Predictors and Outcomes of Minimally Invasive Distal Pancreatectomy Conversion

Abstract

The adoption of minimally invasive distal pancreatectomy (MIDP) has increased over the last decades due to its safety and improved perioperative outcomes in comparison with the open approach. This study aims to assess the rate and predictors of conversion and its effect on perioperative outcomes. We used the pancreas-targeted NSQIP dataset between 2014 and 2015 to identify patients who underwent MIDP (robotic/laparoscopic) and converted cases. We compared patients’ characteristics, perioperative parameters and outcomes in the MIDP and conversion groups. Multivariate analysis (MVA) was used to determine the predictors of conversion and its association with postoperative outcomes. We identified 1,512 MIDP of which 92 (18.0%) were converted. On MVA, the predictors of conversion were BMI (odds ratio [OR]=1.03; 95% CI: 1.01, 1.06), T3/T4 malignant disease (OR=2.46; 95% CI: 1.55, 3.89), pancreatitis (OR=2.83; 95% CI: 1.52, 5.27) compared to benign disease, albumin level (OR=0.60; 95% CI: 0.43, 0.86). Robotic cases were associated with lower risk of conversion compared to laparoscopic (OR=0.32; 95% CI: 0.19, 0.52). Unadjusted outcomes showed that converted cases had higher 30-day mortality compared to MIDP (2.2% vs 0.3%, p=0.001), higher rates of major complications (48.5% vs 29.0%, p<0.001), organ space SSI (14.3% vs 6.7%, p<0.001), bleeding requiring transfusion (20.3% vs 3.0%, p<0.001), sepsis/septic shock (8.2% vs 4.8%, p=0.035) and delayed gastric emptying (7.6% vs 2.2%, p<0.001). There was no difference in the rate of pancreatic fistula. On MVA, conversion was associated with major complications (OR=2.03; 95% CI: 1.46, 2.83) and delayed gastric emptying (OR=2.59; 95% CI: 1.22, 5.52). Conversion is associated with higher morbidity and mortality than completed MIPD. Understanding the risks and predictors of conversion may improve patient counseling, selection and outcomes.