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

Abstract

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. Recent large RCTs [5,6] as well as a systematic review and metaanalysis of the literature [7] have reported similar advantages of laparoscopic rectal resection and total mesorectal excision (TME) compared with open surgery for extraperitoneal rectal cancer. Evidence from the literature also has shown comparable outcomes in terms of oncologic clearance and long-term survival between laparoscopic and open resection for colon [1,[8][9][10] and rectal cancer [10][11][12]. The rates for conversion of laparoscopic colon resection to open surgery reported in the largest multicenter RCTs range from 17 to 25 % [2-4], whereas the conversion rates for laparoscopic rectal resection vary between 0.6 and 32.4 % [7]. With the exception of the conventional versus laparoscopic-associated surgery in colorectal cancer (CLASICC) trial, all RCTs have analyzed converted patients in the laparoscopic group on an "intention-to-treat" basis. A few nonrandomized studies have examined the short-term outcomes for converted cancer patients. Some studies have reported higher morbidity and mortality rates and a longer postoperative hospital stay [3,[13][14][15][16][17][18], whereas others did not find si...

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

“…One might hypothesize that expertise, different patient selection for a laparoscopic approach or a teaching environment are contributing factors to these observations. If a laparoscopic procedure is converted to open, Allaix et al showed no significant differences in short-term postoperative morbidity, mortality, or hospital stay between the converted group compared to the laparoscopic completed group in a cohort of 1114 patients [34]. In contrast, even compared to the OR, we did find a significant higher short-term postoperative complicated course for the converted colon cancer resections, and late conversion (after 30 min) increased this risk.…”

“…Clancy et al performed a systematic review with meta-analysis and found conversion of laparoscopic colorectal cancer resection to be associated with an increase in disease recurrence and overall mortality, but the patients in the converted groups more often had locally advanced disease [25]. Allaix et al showed that converted patients had a worse 5-year overall survival (OS) and disease-free survival (DFS) in univariate analysis, in which patients with pathologic T4 tumors were included [34]. In multivariate analysis, however, only pathologic T4 stage and tumor-positive lymph node ratio > 0.25 were independently associated with OS and DFS.…”

The Impact of Laparoscopic Converted to Open Colectomy on Short-Term and Oncologic Outcomes for Colon Cancer

“…The rate of conversion (15.2 %) in the present study was similar to the conversion rate in the recent COLOR II data 7 (16 %), and it was lower than the conversion rate in the COST trial 4 (21 %) and other previous trials. 1,5,13,[23][24][25][26] This difference might be due to the less-obese population considered in the present study. In addition, as our centers comprise the leading regional teaching hospitals in southern China, the surgeons were all well trained in laparoscopic techniques and had extensive experiences with laparoscopic gastrointestinal surgery before they performed an operation independently.…”

The short-term and oncologic outcomes of laparoscopic versus open surgery for T4 colon cancer

“…Indeed, faster recovery such as shorter time to soft diet and reduced hospital stay was not observed in the converted group. However, timely and deliberately prepared conversions to open surgery might prevent intraoperative complications and unnecessary tumor manipulation [3,27].…”

“…This phenomenon suggests that open surgery is still the gold standard for difficult and complex cases of T4b cancer. Fewer lymph nodes were resected in the laparoscopic group (22) than in the open surgery group (27). However, resection of 22 lymph nodes still exceeds the recommendation of at least 12 nodes from the NCCN guideline [15].…”