associated with laparoscopic colorectal resection converted to open surgery: A meta-analysis

BACKGROUND

Although laparoscopic colorectal cancer resection is an oncologically safe procedure equivalent to open resection,the effects of conversion of a laparoscopic approach to an open approach remain unclear.This study evaluated the cancer characteristic and oncological outcomes associated with conversion of laparoscopic colorectal resection to open surgery.

METHOD

We conducted searches on PubMed, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. We included the literature published until 2018 that examined the impact of laparoscopic conversion to open colorectal resection. Only randomized control trials and prospective studies were included. Each study was reviewed and the data were extracted. Fixed-effects methods were used to combine data, and 95% confidence intervals (CIs) were used to evaluate the outcomes.

RESULTS

Twelve studies with 5427 patients were included. Of these, 4672 patients underwent complete laparoscopic resection with no conversion (LAP group), whereas 755 underwent conversion to an open resection (CONV group). The meta-analysis showedsignificant differences between the LAP group and converted (CONV) group with respect to neoadjuvant therapy (P = .002), location of the rectal cancer (P = .01), and recurrence (P = .01). However, no difference in local recurrence (P = .17) was noted between both groups.

CONCLUSION

Conversion of laparoscopic to open colorectal cancer resection is influenced by tumor characteristics. Conversion of laparoscopic surgery for colorectal cancer is associated with a worse oncological outcome.

Is There a Drawback of Converting a Laparoscopic Colectomy in Colon Cancer?

BACKGROUND

Laparoscopic resection is well established in the treatment of colon cancer. However, conversion rates remain high and the impact of conversion is disputed.

MATERIAL AND METHODS

We retrospectively identified 1347 patients who underwent surgery for colon cancer between 2004 and 2014 at our tertiary center. Morbidity and oncological outcomes were compared between patients who underwent successfully completed laparoscopic surgery (LS), planned open surgery (OS), and conversion to open surgery (CS). Long-term analysis included patients with stage I-III disease. In addition, we performed propensity score matching to adjust for the heterogeneity and selection bias between the treatment groups.

RESULTS

Of all patients, 505 underwent LS, 789 underwent OS, and 53 underwent CS, which corresponded to a conversion rate of 9.5%. Conversion was associated with male gender, left-sided tumors, and stage III disease. Length of stay, morbidity, and readmission rates were lower for LS patients. Kaplan-Meier curves demonstrated worse overall, disease-specific, and disease-free survival in CS than LS, with similar outcomes to OS. However, after propensity score matching, CS was only associated with admission duration and the requirement of blood transfusion, whereas survival outcomes were comparable between all groups.

CONCLUSIONS

CS is associated with adverse short- and long-term outcomes compared to LS. However, when accounting for differences in baseline and pathologic features, CS remained only associated with a longer length of stay and more blood transfusions. Because outcomes were comparable between CS and OS, regardless of stage and other risk factors, our data support a surgeon's attempt to perform LS in patients with colon cancer.

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes

BACKGROUND

Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach.

METHODS

The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data.

RESULTS

A total of 25,253 patients met inclusion criteria-21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality.

CONCLUSIONS

Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

Oncologic outcomes following laparoscopic colon cancer resection for T4 lesions: a case-control analysis of 7-years' experience

BACKGROUND

According to many Societies' guidelines, patients presenting with clinical T4 colorectal cancer should conventionally be approached by a laparotomy. Results of emerging series are questioning this attitude.

METHODS

We retrospectively analysed the oncologic outcomes of 147 patients operated on between June 2008 and September 2015 for histologically proven pT4 colon cancers. All patients were treated with curative intent, either by a laparoscopic or open "en bloc" resection.

RESULTS

Median operative time, blood loss and hospital length of stay were significantly reduced in the laparoscopic group. Postoperative surgical complication rate and 30-day mortality did not significantly differ between the two groups ( p = 0.09 and p = 0.99, respectively). R1 resection rate and lymph nodes harvest, as well, did not remarkably differ when comparing the two groups. In the laparoscopic group, conversion rate was 19%. Long-term outcomes were not affected in patients who had undergone conversion. Five-year overall survival and disease-free survival did not significantly differ between the two groups (44.6% and 40.3% vs. 39.4% and 38.9%). Locally advanced stages (IIIB-IIIC) and R1 resections were detected as independent prognostic factors for overall survival.

