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

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.

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Abbreviations

MIE:

Minimally invasive esophagectomy

OE:

Open esophagectomy

RAMIE:

Robotic-assisted minimally invasive esophagectomy

VAMIE:

Video-assisted minimally invasive esophagectomy

NCDB:

National Cancer Database

RCT:

Randomized controlled trial

GE:

Gastroesophageal

MIS:

Minimally invasive surgical

LOS:

Length of stay

OR:

Odds ratio

CI:

Confidence interval

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Correspondence to Ana L. Gleisner.

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Disclosure

Dr. John D. Mitchell MD is a consultant on the Advisory Board for Medtronic, Dr. Alison L. Halpern MD, Ms. Chloe Friedman MPH, Dr. Robert J. Torphy MD, Dr. Mohammed H. Al-Musawi, MD MSc, Dr. Christopher D. Scott MD, Dr. Robert A. Meguid MD MPH, Dr. Martin D. McCarter MD, Dr. Michael J. Weyant MD, and Ana L. Gleisner MD PhD have no conflicts of interest or financial ties to disclose.

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Halpern, A.L., Friedman, C., Torphy, R.J. et al. Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database. Surg Endosc 34, 3470–3478 (2020). https://doi.org/10.1007/s00464-019-07124-y

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Keywords

  • Minimally invasive esophagectomy
  • Conversion
  • NCDB
  • Esophageal cancer
  • Outcomes