Impact of Unplanned Intra-Operative Conversions on Outcomes in Minimally Invasive Pancreatoduodenectomy

Background: Minimally-invasive pancreatoduodenectomy (MIPD) is fraught with the risk of complication-related deaths (LEOPARD-2), a significant volume-outcome relationship and a long learning curve. With rates of conversion for MIPD approaching 40%, the impact of these on overall patient outcomes, especially, when unplanned, are yet to be fully elucidated. This study aimed to compare peri-operative outcomes of (unplanned) converted MIPD against both successfully completed MIPD and upfront open PD. 

Methods: A systematic review of major reference databases was undertaken. The primary outcome of interest was 30-day mortality. Newcastle–Ottawa scale was used to judge the quality of the studies. Meta-analysis was performed using pooled estimates, derived using random effects model. 

Results: Six studies involving 20,267 patients were included in the review. Pooled analysis demonstrated (unplanned) converted MIPD were associated with an increased 30-day (RR 2.83, CI 1.62- 4.93, p = 0.0002, I ² = 0%) and 90-day (RR 1.81, CI 1.16- 2.82, p = 0.009, I ² = 28%) mortality and overall morbidity (RR 1.41, CI 1.09; 1.82, p = 0.0087, I ² = 82%) compared to successfully completed MIPD. Patients undergoing (unplanned) converted MIPD experienced significantly higher 30-day mortality (RR 3.97, CI 2.07; 7.65, p < 0.0001, I ² = 0%), pancreatic fistula (RR 1.65, CI 1.22- 2.23, p = 0.001, I ² = 0%) and re-exploration rates (RR 1.96, CI 1.17- 3.28, p = 0.01, I ² = 37%) compared upfront open PD. 

Conclusions: Patient outcomes are significantly compromised following unplanned intraoperative conversions of MIPD when compared to successfully completed MIPD and upfront open PD. These findings stress the need for objective evidence-based guidelines for patient selection for MIPD.