Laparoscopic conversion in colorectal cancer surgery; is there any improvement over time at a population level?

Abstract

Conversion of laparoscopic colorectal cancer resection has been associated with worse outcome, but this might have been related to a learning curve effect. This study aimed to evaluate incidence, predictive factors and outcomes of laparoscopic conversion after the implementation phase of laparoscopic surgery at a population level. Patients undergoing elective resection of non-locally advanced, non-metastatic colorectal cancer between 2011 and 2015 were included. Data were extracted from the Dutch Surgical Colorectal Audit. Patients were grouped as laparoscopic completed (LR), laparoscopic converted (CONV) with further specification of timing (within or after 30 min) as registered in the DSCA, and open resection (OR). Uni- and multi-variate analyses were used to determine predictors of conversion and outcome (complicated course and mortality), with evaluation of trends over time. A total of 23,044 patients with colon cancer and 11,324 with rectal cancer were included. Between 2011 and 2015, use of laparoscopy increased from 55 to 84% in colon cancer, and from 49 to 89% in rectal cancer. Conversion rates decreased from 11.8 to 8.6% and from 13 to 8.0%, respectively. Laparoscopic hospital volume was independently associated with conversion rate. Only for colon cancer, the rate of complicated course was significantly higher after CONV compared to OR (adjusted odds ratio 1.486; 95% CI 1.298–1.702), and significantly higher after late (> 30 min) compared to early conversion (adjusted odds ratio 1.341; 1.046–1.719). There was no impact of CONV on mortality in both colon and rectal cancer. The use of laparoscopic colorectal cancer surgery increased to more than 80% at a national level, accompanied by a decrease in conversion which is significantly related to the laparoscopic hospital volume. Conversion was only associated with complicated course in colon cancer, especially when the reason for conversion consisted of an intra-operative complication, without affecting mortality.Electronic supplementary materialThe online version of this article (10.1007/s00464-018-6042-2) contains supplementary material, which is available to authorized users.

A propensity‐score‐matched analysis of laparoscopic vs open surgery for rectal cancer in a population‐based study

“…A similar process could have occurred in Catalonia with rectal cancer, since we observed some selection bias favouring low-risk patients for laparoscopic surgery: this group was more likely to be younger than 80 years, have fewer comorbidities, present a lower ASA and be diagnosed at an earlier disease stage. The conversion rate observed in the present study (13.2%) is similar to that seen in the population-based study by de Neree et al [20] and the meta-analysis by Arezzo et al [11], and it is lower than that reported in a Spanish prospective non-randomized study [38].…”

“…The conversion rate observed in the present study (13.2%) is similar to that seen in the population‐based study by de Neree et al . and the meta‐analysis by Arezzo et al . , and it is lower than that reported in a Spanish prospective non‐randomized study .…”

“…Compared with open surgery, our results did not show any association between conversion and mortality or recurrence, in line with the results published by de Neree et al . .…”

The impact of conversion on the risk of major complication following laparoscopic colonic surgery: an international, multicentre prospective audit

“…These rates were significantly higher in those with late conversion (> 30 min) compared to early conversion (OR 1.34, 1.05-1.72). There was no impact of conversion on mortality in these patients [13]. In contrast, one of the largest series of segmental resections reported, with 207 311 patients operated in the United States, found that conversion had a higher morbidity and mortality than completed laparoscopic procedures, but better outcomes than primary open procedures [16].…”

“…Subsequently, several studies showed conversion rates between 10.4 and 29.0% with detrimental outcome [3,4,[13][14][15]. More recently, a Dutch national review reported a conversion rate of 8.6% for colon cancer [13]. The literature has been divided about whether conversion impacts detrimentally on short-term outcomes.…”