[en] [en] OBJECTIVES: To identify risk factors for conversion, develop a predictive Conversion Risk Score (CRS), and assess the association between conversion and severe postoperative complications.
BACKGROUND: Conversion occurs in 15-30% of minimally invasive left pancreatectomies (MILP). Risk factors and potential negative impacts on postoperative outcomes are poorly described.
METHODS: Retrospective, nationwide, multicenter study including all MILP (laparoscopy and robot) performed between 2010 and 2021. Risk factors for conversion were identified by multivariate mixed model, and a CRS was developed on a "training-set" and validated (calibration diagrams and ROC curves) on a "validation-set." The association between severe complications and conversion was assessed using a propensity score based on the main risk factors for severe complications: age, sex, BMI, ASA score, tumor malignancy, multi-organ resection, operative duration, blood loss, splenectomy.
RESULTS: 2104 patients included from 55 centers. Conversion occurred in 15.6% of MILP. Its risk factors were male sex (OR=1.67;P=0.048), BMI≥25 kg/m2 (OR=2.15;P=0.004), history of laparotomy (OR=2.9;P<0.001), initial pancreatitis (OR=3.58;P=0.007), tumor size≥40 mm (OR=2.12;P=0.003), planned splenectomy (OR=2.63;P<0.001), unplanned splenectomy (OR=4.05;P=0.028), portal vein resection (OR=36.3;P=0.002), multi-organ resection (OR=12.97;P<0.001). A predictive CRS was created based only on preoperatively available variables (the first six), with scores ranging from 0 to 7, corresponding to a conversion risk of 2% to 100%. No association was observed with tumor malignancy, robotic approach, or pancreatectomy volume. Conversion was significantly associated with severe complications [OR=1.80(1.16-2.54)], independent of other risk factors for complications.
CONCLUSIONS: Conversion during MILP can be predicted by CRS, aiding surgeons in decision-making, given its significant association with severe complications.
Disciplines :
Surgery
Author, co-author :
De Ponthaud, Charles; Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France ; Université Paris Cité, Université Sorbonne, Inria, Inserm, HeKA, 75015 Paris, France ; Sorbonne University, Paris, France
Nassar, Alexandra; Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
Dokmak, Safi; Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Centre de Recherche sur l'Inflammation, INSERM Unité Mixte de Recherche 1149, Clichy, France
Bertrand, Thibaud; Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Centre de Recherche sur l'Inflammation, INSERM Unité Mixte de Recherche 1149, Clichy, France
De Martino, Julien; Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Centre de Recherche sur l'Inflammation, INSERM Unité Mixte de Recherche 1149, Clichy, France
Pastier, Clément; Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
Castel, Antoine; Department of Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, CHU Rennes, France
De Rosa, Raffaele; Department of Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, CHU Rennes, France
Boubaddi, Mehdi; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, CHU de Bordeaux, 33000 Bordeaux, France
Iben-Khayat, Abdallah; Department of Digestive and Endocrine surgery, Centre Hospitalier Universitaire d'Orléans, Orléans, France
Giannone, Fabio; Department of Digestive Surgery, Hepatobiliary and Pancreatic Unit, Nouvel Hospital Civil, Hôpitaux Universitaires de Strasbourg, France
Jolly, Elsa; Digestive Surgery and Transplantation Department, Toulouse University Hospital, Toulouse, France
Garnier, Jonathan; Department of Surgical Oncology, Institut Paoli Calmettes, Aix-Marseille University, France
Louis-Gaubert, Clément; Department of Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
Mazzotta, Alessandro D; Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
