Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study

Abstract

Background Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear. Methods This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012–2017) in ten medium-volume (10–19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i). Results Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien–Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs. Conclusion Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

State of the art of robotic pancreatoduodenectomy

“…Multivariable analysis showed that LPD was associated with a higher risk of conversion (OR 5.2, 95% CI. 2.5-10.7; p < 0.001) [20]. Despite RPD reduces the risk of massive intraoperative bleeding (versus LPD), we wish to emphasize that surgeons should be prepared to face hemorrhage from major visceral vessels before embarking upon RPD.…”

“…In general, RPD is as safe ad OPD [35,40] and LPD [33,39,41]. Compared to LPD, RPD reduces the overall risk of conversion to open surgery and the risk of emergency conversion due to major bleeding [20], thus addressing one of the major concerns on safety of minimally invasive PD [19]. Under appropriate conditions, RPD facilitates safe implementation of minimally invasive PD [14] and reduces the learning curve of this procedure, when compared to LPD [28].…”

“…At multivariable analysis, using RPD as reference, LPD was strongly associated with conversion to open surgery (OR 5.2; 2.5-10.7; p < 0.001). Conversions were more frequent in medium-volume centers (10-19 procedures per year) than in high-volume centers (15.2% versus 4.1%; p = 0.001) [20].…”

What Is the Current Role and What Are the Prospects of the Robotic Approach in Liver Surgery?

“…Nevertheless, robotic surgery has generally been associated with a lower conversion rate, compared to the laparoscopic approach, for various surgical procedures [ 48 , 49 ]. This difference becomes more evident when the volume-weighted conversion rate is calculated [ 50 ].…”

A comparative study of robotics and laparoscopic in minimally invasive pancreatoduodenectomy: A single-center experience

“…A retrospective study of European multicenter showed that the risk factors for conversion from MIPD to laparotomy included laparoscopic surgery, large tumour diameter, old age, and pancreas/bile duct tumour. It was also observed that a center with medium flow (10-19 cases/year) has a higher risk of conversion than a center with high flow (more than 20 cases/year) (31). Certainly, there are many factors affecting the conversion; it is not only the patient but also the surgeon's technique.…”