CONCLUSION

Laparoscopic approach might be safe and acceptable for locally advanced colon cancer and does not jeopardize the oncologic results. Conversion to open surgery should be a part of a strategy as it does not seem to adversely affect perioperative and long-term outcomes. We consider laparoscopy, in expert hands, the last diagnostic tool and the first therapeutic approach for well-selected locally advanced colon cancers. Larger prospective studies are needed to widely assess this issue.

Outcomes of laparoscopic surgery in pathologic T4 colon cancers compared to those of open surgery

INTRODUCTION

Despite the oncologic safety of laparoscopic surgery in colon cancer management, laparoscopy is not regarded as a standard treatment for T4 colon cancer. The aim of this study was to investigate the short-term and long-term oncologic outcomes of laparoscopic surgery in patients with locally advanced colon cancer.

MATERIAL AND METHOD

From March 2003 to June 2013, a total of 109 consecutive patients with proven pathologic T4 colon cancer were enrolled. These patients were divided into the laparoscopy group (LG, n = 52) and the open group (OG, n = 57). Perioperative and long-term oncologic outcomes were compared between the two groups.

RESULTS

In the LG, open conversion occurred in four patients (7.6%). Combined resection was less commonly performed in the LG (13.5%) than in the OG (36.8%, P = 0.005). Operation time was similar between the two groups. In the LG, blood loss (129 mL vs. 437 mL, P < 0.001) and overall complication rate (13.5 vs. 36.8%, P = 0.005) were lower and length of hospital stay was shorter (median 7 vs. 17 days, P < 0.001) than in the OG. The 5-year overall survival rate was 60.7% for the LG and 61.9% for the OG (P = 0.817). Local recurrence-free survival did not differ between the groups (88.9% in LG vs. 88.1% in OG, P = 0.725).

CONCLUSION

Considering the benefits of early recovery and similar oncologic outcomes, laparoscopic surgery in T4 colon cancer could be a viable option in selected patients.

Impact of Timing of Conversion to Open Surgery on Short-Term and Oncologic Outcomes in Patients Undergoing Minimally Invasive Surgery for Colorectal Cancer

To evaluate the influence of timing of open conversion on short-term and oncologic outcomes after minimally invasive surgery for colorectal cancer. Six hundred forty-six consecutive patients were enrolled. All patients converted to open surgery were classified into early (n = 10) or late (n = 67) groups based on conversion timing using a 60-minute cutoff. A comparison of early conversion and nonconverted groups showed that history of prior abdominal surgery and pT4 tumor was more common in the early conversion group. Mean operative time was longer in the early conversion group. Rates of 30-day postoperative complications (30% vs 27%), time to soft diet (5 days vs 5 days), and hospital stay (12 days vs 12 days) were not different. A comparison of the late and nonconverted groups showed that history of prior abdominal surgery was more common in the late conversion group. Mean operative time was longer in the late conversion. Rates of 30-day postoperative complications (42% vs 27%), Clavien–Dindo score ≥3 (22% vs 11%), intensive care unit care (31% vs 15%), and transfusion (37% vs 21%) were significantly higher in the late conversion group. Time to soft diet (6 days vs 5 days) and hospital stay (15 days vs 12 days, P = 0.037) were longer in the late conversion group. Cancer-specific and recurrence-free survival rates did not differ among the early, late conversion, and nonconverted groups. Decisions about open conversion need be made within 60 minutes of the beginning of surgery as early conversion does not worsen short-term and oncologic outcomes.

Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

Outcomes of conversion of laparoscopic colorectal surgery to open surgery

Objectives:

There is limited data regarding the outcomes of patients who undergo conversion to open surgery during a laparoscopic operation in colorectal resection. We sought to identify the outcomes of such patients.

Methods:

The NIS (National Inpatient Sample) database was used to identify patients who had conversion from laparoscopic to open colorectal surgery during the 2009 to 2012 period. Multivariate regression analysis was performed to identify risk-adjusted outcomes of conversion to open surgery.