ANDRE, Marie; Department of HPB Surgery, University Hospital of Nancy, Hôpital Brabois, Vandoeuvre-les-Nancy, France
Gagnière, Johan; Department of Digestive and Hepatobiliary Surgery - Liver Transplantation, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
Viennet, Manon; Department of digestive and oncologic surgery, Dijon university hospital, Dijon, France
Souche, François-Régis; Department of Surgery, Hopital Saint Eloi, Montpellier, France
Kianmanesh, Reza; Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, University Reims Champagne-Ardenne, France
Lupinacci, Renato Micelli; Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France
Regimbeau, Jean-Marc; CHU Amiens-Picardie, Service de Chirurgie Digestive et Oncologique Site Sud, 1 Rond-Point du Professeur Christian Cabrol, Amiens, France
Paye, François; Department of Digestive Surgery, AP-HP Saint Antoine Sorbonne Université, Paris, France
Addeo, Pietro; Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
Laurent, Alexis; Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Henri Mondor, Unversité Paris Est Créteil, Créteil, France
VANDERMEULEN, Morgan ; Centre Hospitalier Universitaire de Liège - CHU > > Service de chirurgie abdo, sénologique, endocrine et de transplantation
Caiazzo, Robert; CHU Lille, Department of General, Endocrine and Metabolic Surgery, University of Lille, Lille, France
El Amrani, Mehdi; Department of Digestive Surgery and Transplantation, Claude Huriez Hospital, CHU Lille, Lille, France
Tresallet, Christophe; Department of Digestive, Bariatric, and Endocrine Surgery, APHP, University Hospital Avicenne, Sorbonne Paris Nord University, Bobigny, France
Doussot, Alexandre; Department of Digestive Surgical Oncology - Liver Transplantation Unit, CHU Besancon, Besançon, France
Brunel, Martin; Service de chirurgie digestive, centre hospitalier André Mignot, Le Chesnay, France
Jouffret, Lionel; Department of General and Digestive Surgery, Hospital Centre, Avignon, France
Pinto, Amandine; Service de chirurgie digestive, Centre Hospitalier Tarbes-Lourdes, France
Valverde, Alain; Service de chirurgie digestive, Groupe Hospitalier Diaconesses Croix Saint Simon, Paris, France
Romero Vece, Rodolfo; Service de chirurgie digestive et visceral, Hôpital Delafontaine, France
Fara, Régis; Department of General and Digestive Surgery, Hôpital Européen Marseille, France
Mahfouf, Samir; Department of Oncologic and Visceral surgery, Hôpital Ibn Ziri Bologhine Alger, Algérie
Darnis, Benjamin; Centre Lyonnais de Chirurgie digestive, Lyon, France
Chamakhi, Amine; Service de chirurgie générale, Hopital Universitaire Bougatfa, Bizerte, Tunisie
Thereaux, Jeremie; Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
Lubrano, Jean; Department of Digestive and Hepatobiliary Surgery, Caen University Hospital, Caen, France
Girard, Edouard; Université Grenoble Alpes, Département de chirurgie digestive et de l'urgence, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
Veziant, Julie; Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
Birnbaum, David Jérémie; APHM Digestive Department, Marseille, France
Danion, Jérôme; Department of Digestive and Endocrine Surgery, CHU de Poitiers, France
Corté, Helene; Department of Digestive Oncology, Endocrine Surgery, Saint Louis Hospital, Paris, France
Zemour, Johanna; Department of Digestive and Oncologic Surgery, CHU Sud de la Réunion, France
Piardi, Tullio; University of Reims Champagne - Ardenne, Department of Surgery, HPB Surgery Unit, Simone Veil Hospital, Troyes, France
de Carbonnières, Anne; Department of Digestive Surgery, Bégin Teaching Military Hospital, Saint Mandé, France
Ragot, Emilia; Department of Digestive Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris, France
Zarzavadjian Le Bian, Alban; Service de Chirurgie Viscérale, Digestive, Cancérologique, Métabolique et Endocrinienne, Centre Hospitalier Louis Pasteur, Chartres, France
David, Patrice; Service de chirurgie digestive, Hopitaux civils de Colmar, France
