Impact of conversion at the time of minimally invasive pancreaticoduodenectomy: a review of the national cancer database

Abstract

Presenter: Daisy Sanchez MD | Memorial Healthcare System Background: Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). We aim to compare perioperative, oncologic outcomes and survival between patients who required conversion from MI-PD to open pancreaticoduodenectomy (CO-PD) with patients who underwent open pancreatectomy (O-PD) on a national level. Methods: The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: minimally invasive (MI-PD), converted to open (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes to O-PD while adjusting for patient and tumor characteristics. Results: Among 17,570 patients identified, 2,191 (12.5%) underwent MI-PD (2.3% robotic and 10.2% laparoscopic), 734 (4.2%) CO-PD, and 14,645 (83.4%) O-PD. Baseline demographics and tumor characteristics were similar among cohorts. Robotic pancreaticoduodenectomy (R-PD) resulted in a significantly higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (R-CO, n = 22.4 ± 13.2) when compared to O-PD (n = 17.6, ± 9.5) (p = 0.00). Margin positivity was higher in the CO-PD (robotic converted to open (R-CO) 36.6%, laparoscopic converted to open (L-CO) 25.4%) compared to the MI-PD (R-PD 22.7%, L-PD 21.3%) and O-PD (22.6%) group (p = 0.017). Length of stay (days) was shortest for MI-PD (L-PD 10.4 ± 8.6, R-PD 10.6 ± 8.8) and R-CO (10.7 ± 6.4), compared to the L-CO (11.2 ± 9) and O-PD (11.5 ± 8.9) group (p = 0.000). 30-day readmission, 30-day mortality and 90-day mortality were similar among the groups. After adjusting for patient and tumor characteristics, both MI-PD (OR = 1.40; p = 0.000) and CO-PD (OR = 1.24; P = 0.030) were both significantly associated with an increased likelihood of long-term survival. Conclusion: Minimally-invasive pancreaticoduodenectomy with conversion to an open approach (CO-PD) is not associated with poorer short-term outcomes. Despite the noted increase positive margin rate, CO-PD was still associated with an increased likelihood of long-term survival when compared to O-PD.