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

Abstract

Purpose The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown. Methods A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP. Results Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0–32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients. Conclusion The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.

Benchmarking of robotic and laparoscopic spleen-preserving distal pancreatectomy by using two different methods

“…These findings suggest that a low-risk cohort mainly results in lower rates of conversion, morbidity, and readmission, and to a lesser extent affects parameters such as operating time, duration of hospital stay, and spleen preservation. Previous literature supports these findings given the exclusion criteria used for the low-risk cohort in which the best-patient-in-best-centre benchmarks were established; extended or multivisceral resections, ASA grade at least III, major previous abdominal surgery, and BMI 35 kg/m² or higher have been associated with higher rates of conversion and postoperative morbidity [36][37][38][39] . Excluding such patients may have resulted in better outcomes and thus led to stricter best-patient-in-best-centre 75th percentiles compared with the ABC 75th percentiles.…”

Assessment of difficulty in laparoscopic distal pancreatectomy: A modification of the Japanese difficulty scoring system – A single‐center high‐volume experience

“…The study results demonstrated that the judgment of the surgical skill and the level of the learning curve of the pancreatic surgeon cannot be left out of consideration in the conversion rate and EBL. The use of these indicators as surrogates of surgical difficulty of these parameters has been widely reported in the literature 26,27 . The preoperative patient's characteristics, particularly the body mass index, did not result as additional factors of the complexity of the surgical procedure 28 .…”

“…The use of these indicators as surrogates of surgical difficulty of these parameters has been widely reported in the literature. 26,27 The preoperative patient's characteristics, particularly the body mass index, did not result as additional factors of the complexity of the surgical procedure. 28 Notably, the postoperative outcomes were not influenced by the surgical complexity based on the mDSS, in contrast with previous studies.…”

Minimally invasive robot-assisted and laparoscopic distal pancreatectomy in a pan-European registry a retrospective cohort study

“…Benefits of RDP such as the lower conversion rates have been described 8 – 10 and are mainly attributed to the technical features of the robotic system providing the surgeon with more freedom of movement and better bleeding control. Although conversion in certain circumstances is necessary for a safe progression and to ensure adequate oncological clearance, literature has demonstrated that patients requiring conversion to open surgery in MIDP have worse outcomes than those whose resection is completed minimally invasive 22 .…”