Results:

We sampled 776 007 patients who underwent colorectal resection. 337 732 (43.5%) of the patients had laparoscopic resection. Of these, 48 265 procedures (14.3%) were converted to open surgery. The mortality of converted patients was increased, when compared with successfully completed laparoscopic operations, but was still lower than that of open procedures (0.6% vs. 1.4% vs. 3.9%, respectively; adjusted odds ratio [AOR], 1.61 and 0.58, respectively; P < .01). The most common laparoscopic colorectal procedure was right colectomy (41.2%). The lowest rate of conversion is seen with right colectomy while proctectomy had the highest rate of conversion (31.2% vs. 12.9%, AOR, 2.81, P < .01). Postsurgical complications including intra-abdominal abscess (AOR, 2.64), prolonged ileus (AOR, 1.50), and wound infection (AOR, 2.38) were higher in procedures requiring conversion (P < .01).

Conclusions:

Conversion of laparoscopic to open colorectal resection occurs in 14.3% of cases. Compared with patients who had laparoscopic operations, patients who had conversion to open surgery had a higher mortality, higher overall morbidity, longer length of hospitalization, and increased hospital charges. The lowest conversion rate was in right colectomy and the highest was in proctectomy procedures. Wound infection in converted procedures is higher than in laparoscopic and open procedures.

Risk factors for conversion of laparoscopic colorectal surgery to open surgery: does conversion worsen outcome?

INTRODUCTION

The utilization of laparoscopy in colorectal surgery is increasing. However, conversion to open surgery remains relatively high.

OBJECTIVE

We evaluated (1) conversion rates in laparoscopic colorectal surgery; (2) the outcomes of converted cases compared with successful laparoscopic and open colorectal operations; (3) predictive risk factors of conversion of laparoscopic colorectal surgery to open surgery.

METHODS

Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. Multivariate regression analysis was performed to identify factors predictive for conversion of laparoscopic to open operation.

RESULTS

A total of 207,311 patients underwent intended laparoscopic colorectal resection during this period. The conversion rate was 16.6 %. Considering resection type and pathology, the highest conversion rates were observed in proctectomy (31.4 %) and Crohn's disease (20.2 %). Using multivariate regression analysis, Crohn's disease (adjusted odds ratio [AOR], 2.80), prior abdominal surgery (AOR, 2.45), proctectomy (AOR, 2.42), malignant pathology (AOR, 1.90), emergent surgery (AOR, 1.82), obesity (AOR, 1.63), and ulcerative colitis (AOR, 1.60) significantly impacted the risk of conversion. Compared with patients who were successfully completed laparoscopically, converted patients had a significantly higher complication rate (laparoscopic: 23 %; vs. converted: 35.2 % vs. open: 35.3 %), a higher in-hospital mortality rate (laparoscopic: 0.5 %; vs. converted: 0.6 %; vs. open: 1.7 %) and a longer mean hospital stay (laparoscopic: 5.4 days; vs. converted: 8.1 days; vs. open: 8.4 days); however, converted patients had better outcomes compared with the open group.

CONCLUSIONS

The conversion rate in colorectal surgery was 16.6 %. Converted patients had significantly higher rates of morbidity and mortality compared to successfully completed laparoscopic cases, although lower than open cases. Crohn's disease, prior abdominal surgery, and proctectomy are the strongest predictors for conversion of laparoscopic to open in colorectal operations.

The impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes for colon cancer

PURPOSE

This study was designed to evaluate the impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes and to identify risk factors for long-term survival in patients undergoing colectomy for non-metastatic colon cancer.

METHODS

A prospective database of consecutive operations for non-metastatic colon cancer was reviewed. Patients were grouped as conversion (CONV) group, completed laparoscopic resection (LAP) group, or open resection (OPEN) group. The clinical and perioperative parameters, pathologic features, and oncologic outcomes were collected. Univariate analysis was performed for comparing these data. Patients without evidence of recurrence at last follow-up or still alive at the end of study period were censored. Kaplan-Meier curves were utilized to analyze survival. A multivariate analysis was performed to identify predictors of poor disease-free survival (DFS) and overall survival (OS).