Brunaud, Laurent; Department of Surgery, Unit of Endocrine and Metabolic Surgery, University of Lorraine, CHU Nancy - Hospital Brabois Adultes, Nancy, France
Lermite, Emilie; Service de Chirurgie Digestive, University Hospital of Angers, Angers, France
Chreim, Laura; Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France
Charlaix, Ana Lucia; Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France
Gugenheim, Jean; Department of Digestive Surgery, L'Archet University Hospital, Nice, France
Schwarz, Lilian; Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, Rouen, France
Bigourdan, Jean Marc; Department of Digestive Surgery, Centre hospitalier Perpignan, France
Le Roy, Bertrand; Department of Digestive and Oncologic Surgery, Hospital Nord, CHU Saint-Etienne, France
Karam, Elias; Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France
Rhaiem, Rami; Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, University Reims Champagne-Ardenne, France
Fabre, Jean-Michel; Department of Surgery, Hopital Saint Eloi, Montpellier, France
Lequeu, Jean-Baptiste; Department of digestive and oncologic surgery, Dijon university hospital, Dijon, France
Noirault, Marie; Department of Digestive and Hepatobiliary Surgery - Liver Transplantation, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
Ayav, Ahmet; Department of HPB Surgery, University Hospital of Nancy, Hôpital Brabois, Vandoeuvre-les-Nancy, France
Soubrane, Olivier; Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
Regenet, Nicolas; Department of Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
Turrini, Olivier; Department of Surgical Oncology, Institut Paoli Calmettes, Aix-Marseille University, France
Muscari, Fabrice; Digestive Surgery and Transplantation Department, Toulouse University Hospital, Toulouse, France
Pessaux, Patrick; Department of Digestive Surgery, Hepatobiliary and Pancreatic Unit, Nouvel Hospital Civil, Hôpitaux Universitaires de Strasbourg, France
Thébault, Baudouin; Department of Digestive and Endocrine surgery, Centre Hospitalier Universitaire d'Orléans, Orléans, France
Laurent, Christophe; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, CHU de Bordeaux, 33000 Bordeaux, France
Sulpice, Laurent; Department of Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, CHU Rennes, France
Sauvanet, Alain; Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Centre de Recherche sur l'Inflammation, INSERM Unité Mixte de Recherche 1149, Clichy, France
Fuks, David; Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
Gaujoux, Sébastien ; Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France ; Sorbonne University, Paris, France
van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210‑8.
Hyung WJ, Yang HK, Park YK, Lee HJ, An JY, Kim W, et al. Long-Term Outcomes of Laparoscopic Distal Gastrectomy for Locally Advanced Gastric Cancer: The KLASS-02-RCT Randomized Clinical Trial. J Clin Oncol Off J Am Soc Clin Oncol. 2020;38(28):3304‑13.
de Rooij T, van Hilst J, van Santvoort H, Boerma D, van den Boezem P, Daams F, et al. Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial. Ann Surg. 2019;269(1):2‑9.
van Hilst J, de Rooij T, Klompmaker S, Rawashdeh M, Aleotti F, Al-Sarireh B, et al. Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study. Ann Surg. 2019;269(1):10‑7.
Cucchetti A, Bocchino A, Crippa S, Solaini L, Partelli S, Falconi M, et al. Advantages of laparoscopic distal pancreatectomy: Systematic review and meta-analysis of randomized and matched studies. Surgery. 2023;173(4):1023‑9.
Lof S, van der Heijde N, Abuawwad M, Al-Sarireh B, Boggi U, Butturini G, et al. Robotic versus laparoscopic distal pancreatectomy: multicentre analysis. Br J Surg. 2021;108(2):188‑95.
Gavriilidis P, Lim C, Menahem B, Lahat E, Salloum C, Azoulay D. Robotic versus laparoscopic distal pancreatectomy - The first meta-analysis. HPB. 2016;18(7):567‑74.
