Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database

Surg Endosc. 2020 Aug;34(8):3470-3478. doi: 10.1007/s00464-019-07124-y. Epub 2019 Oct 7.

Abstract

Objective: The objectives were to determine factors associated with conversion to open surgery in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE, including laparo-thoracoscopic and robotic) and the impact of conversion to open surgery on patient outcomes.

Methods: We included patients from the National Cancer Database with esophageal and gastroesophageal junction cancer who underwent MIE from 2010 to 2015. Patient-, tumor-, and facility-related characteristics as well as short-term and oncologic outcomes were compared between patients who were converted to open surgery and those who underwent successful MIE without conversion to open surgery. Multivariable logistic regression models were used to analyze risk factors for conversion to open surgery from attempted MIE.

Results: 7306 patients underwent attempted MIE. Of these patients, 82 of 1487 (5.2%) robotic-assisted esophagectomies were converted to open, compared to 691 of 5737 (12.0%) laparo-thoracoscopic esophagectomies (p < 0.001). Conversion rates decreased significantly over the study period (ptrend = 0.010). Patient age, tumor size, and nodal involvement were independently associated with conversion. Facility minimally invasive cumulative volume and robotic approach were associated with decreased conversion rates. Patients whose MIEs were converted had increased 90-day mortality [Odds Ratio (OR) 1.49; 95% Confidence Interval (CI) 1.10, 2.02], prolonged hospital stay (OR 1.39; 95% CI 1.17, 1.66), and higher rates of unplanned readmission (OR 1.67; 95% CI 1.27, 2.20). No significant differences were found in surgical margins or number of lymph nodes harvested.

Conclusion: Patients undergoing attempted MIE requiring conversion to open surgery had significantly worse short-term outcomes including postoperative mortality. Patient factors and hospital experience contribute to conversion rates. These findings should inform surgeons and patients considering esophagectomy for cancer.

Keywords: Conversion; Esophageal cancer; Minimally invasive esophagectomy; NCDB; Outcomes.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Clinical Competence
  • Conversion to Open Surgery / adverse effects*
  • Conversion to Open Surgery / mortality
  • Conversion to Open Surgery / statistics & numerical data
  • Databases, Factual
  • Esophageal Neoplasms / surgery
  • Esophagectomy / adverse effects*
  • Esophagectomy / methods*
  • Esophagectomy / mortality
  • Esophagectomy / statistics & numerical data
  • Female
  • Humans
  • Laparoscopy / adverse effects
  • Length of Stay
  • Lymph Nodes
  • Male
  • Margins of Excision
  • Middle Aged
  • Minimally Invasive Surgical Procedures / adverse effects*
  • Minimally Invasive Surgical Procedures / trends
  • Odds Ratio
  • Patient Readmission
  • Postoperative Complications
  • Regression Analysis
  • Retrospective Studies
  • Risk Factors
  • Robotic Surgical Procedures / adverse effects
  • Treatment Outcome
  • United States