Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery
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1 Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Abdullah Wafa, M.D. General Surgery Resident, PGY2 St. Joseph Mercy Health System Ann Arbor 2015 ACS NSQIP National Conference July 26, 2015
2 Disclosures Dr. Cleary is a speaker for Intuitive Surgical Drs. Bhama and Wafa do not have any disclosures
3 Background Colorectal surgery was traditionally performed via an open approach until the 1990s when minimally invasive surgery was adopted. Initially, laparoscopy was used to perform minimally invasive operations. The advent of the robotic platform has been found to be particularly applicable to the field of colorectal surgery.
4 Background Minimally invasive techniques for colorectal surgery have been demonstrated to be safe with equal oncologic outcomes compared to open surgery.
5 Background The need to convert from a minimally invasive operation to an open operation has been shown to have worse outcomes. Increased rates of anastomotic leak, wound infection, ileus, and UTI.
6 Background Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery.
7 A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery Tam MS et al (Surgical Endoscopy, 2015)
8 A comparison of laparoscopic and robotic colorectal surgery outcomes using the ACS NSQIP database. 16.0% 14.0% Bhama AR et al (Surgical Endoscopy, 2015) p=0.23 p= % 12.0% 10.0% 9.0% 10.7% 10.0% Robotic 8.0% Laparoscopic 6.0% 4.0% 2.0% 0.0% Abdomen Pelvis
9 Background The patient and procedure factors contributing to the likelihood of conversion in minimally invasive colorectal surgery remain poorly understood.
10 Aims Identify patients who experienced unplanned conversion to an open procedure. Identify significant risk factors for conversion. Utilize this information to assist surgeons: o Patient-centered selection of the appropriate operative approach o Improving preoperative counseling for patients
11 Methodology Identified patients who underwent an unplanned conversion to open surgery. Propensity score matching was used to identify risk factors for conversion from a robotic or a laparoscopic operation to an open operation.
12 Variables Examined Patient Demographics: o Age o Gender o Ethnicity o BMI General Health Factors: o Tobacco Use o Functional Health Status o ASA Class (ASA 1 or 2, ASA 3, ASA 4) Comorbidities: Dyspnea COPD Disseminated Cancer Use of Steroids Recent weight loss Bleeding disorder Recent transfusion Presence of sepsis Hypertension Colorectal Diagnosis
13 Variables Examined Surgery Factors: Use of mechanical bowel prep Location (Pelvis, Abdomen) Need for stoma Operative time Abnormal Lab Values Albumin Alkaline phosphate Bilirubin BUN Creatinine Hematocrit (low/high) Platelets (low/high) PTT LFT WBC (low/high)
14 MIS Colectomy n = 11,477 Abdomen n = 8,089 Pelvis n = 3,388 Laparoscopic n = 7,790 Robotic n= 299 Laparoscopic n = 3,057 Robotic n = 331 Conversion rate 10.7% Conversion rate 9.0% Conversion rate 13.7% Conversion rate 10.0% p=0.23 p<0.01
15 Laparoscopy Abdominal Cases: Predictors for Conversion Risk Factor Odds Ratio (95% CI) Non-white race 1.5 ( ) BMI> ( ) ASA class 1.6 ( ) Diabetes 1.7 ( ) Functional Status 1.5 ( ) Disseminated Cancer 1.5 ( ) Bleeding Disorder 1.8 ( ) Sepsis 3.2 ( ) Hypertension 1.3 ( ) Bowel Prep 1.6 ( ) Abnormal Albumin 2.0 ( ) Abnormal Alk Phos 2.0 ( ) Anemia 1.4 ( ) Thrombocytopenia 1.5 ( ) Thrombocytosis 1.4 ( ) Abnormal LFT 1.5 ( ) Operative time ( ) Age 1.01 ( ) Robot Risk Factor Odds Ratio (95% CI) Abnormal Bilirubin 4.0 ( ) Abnormal creatinine 3.8 ( ) Thrombocytopenia 3.4 ( ) Operative Time ( ) Age 1.01 ( )
16 Pelvic Cases: Predictors for Conversion Risk Factor Odds Ratio (95% CI) Laparoscopy Non-white race 1.5 ( ) BMI> ( ) ASA class 1.6 ( ) Diverticulitis 2.4 ( ) Disseminated Cancer 2.2 ( ) Hypertension 1.4 ( ) Need for stoma 2.5 ( ) Low albumin 1.8 ( ) Abnormal creatinine 1.5 ( ) Robot Risk Factor Odds Ratio (95% CI) Operative Time ( ) Abnormal BUN 2.7 ( ) Thrombocytosis 2.3 ( ) Leukocytosis 1.9 ( ) Operative Time ( )
17 Strengths Protocol driven database Externally audited Regularly validated Does not rely on administrative billing data First identification of unplanned conversion Sets groundwork for future studies
18 Retrospective study o Selection bias Limitations o Unable to control for surgeon operative choices and levels of expertise with each operative platform Dependent upon accurate coding Small case numbers for robotics and large case numbers for laparoscopy Data not collected on adhesions
19 Conclusion Conversion rates are lower for robotic cases than for laparoscopic cases (significant in pelvis). Several risk factors were identified for conversion. Fewer risk factors were identified for robotic cases than laparoscopic cases.
20 Conclusion It appears that the utilization of the robotic platform may help mitigate the influence of certain risk factors on the need to convert to an open procedure.
21 Conclusion Recognition of factors predicting conversion in minimally invasive colorectal surgery may allow surgeons to choose an operative approach for cases that optimize the benefits of the available technologies.
22 Future Directions Case matched controls to account for differences in sample size in each group Compare outcomes of robotic converted to open cases to laparoscopy converted to open cases Evaluate the cost of conversion
23 Acknowledgements Bhama, AR Welch, KB Cleary, RC
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