Hobeika C, Pfister M, Geller D, Tsung A, Chan A, Troisi RI, et al. Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference. Ann Surg. 2024;
Korrel M, Lof S, Al Sarireh B, Björnsson B, Boggi U, Butturini G, et al. Short-term Outcomes After Spleen-preserving Minimally Invasive Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Pan-European Retrospective Study in High-volume Centers. Ann Surg. 2023;277(1):e119‑25.
van der Heijde N, Vissers FL, Manzoni A, Zimmitti G, Balsells J, Berrevoet F, et al. Use and outcome of minimally invasive pancreatic surgery in the European E-MIPS registry. HPB. 2023;25(4):400‑8.
de Rooij T, van Hilst J, Boerma D, Bonsing BA, Daams F, van Dam RM, et al. Impact of a Nationwide Training Program in Minimally Invasive Distal Pancreatectomy (LAELAPS). Ann Surg. 2016;264(5):754‑62.
Balduzzi A, van der Heijde N, Alseidi A, Dokmak S, Kendrick ML, Polanco PM, et al. Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review. Langenbecks Arch Surg. 2021;406(3):597‑605.
Jiang Z, Pan L, Chen M, Zhang B, Sarun J, Fan S, et al. Risk factors and consequences of conversion in minimally invasive distal pancreatectomy. J Minimal Access Surg. 2022;18(3):384‑90.
Casadei R, Ricci C, Pacilio CA, Ingaldi C, Taffurelli G, Minni F. Laparoscopic distal pancreatectomy: which factors are related to open conversion? Lessons learned from 68 consecutive procedures in a high-volume pancreatic center. Surg Endosc. 2018;32(9):3839‑45.
Park Y, Hwang DW, Lee JH, Song KB, Jun E, Lee W, et al. Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients. J Hepato-Biliary-Pancreat Sci. 2022;29(5):540‑51.
Nassour I, Wang SC, Porembka MR, Augustine MM, Yopp AC, Mansour JC, et al. Conversion of Minimally Invasive Distal Pancreatectomy: Predictors and Outcomes. Ann Surg Oncol. 2017;24(12):3725‑31.
Giani A, van Ramshorst T, Mazzola M, Bassi C, Esposito A, de Pastena M, et al. Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study. Br J Surg. 2022;109(11):1124‑30.
Lof S, Claassen L, Hannink G, Al-Sarireh B, Björnsson B, Boggi U, et al. Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers. JAMA Surg. 2023;e232279.
Huang B, Feng L, Zhao J. Systematic review and meta-analysis of robotic versus laparoscopic distal pancreatectomy for benign and malignant pancreatic lesions. Surg Endosc. 2016;30(9):4078‑85.
Stiles ZE, Dickson PV, Deneve JL, Glazer ES, Dong L, Wan JY, et al. The impact of unplanned conversion to an open procedure during minimally invasive pancreatectomy. J Surg Res. 2018;227:168‑77.
Beane JD, Pitt HA, Dolejs SC, Hogg ME, Zeh HJ, Zureikat AH. Assessing the impact of conversion on outcomes of minimally invasive distal pancreatectomy and pancreatoduodenectomy. HPB. 2018;20(4):356‑63.
van Ramshorst TME, van Hilst J, Boggi U, Dokmak S, Edwin B, Keck T, et al. Standardizing definitions and terminology of left-sided pancreatic resections through an international Delphi consensus. Br J Surg. 2024;111(4):znae039.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet Lond Engl. 2007;370(9596):1453‑7.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205‑13.
Kelly KJ, Greenblatt DY, Wan Y, Rettammel RJ, Winslow E, Cho CS, et al. Risk stratification for distal pancreatectomy utilizing ACS-NSQIP: preoperative factors predict morbidity and mortality. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2011;15(2):250‑9, discussion 259-261.
Daniel FE, Tamim HM, Hosni MN, Mailhac AC, Khalife MJ, Jamali FR, et al. Short-term surgical morbidity and mortality of distal pancreatectomy performed for benign versus malignant diseases: a NSQIP analysis. Surg Endosc. 2020;34(9):3927‑35.
