Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study)

Koki Goto; Jun Watanabe; Toshiya Nagasaki; Mamoru Uemura; Heita Ozawa; Yohei Kurose; Tomonori Akagi; Nobuki Ichikawa; Hiroaki Iijima; Masafumi Inomata; Akinobu Taketomi; Takeshi Naitoh; EnSSURE study group collaboratives in Japan Society of Laparoscopic Colorectal Surgery

doi:10.1007/s00464-024-10740-y

Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study)

Surg Endosc. 2024 Mar 8. doi: 10.1007/s00464-024-10740-y. Online ahead of print.

Collaborators

EnSSURE study group collaboratives in Japan Society of Laparoscopic Colorectal Surgery:
Akinobu Furutani, Akiyoshi Kanazawa, Akiyoshi Noda, Atsushi Ishibe, Chikayoshi Tani, Daisuke Yamamoto, Fumihiko Fujita, Fuminori Teraishi, Fumio Ishida, Fumitaka Asahara, Hideaki Karasawa, Hideki Osawa, Hiroaki Nagano, Hiroaki Takeshita, Hirofumi Ota, Hirokazu Suwa, Hiroki Ochiai, Hiroomi Ogawa, Hiroshi Saeki, Hirotoshi Hasegawa, Hiroyuki Bando, Hisanaga Horie, Hisashi Nagahara, Kaori Hayashibara, Kay Uehara, Kazuhiro Takehara, Ken Kojo, Ken Okamoto, Kenichiro Saito, Koji Ikeda, Koji Munakata, Koki Otsuka, Koya Hida, Kunihiko Nagakari, Manabu Shimomura, Manabu Shiozawa, Manabu Takata, Manabu Yamamoto, Masaaki Ito, Masakatsu Numata, Masahiko Watanabe, Masashi Miguchi, Mayumi Ozawa, Mitsuhisa Takatsuki, Naoya Aisu, Naruhiko Sawada, Nobuaki Suzuki, Ryo Ikeshima, Ryo Inada, Ryuichi Oshima, Satoshi Maruyama, Shigehiro Kojima, Shigeki Yamaguchi, Shigenori Homma, Shiki Fujino, Shinichiro Mori, Shinobu Ohnuma, Sho Takeda, Shota Aoyama, Shuji Saito, Shunpei Mukai, Shusaku Takahashi, Takahiro Sasaki, Takahiro Yamanashi, Takeru Matsuda, Takuya Miura, Tatsunari Fukuoka, Tatsunori Ono, Tatsuya Kinjo, Tatsuya Shonaka, Teni Godai, Tohru Funakoshi, Tomohiro Adachi, Tomohiro Yamaguchi, Tomohisa Furuhata, Toshimoto Kimura, Toshisada Aiba, Toshiyoshi Fujiwara, Tsukasa Shimamura, Tsunekazu Mizushima, Yasuhito Iseki, Yasuo Sumi, Yasushi Rino, Yasuyuki Kamada, Yoshiaki Kita, Yoshihiro Kakeji, Yoshihiro Takashima, Yoshihito Ide, Yoshiharu Sakai, Yoshinori Munemoto, Yoshito Akagi, Yoshiyuki Ishii, Yuji Inoue, Yuki Kiyozumi, Yukihito Kokuba, Yukitoshi Todate, Yusuke Suwa, Yusuke Sakimura, Yusuke Shimodaira

Affiliations

¹ Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan.
² Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
³ Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
⁴ Department of Colorectal Surgery, Tochigi Cancer Center, Utsunomiya, Japan.
⁵ Department of Surgery, Fukuyama City Hospital, Fukuyama, Japan.
⁶ Department of Gastroenterological and Pediatric Surgery, Oita University, Oita, Japan. tomakagi@oita-u.ac.jp.
⁷ Department of Gastroenterological Surgery I, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
⁸ Department of Gastroenterological and Pediatric Surgery, Oita University, Oita, Japan.
⁹ Department of Lower Gastrointestinal Surgery, Kitasato University School of Medicine, Sagamihara, Japan.

PMID: 38459211
DOI: 10.1007/s00464-024-10740-y

Abstract

Background and aims: Conversion to laparotomy is among the serious intraoperative complications and carries an increased risk of postoperative complications. In this cohort study, we investigated whether or not the Endoscopic Surgical Skill Qualification System (ESSQS) affects the conversion rate among patients undergoing laparoscopic surgery for rectal cancer.

Methods: We performed a retrospective secondary analysis of data collected from patients undergoing laparoscopic surgery for cStage II and III rectal cancer from 2014 to 2016 across 56 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. Data from the original EnSSURE study were analyzed to investigate risk factors for conversion to laparotomy by performing univariate and multivariate analyses based on the reason for conversion.

Results: Data were collected for 3,168 cases, including 65 (2.1%) involving conversion to laparotomy. Indicated conversion accounted for 27 cases (0.9%), while technical conversion accounted for 35 cases (1.1%). The multivariate analysis identified the following independent risk factors for indicated conversion to laparotomy: tumor diameter [mm] (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.05, p = 0.0002), combined resection of adjacent organs [+/-] (OR 7.92, 95% CI 3.14-19.97, p < 0.0001), and surgical participation of an ESSQS-certified physician [-/+] (OR 4.46, 95% CI 2.01-9.90, p = 0.0002). The multivariate analysis identified the following risk factors for technical conversion to laparotomy: registered case number of institution (OR 0.99, 95% CI 0.99-1.00, p = 0.0029), institution type [non-university/university hospital] (OR 3.52, 95% CI 1.54-8.04, p = 0.0028), combined resection of adjacent organs [+/-] (OR 5.96, 95% CI 2.15-16.53, p = 0.0006), and surgical participation of an ESSQS-certified physician [-/+] (OR 6.26, 95% CI 3.01-13.05, p < 0.0001).

Conclusions: Participation of ESSQS-certified physicians may reduce the risk of both indicated and technical conversion. Referral to specialized institutions, such as high-volume centers and university hospitals, especially for patients exhibiting relevant background risk factors, may reduce the risk of conversion to laparotomy and lead to better outcomes for patients.

Trial registration: This study was registered with the Japanese Clinical Trials Registry as UMIN000040645.

Keywords: Conversion; Endoscopic surgical skill qualification system; Japan; Laparoscopic surgery; Rectal cancer; Rectal resection.