RESULTS

The conversion rate was 15.2 %. The most common reason for conversion was locally advanced cancer (45.5 %). Converted patients were associated with a longer operative time (188 ± 29.1 min, P < 0.001), greater blood loss (147 ± 14 mL, P < 0.001), and a higher rate of intra-operative complications (15.2 %, P = 0.042) compared to the completely laparoscopic or open patients. Days to flatus, early ambulation, and length of hospitalization were significantly shorter in completed laparoscopic resection (LAP) group (P < 0.001); however, the outcomes were comparable between conversion (CONV) and open resection (OPEN) groups. The incidence of wound infection was significantly higher in the OPEN group than in the LAP group (P = 0.005), whereas there were no significant differences observed between the CONV group and the OPEN group (P = 1.000) or between the LAP group and the CONV group (P = 0.073). The 5-year DFS in CONV patients (46.5 %) was comparable to LAP patients (55.5 %, P = 0.138) and OPEN patients (59.1 %, P = 0.113). Moreover, there were no significant differences noted in terms of the 5-year OS in the CONV group (56.7 %) compared to the LAP group (67.3 %, P = 0.317) or the OPEN group (66.3 %, P = 0.420). The multivariate analysis showed that pT3-4 cancer (P < 0.001) and poor differentiation (P < 0.001) were independent predictors of both lower OS and lower DFS, whereas leakage (P = 0.008) and lack of adjuvant chemotherapy (P = 0.023) were independent risk factors only of lower DFS.

CONCLUSION

Conversion to open colectomy from an initial laparoscopic approach does not worsen the long-term survival in patients with non-metastatic colon cancer.

Conversion in mini-invasive colorectal surgery: the effect of timing on short term outcome

INTRODUCTION

Different results have been reported about postoperative outcomes of conversion during laparoscopic colorectal surgery. We aimed to detect the effect of conversion on postoperative outcome and to identify features associated to better outcome after conversion.

METHODS

Two hundred-fourteen mini-invasive left colonic and rectal resections were retrospectively analysed. Two groups were identified: mini-invasive colorectal surgery (MI) that includes both laparoscopic and robotic resections, and conversion to open surgery.

RESULTS

Among 214 colorectal procedures, 189 were MI. Conversion rate was 11.7%. Operating time was shorter for MI at overall analysis (p 0.003) and sub-analysis of left colectomies (p 0.001). MI procedures had shorter hospital stay (p 0.000) both in left colectomy and rectal resection (p 0.008 and p 0.001 respectively). A shorter time to first flatus emission was detected in MI group in both overall analysis (p 0.003) and procedure's sub-analysis (left colectomy p 0.032; anterior rectal resection p 0.040). Oral feeding was resumed earlier after mini-invasive rectal resections (p 0.014). Converted procedures required more blood transfusions (p 0.000) and grade II complication rate was lower after MI procedures (p 0.013). Conversion presented higher anastomotic leakage and reoperation rates (p 0.035 and p 0.006 respectively). Conversion before 105 min (early conversion) had a significant lower number of blood transfusions (p 0.047).

CONCLUSIONS

Conversion is associated to higher rate of blood transfusions, grade II complication and slower recovery. Earlier conversion has better outcomes. Colorectal surgeons should identify any critical aspects that could avoid late conversion allowing reducing negative effects of conversion.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

BACKGROUND

Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer.

METHODS

A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance.

CONCLUSION

Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.

Conversion risk factors in laparoscopic colorectal surgery

Introduction

This study is aimed at identifying important risk factors associated with conversion of laparoscopic colorectal surgery. Laparoscopic surgery is usually associated with less operative trauma, more favourable post-operative course and lower morbidity than open surgery. However, conversion is connected with some risks according to some authors.

Aim

To identify the risk factors associated with conversion and to create a model to predict possible conversion for a patient before surgery.