Goh BKP, Tan YM, Chung YFA, Cheow PC, Ong HS, Chan WH, et al. Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg Chic Ill 1960. 2008;143(10):956‑65.
Montagnini AL, Røsok BI, Asbun HJ, Barkun J, Besselink MG, Boggi U, et al. Standardizing terminology for minimally invasive pancreatic resection. HPB. 2017;19(3):182‑9.
Lee M, Kong L, Weissfeld L. Multiple imputation for left-censored biomarker data based on Gibbs sampling method. Stat Med. 2012;31(17):1838‑48.
Sun Y, Li C, Jin L, Gao P, Zhao W, Ma W, et al. Radiomics for lung adenocarcinoma manifesting as pure ground-glass nodules: invasive prediction. Eur Radiol. 2020;30(7):3650‑9.
Budhathoki S, Diergaarde B, Liu G, Olshan A, Ness A, Waterboer T, et al. A risk prediction model for head and neck cancers incorporating lifestyle factors, HPV serology and genetic markers. Int J Cancer. 2023;152(10):2069‑80.
Wang L, Lv Y. Construction of a Prediction Model for the Mortality of Elderly Patients with Diabetic Nephropathy. J Healthc Eng. 2022:5724050.
Lee J, Kim SH, Kim Y, Park J, Park GE, Kang BJ. Radiomics Nomogram: Prediction of 2-Year Disease-Free Survival in Young Age Breast Cancer. Cancers. 2022;14(18):4461.
Tuerlinckx F, Rijmen F, Verbeke G, De Boeck P. Statistical inference in generalized linear mixed models: a review. Br J Math Stat Psychol. 2006;59(Pt 2):225‑55.
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584‑91.
Lee SY, Allen PJ, Sadot E, D’Angelica MI, DeMatteo RP, Fong Y, et al. Distal pancreatectomy: a single institution’s experience in open, laparoscopic, and robotic approaches. J Am Coll Surg. 2015;220(1):18‑27.
Casadei R, Ricci C, Ingaldi C, Alberici L, Vaccaro MC, Galasso E, et al. The Usefulness of a Preoperative Nomogram for Predicting the Probability of Conversion from Laparoscopic to Open Distal Pancreatectomy: A Single-Center Experience. World J Surg. 2021;45(1):252‑60.
Matsumoto I, Kamei K, Satoi S, Murase T, Matsumoto M, Kawaguchi K, et al. Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients. Surg Today. 2021;51(1):70‑8.
Hua Y, Javed AA, Burkhart RA, Makary MA, Weiss MJ, Wolfgang CL, et al. Preoperative risk factors for conversion and learning curve of minimally invasive distal pancreatectomy. Surgery. 2017;162(5):1040‑7.
Müller PC, Breuer E, Nickel F, Zani S, Kauffmann E, De Franco L, et al. Robotic Distal Pancreatectomy: A Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers. Ann Surg. 2023;278(2):253‑9.
Giglio MC, Celentano V, Tarquini R, Luglio G, De Palma GD, Bucci L. Conversion during laparoscopic colorectal resections: a complication or a drawback? A systematic review and meta-analysis of short-term outcomes. Int J Colorectal Dis. 2015;30(11):1445‑55.
Parascandola SA, Hota S, Tampo MMT, Sparks AD, Obias V. The Impact of Conversion to Laparotomy in Rectal Cancer: A National Cancer Database Analysis of 57 574 Patients. Am Surg. 2020;86(7):811‑8.
Björnsson B, Larsson AL, Hjalmarsson C, Gasslander T, Sandström P. Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial. Br J Surg. 2020;107(10):1281‑8.
Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, et al. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. Lancet Reg Health Eur. 2023;31:100673.
Allaix ME, Furnée EJB, Mistrangelo M, Arezzo A, Morino M. Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival? World J Gastroenterol. 2016;22(37):8304‑13.
