Factors leading to a higher conversion rate after laparoscopic rectal cancer surgery and its impact on morbidity and mortality

Mhgm van der Pas, MD, Gsa Abis, MD, Es de Lange, PhD, Ma Cuesta, PhD, Hj Bonjer, PhD, Color Ii Studygroup. Department of Surgery, Maastricht university Medical Center, the Netherlands andDepartment of Surgery, VU University Medical Center Amsterdam, The Netherlands.

Background: Since the first reports on laparoscopic total mesorectal excision for rectal cancer, different factors influencing conversion rate have been suggested. Incidence, predictive factors, mortality and morbidity of conversion in the COlorectal cancer Laparoscopic or Open Resection COLOR II) trial are presented.
Methods and procedures: Between January 20, 2004 and May 4, 2010, 1044 patients were enrolled in the COLOR II trial, comparing laparoscopic and open surgery for rectal cancer. Six hundred and ninety-nine patients were allocated to laparoscopic surgery. A total of 693 patients actual received laparoscopic surgery. Analysis was by treatment received. One hundred and fourteen (16%) of 693 patients were converted to open surgery. Predictive factors were studied using multivariate analyses. Morbidity and mortality between patients needing conversion and patients who had planned open or laparoscopic surgery were compared.
Results: Factors which were correlated with intraoperative conversion are: age above 65 years (OR 1.9; 95% CI 1.2-3.0: p=0.003), BMI>25 (OR 2.7; 95% CI 1.7-4.3: p<0.001) and tumor location 5-10 cm from the anal verge (OR 2.1; 95% CI 1.2-3.7: p=0.020) and 10-15 cm (OR 2.0; 95% CI 1.1-3.5: p=0.008) compared to tumors located < 5 cm from the anal verge. Gender was not significantly related to the need for conversion (p=0.143). Conversion was associated with more blood loss (p<0.001) and prolonged operating times (p=0.028) when compared to the non-converted laparoscopic group. No significant difference in hospital stay was shown between laparoscopic and converted patients (p=0.063). Patients needing conversion had more postoperative complications compared to laparoscopic surgery and open surgery (p= 0.041 and p=0.042 respectively). Mortality was comparable in both groups.
Conclusions: Patients over 65 years of age with a BMI >25 and a tumor located between 5-15 cm from the anal verge are more likely to need intraoperative conversion reducing the benefits of laparoscopic surgery. After conversion, patients show a significantly higher postoperative complication rate.

Colorectal cancer Laparoscopic or Open Resection II (COLOR II) study group: André D’Hoore, Dan Birch, Chris DeGara, Jaap Bonjer, Chris Jamieson, Poornoroozy Peiman, Karl Juul Jensen, Orhan Bulut, Per Jess, Jacob Rosenberg, Thomas Harvald, Henrik Ovesen, Eskilde Lundhus, Igors Iesalnieks and Ayman Agha, Christina Jaeger, Martin Kreis, Michael Kasparek, Alois Fuerst, Gudrun Liebig-Hoerl, Seon Hahn Kim, Donald van der Peet, Miguel Cuesta, Martijn van der Pas, Mark Buunen, Peter Neijenhuis, Peter Paul Coene, Edwin van der Harst, Yvonne van Riet, Willem Bemelman, Michael Gerhards, Hubert Prins, Eduardo Targarona, Carmen Balague, Carmen Martinez, Juan Franco Osorio, García Molina, Antonio Lacy, Salvadora Delgado, Juan Lujan, Graciela Valero, Alfredo Alonso-Poza, Manual Losadar, Salvador Argudo, Hospital del Sureste de Madrid, Zoltan Lackberg, Stefan Skullman,  Goran Kurlberg, Eva Haglind, Ulf Kressner, Peter Matthiessen.

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