Outcomes of Elective and Emergency Conversion in Minimally Invasive Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: An International Multicenter Propensity Score-matched Study

Abstract

Objective:The aim of this study was to investigate the impact of conversion during minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) on outcome by a propensity-matched comparison with open distal pancreatectomy (ODP).Background:MIDP is associated with faster recovery as compared with ODP. The high conversion rate (15%–25%) in patients with PDAC, however, is worrisome and may negatively influence outcome.Methods:A post hoc analysis of a retrospective cohort including distal pancreatectomies for PDAC from 34 centers in 11 countries. Patients requiring conversion were matched, using propensity scores, to ODP procedures (1:2 ratio). Indications for conversion were classified as elective conversions (eg, vascular involvement) or emergency conversions (eg, bleeding).Results:Among 1212 distal pancreatectomies for PDAC, 345 patients underwent MIDP, with 68 (19.7%) conversions, mostly elective (n = 46, 67.6%). Vascular resection (other than splenic vessels) was required in 19.1% of the converted procedures. After matching (61 MIDP-converted vs 122 ODP), conversion did not affect R-status, recurrence of cancer, nor overall survival. However, emergency conversion was associated with increased overall morbidity (61.9% vs 31.1%, P= 0.007) and a trend to worse oncological outcome compared with ODP. Elective conversion was associated with comparable overall morbidity.Conclusions:Elective conversion in MIDP for PDAC was associated with comparable short-term and oncological outcomes in comparison with ODP. However, emergency conversions were associated with worse both short- and long-term outcomes, and should be prevented by careful patient selection, awareness of surgeons’ learning curve, and consideration of early conversion when unexpected intraoperative findings are encountered.

Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma

“…110,112 In particular, the lower emergency conversion rate is an advantage of robotic pancreatic surgery because lower emergency conversion is associated with many postoperative complications and patients that tend to present with poor prognoses. 110,112,122 4 | MULTIDISCIPLINARY TRE ATMENT…”

The Usefulness of a Preoperative Nomogram for Predicting the Probability of Conversion from Laparoscopic to Open Distal Pancreatectomy: A Single‐Center Experience

“…In fact, it should be noted that recent studies have reported an increase in morbidity, 30-day mortality and length of stay in patients who underwent conversion from LDP to ODP [11,23]. On the other hand, some authors [22] have recently reported that elective conversion was associated with outcomes similar to ODP, while, on the contrary, only emergency conversion, mainly due to bleeding, was related to worse outcomes. In summary, in cases with a high probability of conversion, the indication for LDP should be carefully assessed by an experienced laparoscopic surgeon who can avoid an emergency conversion, can take advantage of minimally invasive approach for easier dissection and enhanced visualization and can perform early conversion when unexpected intra-operative findings are encountered.…”

Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review

“…One (12.5%) study had a high risk of bias (≤ 5 NOS score) because detailed information on patient follow-up was lacking [26]. Only one study used a form of matching [28].…”

“…Three studies stated that an open conversion was defined as a resection performed via a laparoscopic, robotic, or hand-assisted approach but that an open incision was needed to complete the resection regardless of incision size [25,26,32]; two of these studies specifically stated that conversion to a hand-assisted approach was not considered a conversion [25,26]. One study categorized conversions as either elective or emergency conversions, the latter due to unexpected events (e.g., bleeding), the former a result of unexpected findings such as tumor extensions to adjacent organs or vascular structures, difficulty in tumor exposure, and adhesions [28].…”

“…Five (62.5%) studies elaborated on the indications for conversion [25][26][27][28]30]; another study included different types of Fig. 1 PRISMA flowchart of all included studies pancreatic resections but did not specify the indications for distal pancreatectomy separately [27].…”