Material and methods

The source data file contained information about 649 patients who underwent laparoscopic colorectal surgery between 2001 and 2009 at the University Hospital Ostrava, Czech Republic. Conversion to open surgery was necessary in 54 cases. The variables gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, stage of disease, number of previous operations and operation severity were included in the analysis as the potential risk factors of conversion. Discriminant analysis was used for the data evaluation; statistical software SPSS 17 and NCSS 2004 were used for the calculations.

Results

The created model had only low discriminating ability. The variable ASA classification was identified as the most important risk factor of conversion, followed by the variables operation severity, gender and BMI.

Conclusions

Discriminant analysis did not find the chosen input variables satisfactory enough to make a reasonable model for the prediction of conversion. The expected fact was confirmed that large bowel surgery and greater BMI mean greater risk of conversion, whereas there is no reason to refuse laparoscopy for a patient with higher ASA classification.

Impact of conversion on outcome in laparoscopic colorectal cancer surgery

INTRODUCTION

Long-term results after laparoscopic surgery with conversion to open surgery for colorectal cancer are seldom published.

AIM

The study analysed the impact of conversion of laparoscopic surgery to open resection for colorectal cancer on short- and long-term results.

MATERIAL AND METHODS

The prospectively collected data of 469 patients with colorectal cancer in the period from 1 January 2001 to 31 December 2006 were analysed. Short- and long-term results were compared.

RESULTS

The relative frequency of conversion was 7%. The subgroups were statistically similar regarding age, gender, body mass index (BMI), localization of tumour, T stage, and TNM stage. We observed a lower frequency of previous surgery (p = 0.018) in the group of patients with conversions to open surgery as well as statistically significantly higher frequency of patients with American Society of Anesthesiologists (ASA) score II (p = 0.039). There was no statistical difference in morbidity, mortality, or the length of hospital stay between both the groups of patients. The operating time was significantly higher in the group of patients with conversion (p = 0.00001). There was a significantly higher blood loss in the patient groups with conversion to open surgery and in the group with primarily open surgery (p = 0.00023). There was no difference in the overall survival (p = 0.712), disease-free survival (p = 0.072) or in the local (p = 0.432) or distant (p = 0.957) recurrence.

CONCLUSIONS

No negative impact on short- or long-term results of conversion to open surgery was verified in patients with colorectal surgery.

Conversion in laparoscopic colorectal cancer surgery: impact on short- and long-term outcome

INTRODUCTION

Despite the well-documented safety and effectiveness of laparoscopic colorectal surgery in curative intention, the role of conversion and its impact on short- and long-term outcome after resection of a carcinoma are unclear and continue to give rise to controversial discussion.

METHODS

Within the framework of a prospective, multicenter observational study (Laparoscopic Colorectal Surgery Study Group), into which a total of 5,863 patients from 69 hospitals were recruited over a period of 10 years, a subgroup of all patients who had undergone curative resection was analyzed with regard to the effects of conversion.

RESULTS

Of the 1409 patients who had undergone curative resection for colorectal carcinoma, conversion had to be performed in 80 (5.7%) cases for the most diverse reasons. The duration of surgery (median: 183 vs. 241 minutes; P<.001) was significantly longer in the conversion group. Perioperatively, significant disadvantages were noted in converted patients in terms of intraoperative blood loss (median: 243 vs. 573 mL, P<.001), need for perioperative blood transfusion (10.8% vs. 33.8%; P<.001), and resumption of bowel movement (median: after 3 vs. 4 days; P<.001). With regard to postoperative morbidity, significant disadvantages were observed in converted patients, in particular in terms of specific surgical complications, including a higher rate of anastomotic insufficiency (5.0% vs. 13.8%; P=.003) and a higher reoperation rate (4.9% vs. 15.0%; P=.001). In the long term, conversion was associated with lower overall survival, but not with poorer disease-free survival.

CONCLUSION

Significantly higher postoperative morbidity was observed in patients after conversion, in particular in terms of specific surgical complications. In addition, conversion is associated with overall lower survival but not with poorer disease-free survival.

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

PURPOSE

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach.

METHODS

Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009.

RESULTS

Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival.

CONCLUSIONS

These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND

A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery.

METHODS

Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s).

RESULTS

325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case.

CONCLUSIONS

It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.